PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Left direct and

PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Left direct and indirect inguinal hernia. PROCEDURE PERFORMED: Repair of left inguinal hernia with Prolene mesh. ANESTHESIA: IV sedation with local. COMPLICATIONS: None. DISPOSITION: The patient tolerated the procedure well and was transferred to Recovery in stable condition. SPECIMEN: Hernia sac, as well as turbid fluid with gram stain, which came back with no organisms from the hernia sac. BRIEF HISTORY: This is a 53-year-old male who presented to Dr. Y’s office with a bulge in the left groin and was found to have a left inguinal hernia increasing over the past several months. The patient has a history of multiple abdominal surgeries and opted for an open left inguinal hernial repair with Prolene mesh. INTRAOPERATIVE FINDINGS: The patient was found to have a direct as well as an indirect component to the left inguinal hernia with a large sac. The patient was also found to have some turbid fluid within the hernia sac, which was sent down for gram stain and turned out to be negative with no organisms. What are the ICD-10-CM and CPT code(s) for this case? What is/are the APC(s)?

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