What BODY SYSTEM is selected for this procedure? 2. Does the cautery with silver nitrate support a separate code that can be billed? (yes or no) 3. What ICD-10-PCS code should be assigned?
PREOPERATIVE DIAGNOSIS: Epistaxis, left, recurrent
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Control of left nasal hemorrhage
INDICATIONS: The patient was admitted in hypertensive emergency with BP of 190/128 and recurrent epistaxis.BP is now somewhat lower at 178/98 and is being actively treated. Hemoglobin is now 9.1 and patient will be transfused after this procedure.
TECHNIQUE: With the patient in the semi-sitting position, the pharynx was examined. There is no blood in his pharynx. Some dried phlegmy secretions in his oral cavity were cleaned out with a stick sponge and suction.His right nares was partially narrowed with crusting. The right nasal cavity was cleaned using saline spray, nasal suction and lubrication. The right nares was then patent for oxygenation by way of nasal cannula. Attention was then directed towards his left nares. There was oozing from his left nares. An Afri-soaked cotton was placed into the left nares and left for approximately 2 minutes. After removal, the oozing persisted. Cautery with silver nitrate was performed on some of the visible areas of ooze from Kiesselbach’s plexus. Some oozing persisted.The nose was then packed with Surgicel dissolvable packing. Blood loss was approximately 5 mL.
1. What BODY SYSTEM is selected for this procedure?
2. Does the cautery with silver nitrate support a separate code that can be billed? (yes or no)
3. What ICD-10-PCS code should be assigned?
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