Question

A patient with a long history of endometriosis has an open surgical approach to perform an exploratory laparotomy for an enlarged right ovary seen on ultrasound with other possible masses on the uterus and in the peritoneum. Exploration reveals these masses to be endometriosis including a chocolate cyst (endometrioma) of the right ovary, right fallopian tube and peritoneum. The endometriomas are all small, less than 5 cm, and laser is used to ablate them, except the ovarian cyst, which is excised. During the procedure the patient also has a tubal ligation. What are the CPT® and ICD-10-CM codes reported for this service?

Answer 1

The requested CPT and ICD-10-CM codes would be related to the surgical treatment of endometriosis via laparoscopy, as well as a concurrent tubal ligation. Specific codes would depend on the 2023 coding manuals, which should be referenced for accurate coding.

Step-by-step explanation:

The student is asking for the CPT (Current Procedural Terminology) and ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) codes that would be reported for a surgical procedure to address endometriosis in a patient with an enlarged right ovary seen on ultrasound, additional masses on the uterus and peritoneum, and concurrent tubal ligation.

Laparoscopy is a surgical technique often used to diagnose and treat endometriosis, which could be represented by the CPT code for a laparoscopic procedure to ablate endometriotic lesions and excise an endometrioma, plus the code for tubal ligation. The definitive ICD-10-CM diagnosis code would reflect endometriosis involving the ovary, fallopian tube, and peritoneum.

Since the specific CPT and ICD-10-CM codes are not provided within the information given and vary based on the 2023 CPT and ICD-10-CM coding book, the student will need to refer to the latest coding manuals to find the accurate codes.