Using the coding techniques you have learned, carefully read through

Using the coding techniques you have learned, carefully read through the case study and determine the most accurate diagnosis code(s). Remember, check the chapter-specific, subchapter-specific, and category-specific notations within the Tabular List. Then, determine the most accurate ICD-10-PCS procedure code(s). WINTER HILLS MEDICAL CENTER 753 VENTURA BYPASS • CENTRAL, FL 32811 • 407-555-4798 PATIENT: SAMUELLEN, RYAN ACCOUNT/EHR #: S018-056994314 DATE: 05/11/23 Attending Physician: Steven Corralle, MD HPI: During my evaluation of this 2-hour-old male I was unable to get the usual red reflex in either eye with the indirect ophthalmoscope. The reflection in both eyes was grayish white. The mother remembers having flu-like symptoms in her early pregnancy but attributed it to being a part of normal pregnancy. Past Ocular History: None Ocular Medications: None Past Medical History: Birth history: 38-week gestation, normal spontaneous vaginal delivery, no complications Surgical History: None Past Family Ocular History: No history of eye disease, blindness or congenital cataracts Social History: Will live at home with mother and father. Mother denies smoking, alcohol use or other drug use during pregnancy. Medications: None Allergies: None ROS: Otherwise negative Examination: A complete medical history including maternal illness or drug use during pregnancy was taken from the mother. Family ocular history of congenital blindness, congenital cataracts, strabismus, or amblyopia was also addressed. B-scan can be helpful to evaluate the posterior eye to rule out posterior abnormalities. This will be performed next week. A physical examination to determine signs and/or symptoms of systemic intrauterine-acquired infections was also performed. Ocular Exam Visual Acuity (cc): OD: Reacts to light OS: Reacts to light IOP (tonoapplantation): OD: Not tested OS: Not tested Pupils: Equal, round and reactive to light, no APD. Extraocular Movements: Full OU. No nystagmus. Confrontational Visual Fields: Not performed External: Normal, both sides Slit Lamp: Lids and Lashes Normal OU Conjunctiva/Sclera Normal OU Cornea Clear OU Anterior Chamber Deep and quiet OU Iris Normal OU Lens Dense central opacities OU Anterior Vitreous No view Dilated Fundus Examination: OD Unable to perform due to poor view OS Unable to perform due to poor view Other: None Differential Diagnosis: This is a case of bilateral leukocoria, or an abnormal white pupillary reflex, likely due to congenital cataracts. Differential diagnosis of leukocoria includes the following: retinoblastoma, congenital cataracts (from infectious [e.g., intrauterine rubella infection] or congenital etiologies [e.g., galactosemia, Lowe’s syndrome, familial]), retinopathy of prematurity, persistent hyperplastic primary vitreous, Coat’s disease, familial exudative vitreoretinopathy, retinal detachment, coloboma and corneal opacities. Treatment: Cataract surgery was discussed with both parents explaining that a cataract extraction with primary posterior capsulectomy and anterior vitrectomy is the treatment of choice and should be performed as soon as possible to minimize the risk of amblyopia and sensory nystagmus. Consent was obtained and the surgery is scheduled for tomorrow morning. Secondary intraocular lens implantation can be done later in life after the eye has matured. After cataract extraction, patients should be assessed and treated for amblyopia. Lifelong follow-up is important to maximize visual potential. Steven Corralle, MD Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

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