AAPC - Chapter 13 Practical Applications with expert
interventions (Guaranteed Success)
CASE 1
DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately
as it is included in the diagnosis code for the uterine prolapse.)
PROCEDURE: Pessary fitting.
INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has
had four pregnancies with four term births and the last two babies were quite large.) female
with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream
twice a week for six weeks. She is back for a pessary fitting today.
FINDINGS: She has a third-degree cystocele, and after examination we've determined she
actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse.
Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved,
although still atrophic, but much less thin than prior appointment.
DESCRIPTION OF PROCEDURE - answer 57160
N81.3
CASE 2
DIAGNOSES:
, 1. Complete procidentia (The stated diagnosis is Complete Procidentia, and this is well
supported in the body of the operative note. A review of several medical dictionaries shows the
definition of Procidentia, prolapse of an organ or part.)
2. Recurrent urinary tract infections (A history of postmenopausal vaginal bleeding, anemia and
recurrent urinary tract infection (UTI).)
3. Postmenopausal vaginal bleeding (Select codes for the definitive diagnoses.)
PROCEDURES:
1. Vaginal hysterectomy
2. Anterior and posterior colporrhaphy
3. Cystoscopy
4. Vaginal vault suspension
SPECIMENS: Uterus and cervix.
FINDINGS: A thick hypertophic ulcerated cervix was noted. The adnexa were small and atrophic.
Complete procidentia with cystocele and rectocele. (All of these problems are addressed in the
body of the note below.) Cystoscopy done after indigo carmine was administered,(Indigo
carmine is a dye i - answer 57260
58260-51
57283-59
N81.3
interventions (Guaranteed Success)
CASE 1
DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately
as it is included in the diagnosis code for the uterine prolapse.)
PROCEDURE: Pessary fitting.
INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has
had four pregnancies with four term births and the last two babies were quite large.) female
with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream
twice a week for six weeks. She is back for a pessary fitting today.
FINDINGS: She has a third-degree cystocele, and after examination we've determined she
actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse.
Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved,
although still atrophic, but much less thin than prior appointment.
DESCRIPTION OF PROCEDURE - answer 57160
N81.3
CASE 2
DIAGNOSES:
, 1. Complete procidentia (The stated diagnosis is Complete Procidentia, and this is well
supported in the body of the operative note. A review of several medical dictionaries shows the
definition of Procidentia, prolapse of an organ or part.)
2. Recurrent urinary tract infections (A history of postmenopausal vaginal bleeding, anemia and
recurrent urinary tract infection (UTI).)
3. Postmenopausal vaginal bleeding (Select codes for the definitive diagnoses.)
PROCEDURES:
1. Vaginal hysterectomy
2. Anterior and posterior colporrhaphy
3. Cystoscopy
4. Vaginal vault suspension
SPECIMENS: Uterus and cervix.
FINDINGS: A thick hypertophic ulcerated cervix was noted. The adnexa were small and atrophic.
Complete procidentia with cystocele and rectocele. (All of these problems are addressed in the
body of the note below.) Cystoscopy done after indigo carmine was administered,(Indigo
carmine is a dye i - answer 57260
58260-51
57283-59
N81.3
