Assignment Walk = CudinaPRAGCE Instructions. Assign the ICD-10-CM codes to diagnoses and conditions and assign the CFT surgery codes and the appropriate HCPCS level and CPT modifier(s). Do not assign ICD-10-CM external cause codes. Under anesthesia, open treatment of traumatic right closed posterior hip dislocation was performed by an incision made along the posterior aspect of the right hip. After the gluteus maximus muscle was identified, the muscle was split and retracted. The right hip joint was exposed, and the dislocation was reduced. The incision was closed in multiple layers with sutures. (Initial encounter;) 2. The patient presented with the complaint of chronic bronchitis. After the procedure was discussed and consents signed, the patient was taken to the ambulatory surgical unit. With the patient under adequate anesthesia, a needle was inserted into the cricoid cartilage of the neck. The needle allowed for catheter placement, which facilitated the collection of bronchial brush biopsy. The needle and catheter were withdrawn, with the sample being sent to pathology for analysis. With the patient under general anesthesia, gradual pressure was applied in the desired direction after manual manipulation was performed to increase motion. A small number of adhesions were released by gradual pressure. Manipulation of the right hip joint was a closed procedure; no surgical incision was made. This was done due to the patient having congenital dislocation of the right hip
The Correct Answer and Explanation is:
Assigned Codes:
Case 1: Open Treatment of Traumatic Right Closed Posterior Hip Dislocation (Initial Encounter)
- ICD-10-CM Diagnosis Code: S73.004A — Unspecified dislocation of right hip, initial encounter
- CPT Surgery Code: 27266 — Open treatment of hip dislocation (e.g., traumatic or congenital), posterior or anterior, with or without skeletal traction
- Modifiers: RT (Right side)
Case 2: Chronic Bronchitis with Bronchial Brush Biopsy
- ICD-10-CM Diagnosis Code: J42 — Unspecified chronic bronchitis
- CPT Procedure Code: 31623 — Bronchoscopy with brushing or protected brushing
- HCPCS Modifiers: No additional modifiers typically required for this specific code, unless payer-specific instructions apply
Case 3: Closed Manipulation of Right Hip Due to Congenital Dislocation
- ICD-10-CM Diagnosis Code: Q65.81 — Congenital dislocation of right hip
- CPT Surgery Code: 27275 — Manipulation of hip joint under anesthesia
- Modifiers: RT (Right side)
Explanation:
In Case 1, the procedure describes an open treatment for a traumatic dislocation of the right hip. This clearly involves an incision and exposure of the hip joint, with muscle retraction and reduction of the dislocation. The appropriate ICD-10-CM diagnosis for the traumatic hip dislocation is S73.004A. The CPT code that matches this open surgical treatment is 27266. The modifier RT is used to indicate the right side.
In Case 2, the chronic bronchitis diagnosis is coded with J42. The procedure involved bronchial brushing via needle and catheter insertion, which qualifies as a bronchoscopy with brushing (CPT 31623). This code reflects bronchoscopic procedures that include biopsy or sample collection from the airway.
In Case 3, the manipulation of the hip under general anesthesia without an incision aligns with a closed procedure. The diagnosis is congenital hip dislocation of the right side (Q65.81). CPT code 27275 is used for closed manipulation of the hip joint under anesthesia. The RT modifier is again used to specify the right side of the body.
By aligning clinical descriptions with coding rules, these selections ensure accurate reporting for billing and documentation.
