Question

A patient is scheduled for monitored anesthesia care (MAC) to remove an eyelid cyst. Normally the surgeon provides moderate sedation for the removal; however, this patient has a history of failed moderate sedation. Select the correct diagnosis code(s).

A.H02.829
B.H02.829, T88.52XA
C.H02.829, Z92.83
D.Z92.83

Answer 1

The correct diagnosis codes for a patient with a history of failed moderate sedation and an eyelid cyst undergoing monitored anesthesia care are H02.829 and Z92.83. The code T88.52XA is not used as there was no prior complication, and the code Z92.83 alone would not represent the reason for the surgery.

Step-by-step explanation:

When selecting the correct diagnosis code(s) for a patient scheduled for monitored anesthesia care (MAC) for the removal of an eyelid cyst, several factors must be considered. Since the patient has a history of failed moderate sedation, which is an important historical and clinical factor, you must use the correct combination of codes to reflect both the current procedure being performed and the patient's medical history relevant to anesthesia. In this case, the correct codes would be:

• H02.829 - Unspecified disorder of eyelid; this code reflects the primary reason for the procedure, which is the eyelid cyst.
• Z92.83 - Personal history of failed moderate sedation; this code indicates the patient's history related to anesthesia, which is pertinent for the current procedure.

Therefore, the correct answer is C: H02.829, Z92.83. The diagnosis code T88.52XA would apply if there had been a complication due to anesthesia during a previous procedure, which does not appear to be the case based on the information provided. Similarly, the diagnosis code Z92.83 alone would not fully capture the reason for the surgery, which is the eyelid cyst.