Steps for Assign and properly sequence the ICD-10-CM diagnosis and ICD-10-PCS procedures codes for
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Instructions Assign the ICD-10-CM code(s) to diagnoses and conditions and assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). Do not assign ICD-10-CM external cause codes. 1. Under anesthesia, open treatment of a 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 all 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 the catheter placement, which facilitated the collection of a bronchial brush biopsy. The needle and catheter were withdrawn, with the sample being sent to pathology for analysis. 3. 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 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.
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