2026 CODING SCRIPT SOLVED
QUESTIONS VERIFIED ANSWERS A+
◉ AMBULATORY RECORD
DATE: 8/12/20XX
SURGERY RECORD:
PATIENT HISTORY: This patient is seen today to insert an intrathecal
pump for pain management due to ductal carcinoma of the left upper
breast metastatic to the spine. She previously underwent modified
radical mastectomy with general anesthesia and had no adverse effects.
No other surgical history is given. No known allergies, no current
medications. Review of systems is normal ASA = 2.
Following preoperative evaluation and discussion with the patient, local
anesthesia was used to implant an intrathecal programmable pump
surgically placed and attached to a previously placed catheter. The
patient tolerated the procedure well. There were no adverse effects of
anesthesia.
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Enter three diagnosis codes and one procedure code.
PDX
, DX2
DX3
PP1
Answer: Case Studies
PDX 338.3 Neoplasm-related pain (acute) (chronic)
DX2 174.8 Malignant neoplasm of female breast, other specified sites
DX3 198.5 Secondary malignant neoplasm of bone and bone marrow
PP1 62362 Implantation or replacement of device for intrathecal or
epidural drug infusion; programmable pump, including preparation of
pump, with or without programming
Notes for Practice Outpatient Case—Patient 2
338.3 The patient is admitted for pain management due to metastatic
cancer. If the admission is for pain control related to, associated with, or
due to, a malignancy, code 338.3 (Brown 2012, 163; Coding Clinic 2nd
Quarter 2007, 13-14).
174.8, 198.5 The primary site and metastatic (secondary) sites should be
coded (Brown 2012, 378-382).
62362 The reservoir is surgically placed and attached to a previously
placed catheter (CPT Assistant March 1997, 11).