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CASE 7 PROCEDURE PERFORMED: Amniocentesis. INDICATIONS: The patient…

January 10, 2024

CASE 7

PROCEDURE PERFORMED: Amniocentesis.

INDICATIONS: The patient is a 28 year-old G4 P2103 at 36 weeks, here in the office today for amniocentesis for FLM secondary to Rh isoimmunization to D antigen. Following informed consent she elected to proceed with the amniocentesis.

PROCEDURE: An ultrasound was carried out that revealed a single intrauterine gestation of 36+2 weeks in vertex presentation. A site for amniocentesis was identified in the left upper uterine segment which did not transgress the placenta and a image was retained for the record. The amniocentesis site was sterilely prepped and draped with a sterile towel and an alcohol based solution. Following this using direct ultrasound guidance a 22-gauge amniocentesis needle was sharply inserted in the amniotic fluid cavity. This returned clear amniotic fluid. 20 cc was easily aspirated and 10cc sent for FLM and 10cc held for possible OD450 if needed. The patient tolerated the procedure very well and normal fetal cardiac activity was seen following the procedure. The patient will be sent for a follow-up NST. Rhogam is not indicated as the patient is already sensitized.

What are the CPT® and ICD-10-CM codes?

CPT® codes: [a], [b]

ICD-10-CM codes: [c], [d]

Specified Answer for: a	59000
Specified Answer for: b	76946
Specified Answer for: c	036.0130
Specified Answer for: d	Z3A.36

Response Feedback:

There are two CPT® codes and two ICD-10-CM codes reported. In the CPT® Index, look for Amniocentesis/Diagnostic. There was ultrasonic guidance used during the procedure. There is a parenthetical note in the numeric listing instructing to report another code. The procedure is performed in the clinic office. You don’t need to append a modifier for the professional component to the second code. The Indications header shows the reason for the procedure is a pregnancy complicated by Rh immunization. This is the first diagnosis. Look in the ICD-10-CM Alphabetic Index for Pregnancy/complicated by/RH immunization, incompatibility or sensitization NEC/anti-D antibody. The 6th character is determined by the trimester and the 7th character is determined by the fetus affected. This information is found in Indications. Check the notes at the beginning of ICD-10-CM Chapter 15 for choosing the 1st, 2nd, or 3rd trimester. A Z code will identify the weeks of gestation. Look in the Alphabetic Index for Pregnancy/weeks of gestation. This is your last code.

I am missing something in this as I am marked as this has a wrong component in the billing answer. Can you see where I went wrong?

Amniocentesis, case, Health Science, INDICATIONS, patient, PERFORMED, procedure

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