Review for accuracy and determine what you will say

Reference no: EM133265939

Question: You are Sinclair Memorial Hospital's coding trainer. You have a new employee that you are training and the new employee gave you this encounter to review. You will need to review for accuracy and determine what you will say to your employee about what was and was not coded and why. It is your job to make sure the information you give is clear. To do this you will need to use your ICD-10-CM and CPT coding knowledge along with your coding guidelines to need to explain why you would and would not apply any condition listed within the scenario.

A 36-year-old patient with HIV is admitted through the Emergency Department with epigastric abdominal pain and diarrhea. An ultrasound shows calculus in her gallbladder but no obstruction. The doctor diagnoses the pain as cholelithiasis with acute cholecystitis. The doctor sends the patient to same day surgery where an intraoperative cholangiogram and a laparoscopic cholecystectomy are performed under fluoroscopic guidance.

The diagnosis and procedure codes submitted for your review are:

Diagnosis codes:

B20 Human immunodeficiency virus (HIV)

R10.13 Epigastric pain

R19.7 Diarrhea unspecified

K80.00 Calculus of gallbladder with acute cholecystitis w/o obstruction

Procedure codes:

47563 Laparoscopy, surgical; cholecystectomy with cholangiography

74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation

Where did the coder do wrong?

Reference no: EM133265939

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