From the health record of a patient having office-based surgery: Operative Report Preoperative...


From the health record of a patient having office-based surgery:

Operative Report

Preoperative Diagnosis: Bilateral entropion, lower eyelids

Postoperative Diagnosis: Bilateral entropion, lower eyelids

Operation: Repair of entropion of right eye

Anesthesia: Local

Procedure: The patient was sterily prepped and draped for ocular solution of 2 percent lidocaine, mixed in equal proportions with 0.75 percent Marcaine with the addition of Wydase, and a modified Van Lint technique was performed on the right eye.

Incision was made in the inferior lid margin extended inferiorly. This consisted of a diamond shape, with 6-mm lengthwise incisions interconducted. Hemostasis was obtained using wet-field cautery. The incision was then sutured using a tapered needle. The first suture was placed through the approximate lash line, in addition to one suture through the area of the meibomian gland. Using the tapered needle, the tarsal plate was approximated and reapproximated. The incision was then reapproximated with subcuticular sutures. This was followed by implantation of approximately four interrupted skin sutures using 6-0 nylon.

What are the correct ICD-10-CM and CPT codes for this procedure performed in the hospital surgery center?

a. H02.002, H02.005, 67921-E4

b. HO2.002, H02.005, 67921-50

c. HO2.102, H02.105, 67921-RT

d. H02.002, H02.005, 67923

ICD-10-CM and CPT Codes

The ICD-10-CM codes are the latest version of codes used to label diagnoses. The CPT codes are the codes that are used to label medical procedures performed or services provided. These codes act as a form of communication between healthcare professionals.

Answer and Explanation: 1

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First, we will look at the ICD-10-CM codes:

  • H02.002: This code refers to unspecified entropion of the right lower eyelid
  • H02.005: This code refers to...

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What is a Diagnosis Code? - Definition & Uses


Chapter 1 / Lesson 6

A diagnosis code is a combination of letters and numbers that represents a certain medical condition, procedure, symptom, or disease. Understand the definition and uses of a diagnosis code, and explore the International Classification of Diseases (ICD) coding system.

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