T12-1C DISCHARGE SUMMARY
She had an MRI (magnetic resonance imaging) done that showed a large disc at L4-5 (fourth lumbar vertebra-fifth) on the left. She had not responded to conservative measures. She is a truck driver.
EXAM: Chest: Clear. Cardiovascular exam: No murmurs. Abdomen: Soft.
I saw her in the office. She continued to have pain, which was refractory to conservative measures.
HOSPITAL COURSE: The patient underwent a laminotomy, foraminotomy, and removal of disc at L4-5. Her postoperative course was uneventful. The wound is clean. She is discharged to convalesce at home.
FINAL DIAGNOSIS: Herniated disc L4-5 on the left
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc
T12-1C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

T12-1C DISCHARGE SUMMARY
  She had an MRI (magnetic resonance imaging) done that showed a large disc at L4-5 (fourth lumbar vertebra-fifth) on the left. She had not responded to conservative measures. She is a truck driver.
EXAM: Chest: Clear. Cardiovascular exam: No murmurs. Abdomen: Soft.
I saw her in the office. She continued to have pain, which was refractory to conservative measures.
HOSPITAL COURSE: The patient underwent a laminotomy, foraminotomy, and removal of disc at L4-5. Her postoperative course was uneventful. The wound is clean. She is discharged to convalesce at home.
FINAL DIAGNOSIS: Herniated disc L4-5 on the left
PROCEDURE PERFORMED: Laminotomy, foraminotomy, and removal of disc
T12-1C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Quizplus · Accepted Answer

The Answer is Professional Services: 99238 (Evaluation and Management, Hospital, Discharge Service)
ICD-10-CM DX: M51.26 (Displacement/displaced, intervertebral disc, lumbar region)

T12-1C DISCHARGE SUMMARY She Had an MRI (Magnetic Resonance Imaging) Done