PREOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. POSTOPERATIVE DIAGNOSIS: Adenoidal hypertrophy and serous otitis media with effusion. (Two diagnoses to report.)
Rationale: The external auditory meatus is also referred to as the external auditory canal which starts from the opening of the ear to the eardrum. If you look in the CPT® Index under Ear Canal it refers you to See Auditory Canal. Look up Auditory Canal/External/Abscess/Incision and Drainage which guides you to codes 69000, 69005 and 69020.
RATIONALE: Although the area biopsied is skin, a code from the Auditory System chapter of CPT® is appropriate for this biopsy. CPT® tells us to report code 69100 for a biopsy of the external ear, and 69105 for a biopsy of the external auditory canal.
41.
H66. 41 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM H66. 41 became effective on October 1, 2021.
Unspecified nonsuppurative otitis media, bilateral The 2022 edition of ICD-10-CM H65. 93 became effective on October 1, 2021. This is the American ICD-10-CM version of H65. 93 - other international versions of ICD-10 H65.
ICD-10-CM Code for Anisometropia H52. 31.
Definition. Chronic suppurative otitis media is persistent inflammation of the middle ear or mastoid cavity. Synonyms include chronic otitis media, chronic mastoiditis, and chronic tympanomastoiditis.
ICD-10 Code for Otitis media, unspecified- H66. 9- Codify by AAPC.
H65. 2 - Chronic serous otitis media. ICD-10-CM.
Otitis media with effusion (OME) is a collection of non-infected fluid in the middle ear space. It is also called serous or secretory otitis media (SOM). This fluid may accumulate in the middle ear as a result of a cold, sore throat or upper respiratory infection.
Otitis media, unspecified An acute or chronic inflammatory process affecting the middle ear. Inflammation of the middle ear including the auditory ossicles and the eustachian tube. Inflammation of the middle ear.
ICD-10-CM Code for Acute actinic otitis externa H60. 51.
Aniseikonia is the difference in image size perceived between the eyes from unequal magnification due to either anisometropia or retinal pathology. This can manifest with symptoms of headache, dizziness, disorientation, and excessive eye strain.
Intraocular Lens ProceduresCPT® 66985, Under Intraocular Lens Procedures The Current Procedural Terminology (CPT®) code 66985 as maintained by American Medical Association, is a medical procedural code under the range - Intraocular Lens Procedures.
Rationale: Look in the ICD-10-CM Alphabetic Index for Otitis/media/suppurative which directs you to H66.4-. In the Tabular List a 5 th character is required to identify the laterality.
Rationale: In the CPT® Index look for Tympanostomy/General Anesthesia directing you to 69436 , then verify the code in the numeric section. Code 69436 is the correct code to report because a small incision is made in the tympanum, the fluid in the middle ear is suctioned, and an insertion of a small ventilating tube is placed into the opening of the tympanum under general anesthesia. Modifier RT is appended to indicate the side of the body the procedure was performed. In the ICD-10-CM Alphabetical Index look for Otitis/media/chronic/serous which states see Otitis, media, nonsuppurative, chronic, serous. Look for Otitis/media/nonsuppurative/chronic/serous directing you to H65.2. The Tabular List indicates a 5th character is needed to show laterality. 5 th character 1 is for the right ear.
Rationale: In the CPT® Index look for Chemodenervation/Facial Muscle 64612, 64615. Code 64612 is used for chemodenervation of muscles that are innervated by the facial nerve for conditions such as blepharospasm. Modifier RT is appended to the CPT® code to indicate the procedure is performed on the right eye. Botulinum toxin is the substance most commonly used for chemodenervation of muscle tissue innervated by the facial nerve. In the ICD-10-CM Alphabetic Index look for Blepharospasm directs you to G24.5. Verification in the Tabular List confirms code selection.
Rationale: In the CPT® Index look for Otoplasty which directs you to code 69300 and is confirmed by the code description in the Auditory System numeric section. The parenthetical note beneath 69300 instructs us to report the code with modifier 50 for a bilateral procedure.
Rationale: This is a repair of blepharoptosis. In the CPT® Index, look for Blepharoptosis/Repair directs you to code range 67901-67909. The codes are selected based on the approach and technique. After verifying in the numeric section, code 67908 is the correct code.
Rationale: In the CPT® Index look for Hearing Aid/Implants/Bone Conduction/Implantation. You are referred to 69710. Review the code to verify accuracy. In the ICD-10-CM Alphabetical Index look for Loss (of)/hearing which states see also Deafness. Look for Deafness/mixed conductive and sensorineural/unilateral. You are referred to H90.7-. Review the code in the Tabular List to verify accuracy and 5 th character 1 is for right ear.
Rationale: Code 67312 represents strabismus surgery on two (2) horizontal muscles. In the CPT® Index look for Strabismus/Repair/Two Horizontal Muscles. In the numeric section below code 67316, there is a parenthetical note with instructions to use code 67335 in addition to codes 67311-67334 when adjustable sutures are used for primary procedure reflecting number of muscles operated on. Code 67335 is an add-on code and exempt from multiple procedures modifier 51. This is located in the CPT® Index by looking for Strabismus/Repair/Adjustable Sutures.
Acute suppurative otitis media without spontaneous rupture of ear drum, right ear 1 H66.001 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. 2 Short description: Acute suppr otitis media w/o spon rupt ear drum, right ear 3 The 2021 edition of ICD-10-CM H66.001 became effective on October 1, 2020. 4 This is the American ICD-10-CM version of H66.001 - other international versions of ICD-10 H66.001 may differ.
The 2022 edition of ICD-10-CM H66.001 became effective on October 1, 2021.
Rationale: Look in the ICD-10-CM Alphabetic Index for Otitis/media/suppurative which directs you to H66.4-. In the Tabular List a 5th character is required to identify the laterality.
Rationale: In the CPT® Index look for Auditory Canal/External/Biopsy. Verify in the CPT® numeric section. Code 69105 with modifier LT is correct since the biopsy was taken from the left ear in the auditory canal.
Rationale: In the CPT® Index look for Auditory Canal/External/Removal/Foreign Body which directs you to code range 69200-69205. Verify the code in the numeric section. Code 69200 is the appropriate code for the removal of a foreign body from the external auditory canal without general anesthesia. Code 69205 is with anesthesia. Under direct visualization the foreign body is removed from the external auditory canal using delicate forceps, a cerumen spoon or suction. No anesthetic or local anesthetic is used.
You are directed to 67311. Strabismus surgery add-on code 67332 is used to indicate the procedure is performed on a patient with scarring of the extraocular muscles. The parenthetical note for this code states to use 67332 in conjunction with 67311-67318.
Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes/type 2/with/retinopathy/nonproliferative/mild/with macular edema and you are directed to E11.321- . The Category E11.- indicates the type of diabetes. Since the type is not indicated, the default is type 2 per ICD-10-CM guideline I.C.4.a.1. Verify code selection in the Tabular List. The code requires a 7th character to identify the eye involved. Because the laterality of the eye is not indicated in the question, use the 7th character 9 for unspecified eye.
Rationale: The provider aspirated a cyst that was in the left orbit. In the CPT® Index look for Aspiration/Orbital Contents referring you to code 67415. Code 67500 is reported when there is an injection of a therapeutic or local anesthetic behind the eyeball (retrobulbar). Diagnoses documented as versus are not definitive diagnosis codes and are not coded. The postoperative header indicates an orbital cyst. In the ICD-10-CM Alphabetical Index look for Cyst/orbit referring you to code H05.81-. Verify code in the Tabular List. A 6th character is required to indicate which eye; 2 is reported for the left eye.
Verify the code in the numeric section. In the ICD-10-CM Alphabetical Index, look for Salpingitis/eustachian (tube)/acute and you are directed to H68.01-. Verification in the Tabular List indicates a 5th character is needed for laterality. 5th character of 2 for the left ear.
Electrocautery was used for hemostasis and further dissection. An iris scissors was used to dissect the soft tissues off of the mastoid region and the posterior ear. The concha was shut back and sutured in place with clear 4-0 nylon suture and in a horizontal mattress pattern.
Rationale: In the CPT® Index look for Retina/Repair/Detachment/with Vitrectomy referring you to 67108, 67113. Code 67113 is used for the repair of a giant tear of the retina, with vitrectomy, and endolaser photocoagulation. In the ICD-10-CM Alphabetical Index look for Detachment/retina/with retinal/break/giant referring you to H33.03-. In the Tabular List a 6th character 1 is reported for the right eye. In the ICD-10-CM External Cause of Injuries Index look for Struck (accidentally) by/ball (hit) (thrown)/baseball referring you to W21.03-. In the Tabular List seven characters are reported to complete the code. The 6th character is a placeholder X and the 7th character A is used to identify the initial encounter. Surgical management represents an initial encounter.
Repair of right eye retinal detachment with a giant tear is performed for an accidental injury sustained from a baseball to the eye at fastball practice. Vitrectomy, drainage of subretinal fluid, silicone oil tamponade, and endolaser photocoagulation are performed to correct the tear. What are the procedure and diagnosis codes for this service?
RATIONALE: In the ICD-10-CM Alphabetic Index look for Neuroma/acoustic (nerve) D33.3. Although an acoustic neuroma is indexed to D33.3, the question indicates malignant which changes the way the diagnosis is reported. A note at the beginning of the Table of Neoplasms discusses classifications in the columns of the table, and advises, "the guidance in the index can be overridden if one of the descriptors is present." Because the pathologist stated this particular acoustic neuroma is malignant, the word malignant overrides the index entry. Look in the Table of Neoplasms for Neoplasm, neoplastic/acoustic nerve/Malignant Primary which directs you to C72.4-. Verify in the Tabular List and code C72.40 is reported because the laterality is not addressed. It's very important to study and understand the information provided in the guidelines and notes within the codebook. Be willing to look beyond the codes for the answers because the answers may be in the instructional notes and guidelines.
Excision of a pterygium is reported separately from other conjunctival disorders, with codes 65420 and 65426. Because this was a simple repair without a graft, 65420 is the correct code.
RATIONALE: In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic/type 1/with/retinopathy/non-proliferative/mild and directs you to E10.329. In the Tabular List, 7th character 2 is reported to indicate the left eye. This is a combination code that includes the diabetes and the complication of retinopathy. A separate code for retinopathy is not reported. Because macular edema is not indicated in the scenario, the default is without macular edema.
Rationale: In the CPT® Index look for Phacoemulsification/Removal/Extracapsular Cataract and you are directed to 66982 and 66984. Verify these codes in the numeric section. Code 66982 is for a complex procedure. There is nothing in the note indicating this is a complex procedure. The correct code is 66984 which includes the insertion of the intraocular lens. Modifier RT is used to indicate it is performed on the right eye.
The 2022 edition of ICD-10-CM H66.90 became effective on October 1, 2021.
Clinical Information. A disorder characterized by inflammation (physiologic response to irritation), swelling and redness to the middle ear. An acute or chronic inflammatory process affecting the middle ear.
RATIONALE: Without more specific information for the type of hearing loss, a nonspecific diagnosis is reported. In the ICD-10-CM Alphabetic Index, look for Loss/hearing (see also Deafness). Look for Deafness directing you to H91.9-. In the Tabular List, select code H91.90 Unspecified hearing loss, unspecified ear. No scientific study of the hearing loss was made, making R94.120 incorrect.
This was done with a 15-blade scalpel. Electrocautery was used for hemostasis and further dissection. An iris scissors was used to dissect the soft tissues off of the mastoid region and the posterior ear.
RATIONALE: In the CPT® Index, look for Mastoidotomy. Code 69637 represents a mastoidotomy (including atticotomy and tympanic membrane repair) with ossicular chain reconstruction and partial ossicular replacement prosthesis.
RATIONALE: In the ICD-10-CM Alphabetic Index look for Neuroma/acoustic (nerve) D33.3. Although an acoustic neuroma is indexed to D33.3, the question indicates malignant which changes the way the diagnosis is reported. A note at the beginning of the Table of Neoplasms discusses classifications in the columns of the table, and advises, "the guidance in the index can be overridden if one of the descriptors is present." Because the pathologist stated this particular acoustic neuroma is malignant, the word malignant overrides the index entry. Look in the Table of Neoplasms for Neoplasm, neoplastic/acoustic nerve/Malignant Primary which directs you to C72.4-. Verify in the Tabular List and code C72.40 is reported because the laterality is not addressed. It's very important to study and understand the information provided in the guidelines and notes within the codebook. Be willing to look beyond the codes for the answers because the answers may be in the instructional notes and guidelines.
RATIONALE: In the CPT® Index, look for Strabismus/Repair/Superior Oblique Muscle 67318. Code 67318 is the only code listed describing a procedure on the superior oblique muscle. In addition to 67318, report add-on codes for adjustable sutures. In the index, see Strabismus/Repair/Adjustable Sutures 67335. This patient has a history of ophthalmic surgery . The medical history of ocular surgery makes the procedure riskier and more difficult. Look in the index for Strabismus/Repair/Previous Surgery, Not Involving Extraocular Muscles 673331. Modifier 51 never is applied to add-on codes.
NAME OF PROCEDURE: Right tympanoplasty via the postauricular approach.
Round window implants are a new technology not yet assigned CPT® a code. The word transducer should alert you to the hearing aid component of this procedure. There isn't a new technology Category III code for this type of procedure so an unlisted code is the best choice. The round window is the barrier between the middle and inner ear, but it is still considered middle ear.
Look up Auditory Canal/External/Abscess/Incision and Drainage which guides you to codes 69000, 69005 and 69020. Verify the correct code in the numeric section. 69020 is the correct code for an abscess of the auditory canal. The other codes refer only to the external ear.
Rationale: The medical term for eardrum is tympanic membrane. In the CPT® Index look for Repair/Tympanic Membrane which directs you to code 69450, 69610. Repair of the tympanic membrane with or without site preparation of perforation for closure, with or without patch is the description for code 69610 is confirmed in the numeric section. Modifier LT is used to indicate the procedure was performed on the left side.
Rationale: In the CPT® Index look for Chemodenervation/Facial Muscle 64612, 64615. Code 64612 is used for chemodenervation of muscles that are innervated by the facial nerve for conditions such as blepharospasm. Modifier RT is appended to the CPT® code to indicate the procedure is performed on the right eye. Botulinum toxin is the substance most commonly used for chemodenervation of muscle tissue innervated by the facial nerve. In the ICD-10-CM Alphabetic Index look for Blepharospasm directs you to G24.5. Verification in the Tabular List confirms code selection.
Rationale: Code 67312 represents strabismus surgery on two (2) horizontal muscles. In the CPT® Index look for Strabismus/Repair/Two Horizontal Muscles. In the numeric section below code 67316, there is a parenthetical note with instructions to use code 67335 in addition to codes 67311-67334 when adjustable sutures are used for primary procedure reflecting number of muscles operated on. Code 67335 is an add-on code and exempt from multiple procedures modifier 51. This is located in the CPT® Index by looking for Strabismus/Repair/Adjustable Sutures.
Rationale: In the CPT® Index, look for Abscess/Tissue/Auditory Canal, External/Incision and Drainage which directs you to 69020. Verify in the numeric section that code 69020 is the appropriate code for drainage of an abscess located in the external auditory canal of the ear. For this procedure, the provider makes an incision in the skin and drains the external auditory canal abscess.
Rationale: This is a repair of blepharoptosis. In the CPT® Index, look for Blepharoptosis/Repair directs you to code range 67901-67909. The codes are selected based on the approach and technique. After verifying in the numeric section, code 67908 is the correct code.
Rationale: In the ICD-10-CM Alphabetic Index look for Diabetes/type 2/with/retinopathy/nonproliferative/mild/with macular edema and you are directed to E11.321- . The Category E11.- indicates the type of diabetes. Since the type is not indicated, the default is type 2 per ICD-10-CM guideline I.C.4.a.1. Verify code selection in the Tabular List. The code requires a 7thcharacter to identify the eye involved. Because the laterality of the eye is not indicated in the question, use the 7th character 9 for unspecified eye.