Please review the inpatient scenario:
1. Determine if the code(s) are correct (yes/no the code(s) are correct/incorrect).
2. Determine if the sequence listed is correct (yes/no the sequence is correct/incorrect).
3. If either the code(s) or sequence is incorrect you must list the corrected code(s) and or sequence. If no changes are necessary you will state, "No changes should be made"
Pre-operative Diagnosis: Left progressive acoustic neuroma
Post-operative diagnosis: Left progressive acoustic neuroma
Procedure performed: Gamma-knife resection of the neuroma
Indications: This 46-year-old, male, patient with chronic benign HTN and rheumatoid arthritis presented a month ago with new onset symptoms of hearing loss on the left side, tinnitus, and headache. MRI shoed an enhancing mass in the left cerebellopontine (CP) angle cistern and left internal auditory canal. The mass measured 2.8 cm in length with the left CP angle cistern component measuring1.6 cm in transverse diameter. Due to the complexity of the mass location, the patient opted to have gamma knife surgery.
Diagnostic codes:
D33.3 - Benign neoplasm of cranial nerves
I10 - Essential (primary) hypertension
M06.9 - Rheumatoid arthritis, unspecified
H91.92 - Unspecified hearing loss, left ear
H93.19 - Tinnitus, unspecified
R51.9 - Headache, unspecified
H93.8X2 - Other specified disorders of left ear