Question

patient is diagnosed with infertility due to endometriosis and undergoes a laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately, what steps must the coder take?

Answer 1

To code the encounter accurately, the coder must identify the diagnosis code for infertility due to endometriosis and assign procedure codes for the laparoscopic laser destruction of pelvic endometriosis, ensuring that the documentation supports the medical necessity.

Step-by-step explanation:

In order to accurately code the encounter for a patient diagnosed with infertility due to endometriosis and undergoing laparoscopic laser destruction of pelvic endometriosis, the coder must follow certain steps:

1. Identify the diagnosis code for infertility due to endometriosis, which would fall under the category of endometriosis (N80).
2. Assign procedure codes for the laparoscopic laser destruction of pelvic endometriosis, using the appropriate codes from the Current Procedural Terminology (CPT) manual. These codes would depend on the specific procedures performed during the surgery.
3. Ensure that the documentation supports the medical necessity for the procedure, and that it is accurately documented in the medical record.