(A patient is seen for nausea, vomiting, and sharp right lower abdominal pain. CT and labs support a diagnosis ofchronic appendicitis. The physician schedules anopen appendectomyand removes the appendix. What CPT® and diagnosis codes are reported?)
The operative approach is explicitlyopen surgery, so the correct CPT procedure code is44950(appendectomy; open). Code44970is thelaparoscopicappendectomy code and is not supported because the scenario states “open surgery.” For diagnosis, the physician’s final diagnosis ischronic appendicitis, which is reported withK36(other appendicitis) in the context of this question’s choices;K35.80represents acute appendicitis (unspecified acute) and does not match “chronic.” You also do not report symptom codes (nausea/vomiting/abdominal pain) once a definitive diagnosis is established and documented as the reason for the surgery, unless a guideline or scenario specifically requires them as additional reporting (this question does not). Therefore, the correct pairing is44950withK36only. CPC exam tip: always matchapproach(open vs laparoscopic) and code thefinal confirmed diagnosisrather than presenting symptoms when the definitive diagnosis is known.
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