All- PRACTICAL Application Case Review

CASE 8 Operative Report PREOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. POSTOPERATIVE DIAGNOSES: Splenic abscesses and multiple intra-abdominal abscesses, related to HIV, AIDS, and hepatitis C. OPERATIVE PROCEDURE: 1. Exploratory laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure. FINDINGS: This is a 42-year-old man who was recently admitted to the medical service with a splenic defect and found to a splenic vein thrombosis. He was treated with antibiotics and anticoagulation. He returned and was admitted with a CT scan showing mass of left upper quadrant with abscesses surrounding both sides of the spleen, as well as, multiple other intra-abdominal abscesses below the left lobe of the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry consultation and phone consent from the patient's father, he was brought to the operating room. OPERATIVE PROCEDURE: The patient was brought to operating room, a time-out procedure was performed. He was already receiving parenteral antibiotics. He was placed in the supine position and then given a general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped and draped in the sterile fashion, a long midline incision was made through the skin. This was carried through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from the free peritoneal cavity. This was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid were removed. Once the abscess cavity was completely opened, it was evident that the spleen was floating within this pus as had been predicted by the CT. This was irrigated copiously and the left lower quadrant subhepatic and pelvic abscesses were likewise discovered containing the same foul smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated multiple times. We thought it reasonable to go ahead with the splenectomy. The anatomic planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon spleen, etc., but most of the dense attachments were to the abscess cavity peel. Using this as a guide, the spleen was eventually rotated up and out to the point where the upper attachments presumably where the short gastric used to reside were taken via Harmonic scalpel. The single fire of a 45 mm stapler with vascular load was taken across the lower pole followed by two firings of the echelon stapler across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic artery was controlled with two stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse ooze in the area and the fact that the patient would be scheduled for a return visit to the operating room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the appropriate level. The patient was critical throughout the procedure and will be taken directly to the intensive care unit, intubated, with a plan for reexploration and removal of the packs tomorrow. The patient received four units of packed cells during the procedure, as well as albumin and a large volume of crystalloid. There were no intraoperative complications noted and the specimen sent included the spleen. Cultures from the abscess cavity were also taken. What diagnosis code(s) are reported?

B20, D73.3, K65.1, B19.20

CASE 7 S: The patient presents today for reevaluation and titration of carvedilol for his coronary artery disease and hyperlipidemia. His weight is up 7 pounds. He has quit smoking. He has no further cough and he states he is feeling well except for the weight gain. He states he doesn't feel he's eating more, but his wife says he's eating more. We've been attempting to titrate up his carvedilol to 25mg twice a day from initially 6.25mg. He has tolerated the titration quite well. He gets cephalgias on occasion. He states he has a weak spell but this is before he takes his morning medicine. I updated his medical list here today. I gave him samples of Lipitor. O: Weight is 217, pulse rate 68, respirations 16, and blood pressure 138/82. HEENT examination is unchanged. His heart is a regular rate. His lungs are clear. A: 1. CAD 2. Hyperlipidemia P: 1. The plan is samples of Lipitor using the two months' supply that I have given him. 2. We've increased his Coreg to 25mg bid. He'll recheck with us in six months. What diagnosis code(s) are reported?

I25.10, E78.5, Z87.891, Z79.899

Emergency Department Visit HPI: According to the patient's mother, the patient attempted suicide yesterday by taking 17-18- 500 mg of acetaminophen. She is experiencing situational problems including her parents are divorcing, she is fighting with her boyfriend and best best-friend moved away. She has attempted suicide previously by cutting her wrists. She currently has a fever, stomach pain, and diarrhea. Clinical impression: Suicide attempt. The patient is cleared medically for psychiatric referral. What ICD-10-CM code(s) is/are reported?

T39.1X2A, R50.2, K52.1, R10.9, Z91.5

CASE 6 Follow-up Visit: The patient has some memory problems. She is hard of hearing. She is legally blind. Her pharmacist and her family are very worried about her memory issues. She lives at home, family takes care of laying out her medications and helping with the chores, but she does take care of her own home to best of her ability. Exam: Pleasant 85-year-old woman in no acute distress. She has postop changes of her eyes. TMs are dull. Pharynx is clear. Neck is supple without adenopathy. Lungs are clear. Good air movement. Heart is regular. She had a slight murmur. Abdomen is soft. Moderately obese. Non-tender. Extremities; no clubbing or edema. Foot exam shows some bunion deformity but otherwise healthy. Light touch is preserved. There is no ankle edema or stasis change. Examination of the upper arms reveal good range of motion. There is significant pain in her shoulder with rotational movements. It is localized mostly over the deltoid. There is no other deformity. There is a very slight left shoulder discomfort and slight right hip discomfort. Impression: 1. Dementia 2. Right shoulder pain. 3. Benign hypertensive cardiovascular disease, a complication of diabetes. 4. Type 2 diabetes good control. Most recent AlC done today 5.9%. Liver test normal. Cholesterol 199, LDL a little high at 115. Plans: 1. I offered her and her family neuropsychological evaluation to evaluate for dementia. Her system complex is consistent with dementia, whether it be from cerebral small vessel disease or Alzheimer's is unknown. At this point, they would much rather initiate treatment than go through an exhaustive neuropsychological test. 2. For the shoulder we decided on right deltoid bursa steroid injection. She has had injection for bursitis in the past and prefers to go this route. She will ice and rest the shoulder after injection. 3. Follow up in 3 months. Procedure: Injection right deltoid bursa. The point of maximal tenderness was identified, skin was prepped with alcohol. A 25-gauge, 1 ½-inch needle was advanced to the posterolateral edge of the acromion and into the subacromial space and then aspirated. 1 cc of 0.25% Marcaine mixed with 80 mg Depo Medrol was deposited. Needle was withdrawn. Band-aid was applied. Post injection she had marked improvement; increased range of motion consistent with good placement of the medication. She was started on Cerefolin, plus NAC and Aricept starter pack was given with email away script. Follow-up in 3 months and we will reassess her dementia at that time. What diagnosis code(s) are reported?

F03.90, M25.511, I11.9, E11.59

CASE 2 CHIEF COMPLAINT: The patient is a 42-year-old female with infected right axillary hidradenitis. (The diagnosis to report, and location of the hidradenitis.) PROCEDURE NOTE: With the patient in supine position and under general anesthesia, the right axilla was prepped and draped in the usual sterile fashion. A skin incision was made in the axilla to excise most of the hidradenitis tracts. The incision was carried down through the subcutaneous tissue. The underlying subcutaneous tissue was excised. (The excision went to the subcutaneous tissue.) Bleeding points were controlled by means of electrocautery. The subcutaneous tissues were closed in intermediate layers (The repair was intermediate.) with a suture of 2-0 Vicryl. The skin edges were stapled together, and a dry sterile dressing was applied. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported?

11450-RT, L73.2

CASE 6 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlarging suspicious lesion on the right side of his forehead. DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on the table, and was given no sedation. The area of his right forehead was draped and prepped with Betadine paint in normal sterile fashion. The area to be excised was on the right side of the patient's mid forehead. This lesion had a maximum diameter of 1.1 cm with a 0.3 cm margin designed for total resection of 1.7 cm . The area for excision was infiltrated with 1% lidocaine with epinephrine. Careful dissection of the lesion was carried down through the dermis into the subcutaneous tissues. After waiting for hemostasis, it was excised, tagged, and sent for permanent pathology. The wound was irrigated; several bleeders were cauterized. The defect was closed in multiple layers with 3-0 Vicryl, a running subcuticular stitch of 4-0 Vicryl and a few 5-0 chromics. The total length of this closure was 3 cm. This was covered with Steri-Strips, adaptic gauze, and tape. Patient tolerated this procedure with no complication and was sent home in stable condition. FINAL DIAGNOSIS: Skin, right forehead, wide local excision, keratoacanthoma, possible squamous cell carcinoma, margins are free of tumor. What are the CPT® and ICD-10-CM codes reported?

12052, 11442-51, L85.8

CASE 7 PREOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest. POSTOPERATIVE DIAGNOSES: Large Dysplastic nevus, right chest. PROCEDURES PERFORMED: Excision, dysplastic nevus, right chest with diameter of 1.2 cm and 0.5 cm margins on each side, and complex repair of 4.0 cm wound. ANESTHESIA: Local using 20 cc of 1% lidocaine with epinephrine. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Less than 2 cc. SPECIMENS: Dysplastic nevus, right chest with suture at superior tip, 12 o'clock for permanent pathology. INDICATIONS FOR SURGERY: The patient is a 49-year-old white woman with a dysplastic nevus of her right chest, which I marked for elliptical excision in the relaxed skin tension lines of her chest with gross normal margins of around 0.5 cm. I drew my best guess at the resultant scar, and she observed these markings well and we proceeded. DESCRIPTION OF PROCEDURE: We started with the patient supine. The area has been infiltrated with local anesthetic. The chest prepped and draped in sterile fashion. I excised the dysplastic nevus as drawn into the subcutaneous fat. Hemostasis was achieved using the Bovie cautery. To optimize the primary repair extensive undermining was done to pull wound edges together and retention sutures were used to keep it closed. This constituted a very a complex repair technique due to skin tension. The wound was closed in layers using 4-0 Monocryl and 5-0 Prolene. A loupe magnification was used. The patient tolerated the procedure well. ADDENDUM: Pathology report confirms it is benign. What are the CPT® and ICD-10-CM codes reported?

13101, 11403-51, D23.5

PREOPERATIVE DIAGNOSIS: Necrotizing fasciitis. POSTOPERATIVE DIAGNOSIS: Necrotizing fasciitis. PROCEDURE: Planned return to the OR to assess wound closure options. Wound excision and homograft placement with surgical preparation, exploration of distal extremity. FINDINGS AND INDICATIONS: This very unfortunate gentleman with liver failure, renal failure, pulmonary failure, and overwhelming sepsis was found to have necrotizing fasciitis last week. At that time, we excised the necrotizing wound. The wound appears to have stabilized; however, the patient continues to be very sick. On return to the operating room, he appears to have no evidence of significant healing of any areas with extensively exposed tibia, fibula, Achilles tendon, and other tendons in the foot as well as the tibial plateau and fibular head without any hope of reconstruction of the lower extremity or coverage thereof. There is an area on the lateral thigh that we may be able to be closed with a skin graft for a viable above-the-knee amputation. PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed in supine position on the operating table. The above findings were noted. Sharp debridement with the curved Mayo scissors and the scalpel were helpful in demonstrating the findings noted above. Because of the unviability of this area, it was felt that we would not perform a homografting to this area; however, the lateral thigh appeared to be viable and this was excised further with curved Mayo scissors. Hemostasis was achieved without significant difficulty. The homograft was meshed 1.5:1 and then placed over the hemostatic wound on the lateral thigh. This was secured in place with skin staples. Upon completion of the homografting, photos were taken to demonstrate the rather desperate nature of this wound and the fact that it would require above the knee amputation for closure. The wound was dressed with a moist dressing with incorporated catheters. The patient was taken back to the ICU in satisfactory condition What are the CPT® and ICD-10-CM codes reported?

15002-58, 15271-58-51, M72.6

CASE 10 PREOPERATIVE DIAGNOSES: 1. Basal cell carcinoma, right temple. 2. Squamous cell carcinoma, left hand. POSTOPERATIVE DIAGNOSES: Same PROCEDURES PERFORMED: 1. Excision of basal cell carcinoma right temple, with excised diameter of 2.2 cm and full thickness skin graft 4 cm2. 2. Excision squamous cell carcinoma, left hand, with rhomboid flap repair 2.5 cm2. ANESTHESIA: Local using 8 cc of 1% lidocaine with epinephrine to the right temple and 3 cc of 1% plain lidocaine to the left hand. INDICATIONS FOR SURGERY: The patient is a 77-year-old white woman with a biopsy-proven basal cell carcinoma of right temple that appeared to be recurrent and a biopsy-proven squamous cell carcinoma of her left hand. I marked the lesion of her temple for elliptical excision in the relaxed skin tension lines of her face with gross normal margins of around 2-3 mm. I also marked my planned rhomboidal excision of the squamous cell carcinoma of her left hand with gross normal margins of around 3 mm, and I drew my planned rhomboid flap. She observed all these markings with a mirror so she could understand the surgery and agree on the locations, and we proceeded. DESCRIPTION OF PROCEDURE: All areas were infiltrated with local anesthetic (the anesthetic with epinephrine). The face and left upper extremity were prepped and draped in normal sterile fashion. I excised the lesion of her right temple and left hand as drawn to the subcutaneous fat. Hemostasis was achieved with Bovie cautery. It took a few more passes to get the margins clear from the basal cell carcinoma on the right temple. The wound had become very large by that time, around quarter sized, and I attempted to close the wound. I began with a 3-0 Monocryl. It was simply too tight and was deforming her eyelid. I felt that we would have to close with a skin graft. I marked the area of her right clavicle for the donor site, and I prepped and draped this area in a sterile fashion. I infiltrated with a plain lidocaine. I harvested and defatted the full-thickness skin graft using scissors. I achieved meticulous hemostasis in the donor site using the Bovie cautery. The skin graft was inset into the temple wound using 5-0 plain gut suture. The skin graft was vented, and a xeroform bolster was placed using xeroform and nylon. The donor site was closed in layers using 4-0 Monocryl and 5-0 Prolene. I then turned my attention to the hand. The margins had been cleared from that region, even though it did take two passes. I incised the rhomboid flap and elevated it with a full-thickness subcutaneous fat. Hemostasis was achieved in the wound and donor site using Bovie cautery. The flap rotated into the defect. The donor site was closed with flap inset in layers using 4-0 Monocryl and 5-0 Prolene. Loupe magnification was used. The patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes reported?

15240, 14040-51, 11643-59, C44.319, C44.629

CASE 8 PREOPERATIVE DIAGNOSIS: Panniculus, Diastasis recti POSTOPERATIVE DIAGNOSIS: Panniculus, diastasis recti PROCEDURE PERFORMED: Abdominoplasty ANESTHESIA: General CLINICAL NOTE: The patient has had multiple pregnancies, with diastasis recti occurring with the last pregnancy. She has had long term problems with low back pain and constipation as a result of the diastasis recti to the point where child care and every day activities are limited. Since having her last child she has also developed a pannus causing significant chaffing and irritation, which at times results in bleeding and infection. She is here today for the above procedure. She understood the potential risks and complications including the risks of anesthesia, bleeding, infection, wound healing problems, unfavorable scaring, and potential need for secondary surgery. She wanted to proceed. She also understood the possibility of impaired circulation to the flaps and hematoma/seroma formation. PROCEDURE IN DETAIL: The patient was placed on the operating table in supine position. General anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion and marked for abdominoplasty along the suprapubic natural skin crease. This coursed 36 cm in total. The umbilicus was also marked, and the area was infiltrated with 100 cc of 0.5% Xylocaine with 1:200,000 epinephrine. After adrenaline effect, the incision was made. The flap was elevated to the umbilicus. The umbilicus was circumscribed and dissected free, with care taken to maintain a generous vascular stalk. Dissection was then taken to the subcostal margin as it tapered superiorly and narrowed the exposure. Hemostasis was obtained by electrocautery. There was still a lot of skin laxity, and it appeared that an ellipse of skin could be removed through the superior margin of the umbilicus. The flap was incised at the midline for greater exposure. She had significant diastasis recti, which was closed with interrupted mattress sutures of 0 Ethibond, followed by a running suture of 0 Ethibond. She was placed in semi-flexed position and the ellipse of skin was excised to the superior margin of the umbilicus in the midline. This gave an easy fit for the flap without undue tension. The #No. 15 drains were placed through the mons area and secured with 3-0 Prolene. The skin was then closed at Scarpa fascia with sutures of 2-0 PDS. The umbilicus site was marked and a disc of skin was removed. The umbilicus was delivered and sutured with dermal sutures of 4-0 PDS, and the skin with 5-0 fast absorbing plain gut. Deep dermal repair was completed with reabsorbable staples, and the skin was closed with a subcuticular suture of 4-0 PDS. Steri-Strips were applied over Mastisol. An abdominal binder was placed. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. Estimated blood loss was less than 30 cc. What are the CPT® and ICD-10-CM codes reported?

15830, 15847, E65,M62.08

CASE 4 PREOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. POSTOPERATIVE DIAGNOSIS: Segmental obesity of posterior thighs. (Postoperative diagnosis to be used for coding) OPERATIVE PROCEDURE: Posterior thigh suction-assisted lipectomy of posterior medial thigh, bilateral. (procedure performed) CLINICAL NOTE: This obese patient presents for the above procedure. She understood the potential risks and complications including the risk of anesthesia, bleeding, infection, wound healing problems, unfavorable scarring, and potential need for secondary surgery. She understood and desired to proceed. PROCEDURE: The patient was placed on the operating table in supine position. General anesthesia was induced.(General anesthesia.) Once she was asleep, she was turned and positioned prone. The buttocks and thigh regions were prepped and draped in the usual sterile fashion. She had been marked in the awake, standing position, outlining the incision area, along the gluteal crease that was in continuity with her medial thigh lift scar and extended to the posterior axillary line. The right posterior medial thigh(Location) region was infiltrated with tumescent solution utilizing 750 ml. The liposuction (Liposuction performed.) was then accomplished, removing a total of 200 ml. Then an incision was made along the gluteal crease at the desired site for the final incision. A posterior skin flap was elevated approximately 3 to 4 cm. Hemostasis was assured by electrocautery. There was no residual flap or dead space and the fascia was closed at the deep level with 0 PDS, and then in anatomical layers the closure was completed with 2-0, 3-0, and 4-0 PDS. Dermabond and Steri-Strips were then applied. The medial third was also closed with a running 4-0 plain gut. The same was then accomplished on the left side in similar fashion and steps, achieving a symmetric result, and closure was accomplished similarly (same procedure performed on both left and right sides requiring the use of modifier). A compression garment was applied. The patient was awakened, extubated, and transferred to the recovery room in satisfactory condition. There were no operative or anesthetic complications. What are the CPT® and ICD-10-CM codes reported?

15879-50, E66.8

CH7- CASE 1 PREOPERATIVE DIAGNOSIS: Basal cell carcinoma (postoperative and preoperative diagnosis) POSTOPERATIVE DIAGNOSIS: Same OPERATION Mohs micrographic surgery (Mohs surgery is performed) Indications: The patient has a biopsy proven basal cell carcinoma on the nasal tip (Location) measuring 8 x 7 mm.(Size) Due to its location, Mohs surgery is indicated. Mohs surgical procedure was explained including other therapeutic options, and the inherent risks of bleeding, scar formation, reaction to local anesthesia, cosmetic deformity, recurrence, infection, and nerve damage. Informed consent was obtained and the patient underwent fresh tissue Mohs surgery as follows. STAGE I: (Mohs surgery is performed in stages, this report indicates only one stage) The site of the skin cancer was identified concurrently by both the patient and doctor and marked with a surgical pen; the margins of the excision were delineated with the marking pen. The patient was placed supine on the operating table. The wound was defined and infiltrated with 1% lidocaine with epinephrine 1:100,000 (Local anesthesia was used). The area of the tumor and margins were marked for excision. Additional soft tissue markings were created to keep the specimen oriented with the excision site.(Noting the tumor has been removed, which supports stage 1.) Hemostasis was obtained by electrocautery. A pressure dressing was placed. The tissue was divided into two tissue blocks (The tissue is divided into two tissue blocks.) which were mapped, color coded at their margins, and sent to the technician for frozen sectioning. The surgeon examined the tissue and no microscopic tumor was found persisting in the tumor margins on the tissue blocks. Following surgery, the defect measured 10 x 13 mm to the subcutaneous tissue.(Size and depth of the defect.) Closure will be done by the Dr. Hill from Plastics with a Burow's graft.(A Burow's graft is not reported because it was performed by a different provider.) CONDITION AT TERMINATION OF THERAPY: Carcinoma removed. Pathology report on file. What CPT® and ICD-10-CM codes are reported?

17311, C44.311

CASE 3 PREOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant. POSTOPERATIVE DIAGNOSIS: Right breast mass, lower outer quadrant.(Postoperative diagnosis is used for coding.) PROCEDURE: Right breast lumpectomy.(Procedure to be performed.) ANESTHESIA: A 1% lidocaine with epinephrine mixed 1:1 with 0.5% Marcaine along with IV sedation. INDICATIONS: The patient is a 23-year-old female who recently noted a right breast mass (lower outer quadrant). This has grown somewhat in size and we decided it should be excised. FINDINGS AT THE TIME OF OPERATION: This appeared to be a fibroadenoma.("Appeared to be" would not be considered a definitive diagnosis.) OPERATIVE PROCEDURE: The patient was first identified in the holding area and the surgical site was reconfirmed and marked. Informed consent was obtained. She was then brought back to the operating room where she was placed on the operating room table in supine position. Both arms were placed comfortably out at approximately 85 degrees. All pressure points were well padded. A time-out was performed. The right breast(The procedure was performed on the right breast.) was prepped and draped in the usual fashion. I anesthetized the area in question with the mixture noted above. This mass was at the areolar border at approximately the outer central to lower outer quadrant.(Specific location of the breast mass.) I made a circumareolar incision on the outer aspect of the areola. This was carried down through skin, subcutaneous tissue, and a small amount of breast tissue.(Depth of incision.) I was able to easily dissect down to the mass itself. Once I was there, I placed a figure-of-eight 2-0 silk suture for traction. I carefully dissected this mass out from the surrounding tissue along with a margin of healthy breast tissue. Once it was removed from the field, the traction suture was removed, and the mass was sent in formalin to pathology. The wound was then inspected for hemostasis, which was achieved with electrocautery. I then re-approximated the deep breast tissue with interrupted 3-0 vicryl suture and another 3-0 vicryl suture in the superficial breast tissue. The skin was then closed in a layered fashion(Layered closure for intermediate repair.) using interrupted 4-0 Monocryl deep dermal sutures followed by a running 4-0 Monocryl subcuticular suture. Benzoin, Steri-Strips and dry sterile pressure were applied. The patient tolerated the procedure well and was taken back to the short stay area in good condition. What are the CPT® and ICD-10-CM codes reported?

19301-RT, N63.13

CASE 5 PREOPERATIVE DIAGNOSIS: Hypoplasia of the breast. POSTOPERATIVE DIAGNOSIS: Hypoplasia of the breast.(Postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Bilateral augmentation mammoplasty.(Breast augmentation performed bilaterally.) ANESTHESIA: General.(General anesthesia.) OPERATIVE SUMMARY: The patient was brought to the operating room awake and placed in a supine position, where general anesthesia was induced without any complications. The patient's chest was prepped and draped in the usual sterile fashion. The patient had previous inframammary crease incisions on both the left and right sides. The extent of the dissection would be to the sternal border within two fingerbreadths of the clavicle and slightly beyond the anterior axillary line. The left breast(Left breast.) was operated upon first. An incision was made in the inframammary crease going through skin, subcutaneous tissue, down to the muscle fascia. Dissection at the subglandular level was then performed until an adequate pocket was made according to the previous limits. After irrigation with normal saline and careful hemostasis, a Mentor and Allergan silicone filled, high profile, textured implant was used and placed into the pocket.(Prosthetic implant used on the left breast filled to 300cc.) It was 300 cc. The skin was closed using 4-0 vicryl in an interrupted fashion for the deep subcutaneous tissue 4-0 Monocryl in an interrupted fashion was used for the superficial subcutancous tissue and the skin was closed using 4-0 Monocryl in a subcuticular fashion. Antibiotic ointment and Tegaderm were applied. The right breast(Right breast.) was operated on in a very similar fashion. The implant was a 340 cc silicone gel, high profile, textured implant from Allergan.(Prosthetic implant used on the right breast filled to 340cc.) Skin closure was the same. Both left and right breasts were very similar in size and shape. The patient had a bra applied. The patient tolerated this procedure well and left the operating room in stable condition. What are the CPT® and ICD-10-CM codes reported?

19325-50, N64.82

CASE 9 Procedure performed in office. PREOPERATIVE DIAGNOSIS: Right-sided thoracic pain. POSTOPERATIVE DIAGNOSIS: Right-sided thoracic pain. OPERATION: Trigger point injection into the right-sided thoracic spine musculature, into the rhomboid major, rhomboid minor, and levator scapular muscles. PROCEDURE: The patient was seated on the bed. He has metastatic right lung cancer. The risks of the procedure, including bleeding, infection, nerve damage, and no guarantee of symptom relief were explained. The patient agreed to the procedure and the informed consent was signed. I palpated for areas of maximal tenderness. Five points were marked over the right-sided thoracic paraspinal musculature. I then cleaned off his back with chlorhexidine x2. Then I used a 25 gauge 1.5-inch needle on a 10 cc controlled syringe with 40 mg/ml Depo-Medrol. After negative aspiration, 1 cc was injected into each point. A total of four points were injected. A total of 4 cc (160mg) was used. The patient tolerated the procedure well. Band-Aids were not placed. The patient was not bleeding. We are refilling the patient's pain medication. He is seeing an oncologist and gets Percocet 7.5/500. He takes four a day, providing him with pain relief. We will dispense to him today a three-week supply. We are going to dispense #84. He is to return to the office in two weeks, at that time we will get a urine specimen for follow-up. Emphasized to the patient, once again, that he had to bring his pills to every appointment according to the opioid contract. What are the CPT® and ICD-10-CM codes reported?

20553 J1030x4 M54.6 C78.01

CASE 4 PREOPERATIVE DIAGNOSIS: Painful hardware, left foot. POSTOPERATIVE DIAGNOSIS: Painful hardware, left foot.(The postoperative diagnosis is used for coding.) PROCEDURE PERFORMED: Removal of hardware, left foot.(This is the working procedure until the report is read.) ANESTHESIA: Sedation and local DRAIN: None. ESTIMATED BLOOD LOSS: Minimal. INDICATIONS FOR PROCEDURE: The patient had his status post metatarsal fracture, treated with internal fiixation. Patient has suffered pain due to hardware for the past six months.(The diagnosis is confirmed in the body of the report.) Patient's pain has been unresponsive to conservative treatment. We discussed the above-mentioned surgery, along with the potential risks and complications, and the patient understood and wished to proceed. DESCRIPTION OF PROCEDURE: With the patient supine on the operating table after the successful induction of anesthesia, the left foot was prepped and draped in the usual sterile fashion. In the area of the screw heads, 0.5% Marcaine was injected, both on the lateral side of the foot and the dorsal midfoot, administering about 5 ml in each area. Small 0.5 cm incisions through the skin were made and blunt dissection was carried down to the screw heads. The screws were removed with the screwdrivers.(The removal of hardware is described.) The incisions were irrigated and closed with simple 4-0 nylon sutures. A sterile compression dressing was applied. The patient was taken to the recovery room in satisfactory condition. MATERIAL SENT TO LABORATORY: None. COMPLICATIONS: None. CONDITION ON DISCHARGE: Satisfactory. DISCHARGE DIAGNOSIS: Painful hardware, left foot. DISCHARGE PLAN: Discharge instructions were discussed with the patient. A copy of the instructions was given to the patient and a copy retained for the medical record. The following items were discussed: diet, activity, wound care medications if applicable, when to call the physician, and follow-up care. What are the CPT® and ICD-10-CM codes reported?

20680-LT T84.84XA G89.18

CASE 6 PREOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. POSTOPERATIVE DIAGNOSIS: Comminuted intraarticular distal radial Colles' fracture, left wrist. PROCEDURE: Application of a uniplane fixation and closed reduction of left distal radial fracture under fluoroscopy. ANESTHESIA: General endotracheal. DESCRIPTION OF THE PROCEDURE: After induction of adequate general anesthesia, the patient's left upper extremity was routinely prepped and draped into a sterile field. The extremity was elevated and exsanguinated with an Esmarch bandage. The tourniquet was inflated to 300 ml of mercury. We placed two half pins distally over the dorsoradial aspect of the second metacarpal. The first was placed in freehand technique making an incision, spreading with a hemostat, and then placing the half pin. The second pin was placed identically by using the pin guide. Similarly, we placed pins in the dorsoradial aspect of the distal third of the radius. We connected these two pins with clamps, and then under C-arm control, we reduced the fracture. All pins are now attached to the external fixation. This fracture at both the dorsal and volar comminution and intraarticular fractures was significantly shortened and telescoped. We obtained the best reduction possible, and tightened down the clamps to the bars. The pin tracks were dressed with Xeroform and 2 x 2 gauze, and volar 3 x 15 plaster splints were applied. The tourniquet was allowed to deflate during application of the dressing. Total tourniquet time was 14 minutes. There were no intraoperative complications. What are the CPT® and ICD-10-CM codes reported?

20690-LT 25605-51-LT S52.532A

CH8- CASE 1 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain once again. The repeat MRI two weeks later showed that she had fresh high intensity signal changes in the body of L2 and some scalloping of the superior end plate, consistent with a compression fracture at L2.(The diagnosis is confirmed in the body of the report.) After some preoperative discussions and patience to see if she would get better, she was admitted to the hospital for L2 kyphoplasty when she did not improve. At surgery, L2 had some scalloping of the superior end plate. Most of the softness was in the back part of the vertebral body. PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia(The type of anesthesia utilized is documented within the report. General anesthesia was used.) in a supine position. She was then placed prone on the Jackson table and her back was prepped and draped in the usual sterile fashion. Using biplane image intensifiers, the skin incision sites were marked. 0.5% Marcaine with epinephrine was injected. Initially on the left side. A Kyphon trocar was passed down to the superior lateral edge of the pedicle, through the pedicle, and into the vertebral body in the usual fashion.(This describes the approach to the defect. It is percutaneous using trocars.) The drill was placed into the vertebral body followed by the Kyphon bone tamp. In a similar fashion, the same thing was done on the other side. Balloons were inflated uneventfully. The balloons were then deflated and removed, and the cement (when it was in the doughy state) was injected into the two sides in the usual fashion.(This describes how the area is enlarged and the cement is placed in a kyphoplasty procedure.) This was done carefully and sequentially to make sure there were no cement extrusions, which, after inspection, there were none. There was a good fill to the vertebral body edges, up towards the superior end plate, and across the midline. The bone filling devices were removed, and the trocars were removed, Pressure was applied after which the skin was sutured with 4-0 nylon. Sand-Aids were applied and she was taken to recovery in stable condition. COMPLICATIONS: There were no complications. BLOOD LOSS: Minimal blood loss. COUNTS: Sponge and needle counts were correct. What are the CPT® and ICD-10-CM codes reported?

22514 M48.56XA

CASE 2 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.) INDICATIONS: The patient is a 66-year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where she was prepped and draped in the usual sterile fashion in beach chair position after administering general anesthesia. Standard deltopectoral approach was used.(The approach is documented within the body of the operative report.) The cephalic vein was taken laterally with the deltoid. Dissection was carried out down to the fracture site and the fracture was identified. The fragments were mobilized and the humeral head fragments were removed. Once this was done, the stem was prepared up to a size 10.(This further explains the comminuted fracture.) A trial reduction was carried out with the DePuy trial stem and implant head.(Placement of the prosthesis is described.) This gave good range of motion with good stability. Sutures down to and through the shaft were placed in key positions for closure of the tuberosities. The shaft was prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and then reduced. A bone graft was placed around the area where the tuberosities were being brought down.(Bone grafts are common in prosthetic placement. A matrix is provided where new bone can grow and further stabilize the prosthesis. These are not reported separately.) The tuberosities were tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with vicryl over a drain and staples in the epidermis. A sterile dressing and sling were applied. The patient was taken to recovery in stable condition. There were no immediate complications. What are the CPT® and ICD-10-CM codes reported?

23616-LT S42.202A

CASE 7 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Dislocation of right elbow. POSTOPERATIVE DIAGNOSIS: Dislocation of right elbow with medial epicondyle fracture. OPERATIVE PROCEDURE: Closed reduction of elbow dislocation with a closed reduction of medial epicondyle fracture. ANESTHESIA: General. INDICATIONS: This is a 12-year-old male who had an injury, sustaining a dislocation of his right elbow and medial epicondyle fracture. The risks and benefits of surgical treatment were discussed with the family, who stated they understood and wanted to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining informed consent, the patient was taken to the main operating room where general anesthesia was induced. Once he was under adequate anesthesia, the reduction maneuver was performed. The elbow was reduced and was stable. Through full range of motion there was noted to be a slight crepitus on the medial elbow and some mobility was felt in the medial epicondyle. Examination under C-arm imagery revealed a concentric reduction of the elbow, but with mildly unstable medial epicondyle fracture. When the elbow was held in the appropriate position, the medial epicondyle was well reduced in an acceptable position. It was elected to treat this non-surgically. A long arm splint was applied. The patient was awakened from anesthesia and taken to recovery in stable condition with no immediate complications. What are the CPT® and ICD-10-CM codes reported?

24565-RT 24605-51-RT S42.441A S53.104A

CASE 8 PREOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. POSTOPERATIVE DIAGNOSIS: Right long finger, trigger finger. Left subacromial bursitis. PROCEDURES: Right long finger trigger release. Injection of the left shoulder with Xylocaine, Marcaine and Celestone via anterior subacromial approach. ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: Minimal. REPLACEMENT: Crystalloids. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where he was given general anesthesia. The right upper extremity was prepped and draped in the usual sterile fashion. While draping, the left shoulder was prepped with Betadine; and through an anterior subacromial approach, the left shoulder was injected with 1 cc of Xylocaine, 1 cc of Celestone, and 1 cc of Marcaine. The patient tolerated the procedure well. Meanwhile, the right hand had been prepped and draped. It was exsanguinated with an Esmarch bandage, and the tourniquet inflated to 250 mm. I made an incision over the A1 pulley in the distal transverse palmar crease, about an inch in length. This was taken through skin and subcutaneous tissue. The Al pulley was identified and released in its entirety. Care was taken to avoid injury to the neurovascular bundle. The wound was irrigated with antibiotic saline solution. The subcutaneous tissue was injected with Marcaine without epinephrine. The skin was closed with 4-0 Ethilon suture. A clean dressing was applied. The patient was awakened and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

26055-F7 20610-51-LT M65.331 M75.52

CASE 10 PREOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. POSTOPERATIVE DIAGNOSIS: Left Achilles' tendon rupture. OPERATION PERFORMED: Open Left Achilles' tendon repair. ANESTHESIA: General anesthesia INDICATIONS: The patient is a 25-year-old male who was playing basketball when he was hit by another player and felt a pop in the back of his ankle approximately two months ago. Examination reveals a positive Thompson test, but no plantar flexion on squeezing the calf. There is a palpable defect in the Achilles' tendon. There is swelling in this region and neurovascular examination is intact. Given these clinical findings, the patient is taken to the operating room for the aforementioned procedure. DESCRIPTION OF PROCEDURE: Following induction of general anesthesia the patient was placed prone on the operating table and all bony prominences were well-padded. The patient received a 1g dose of Ancef. Under tourniquet control of 250 mmHg, a longitudinal incision was made followed by opening up the paratenon of the Achilles' tendon. An obvious rupture was noted. The hematoma was evacuated and the ends were then debrided with a Metzenbaum scissors. A No. 2 FiberWire® was placed in a Bunnell-type fashion in both the proximal and distal portions of the Achilles' tendon. A No. 2 Orthocord was then used and placed in a running fashion along the proximal and distal portions of the Achilles' tendon. A total of four sutures were used. These were then tied together to re-approximate the tendon with no significant tension on the repair. A secure repair was noted. The ends of the repair were further augmented with a 2-0 Vicryl suture. The wound was thoroughly irrigated with antibiotic irrigation solution. The fascial plane was closed with a 2-0 Vicryl suture, followed by closing the skin with a 2-0 in subcuticular fashion. Approximately 10 cc of 0.5% Marcaine was injected for postoperative pain control. A routine dressing was applied to the extremity, and it was placed into a short leg cast with the foot slightly plantar-flexed. The anterior aspect of the cast was then univalved. The tourniquet was deflated for a total tourniquet time of 42 minutes. The patient was awakened in the operating room breathing spontaneously and taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

27650-LT S86.012A W50.0XXA Y93.67 Y99.8

CASE 5 PREOPERATIVE DIAGNOSIS: Right ankle triplane fracture POSTOPERATIVE DIAGNOSIS: Right ankle triplane fracture(The postoperative diagnosis is used for coding.) PROCEDURE: Open reduction and internal fixation (ORIF), right ankle triplane fracture(This is the working procedure until the report is read.) ANESTHESIA: General endotracheal(The type of anesthesia utilized is provided. General anesthesia was used.) COMPLICATIONS: None SPECIMEN: None IMPLANT USED: Synthes 4.0 mm cannulated screws INDICATIONS FOR PROCEDURE: The patient is a pleasant 15-year-old male who fell and sustained a right ankle triplane fracture. This was confirmed on both X-ray and CT scan. The indications for ORIF were explained to the patient, as well as the possible risks and complications, which include infection, bleeding, stiffness, hardware pain, the need for hardware removal, and there is no guarantee of a functional ambulatory result. The patient and family understood and wished to proceed. PROCEDURE IN DETAIL: The patient was brought back to the operating room and placed on an operating table, given a general anesthetic without any complications, and given preoperative antibiotics per usual routine. He had the right lower extremity prepped and draped in the usual sterile fashion with alcohol prep followed by routine Betadine prep. Under X-ray guidance(Radiologic guidance was used.), a pointed reduction clamp was placed from the anterolateral corner of the distal tibia(Documentation within the body of the report further specifies the fracture and treatment were of the distal tibia.) to the medial side, and I reduced the triplane fracture.(The fracture was reduced.) It was confirmed on both AP and lateral X-ray images the gap was reduced. The patient then had guidewires taken from the Synthes 4.0 mm cannulated screw set. One was placed medially along the epiphysis on the anterior half of the epiphysis and parallel to the joint to catch the lateral aspect of the epiphysis. One screw was placed above the physis from anterior to posterior to capture that spike. Once the wires were in the appropriate position, the length was measured and partially threaded 4.0 mm cancellous screws were selected so all threads were across the fracture site.(Internal fixation was accomplished with screws.) The appropriate length screws were placed, confirmed by an X-ray to be in good position. The fracture was anatomically reduced, and the ankle joint was anatomic. The patient had wounds copiously irrigated. Closure was done with interrupted horizontal mattress 3-0 nylon suture. The patient had a sterile compressive dressing applied, was placed into a three-sided posterior mold splint, was extubated, and brought to the recovery room in stable condition. There were no complications. There were no specimens. Sponge and needle counts were equal at the end of the case. What are the CPT® and ICD-10-CM codes reported?

27827-RT S82.391A W19.XXXA

CASE 3 OPERATIVE REPORT Preoperative Diagnosis: Plantar fasciitis, left Postoperative Diagnosis: Same as preoperative diagnosis.(The postoperative diagnosis is used for coding.) Procedures: Plantar fasciotomy, left heel.(This is the working procedure until the report is read.) For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient. An appropriate consent form was signed, indicating the patient understands the procedure and its possible complications. This 61-year-old male was brought to the operating room and placed on the surgical table in a supine position. Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion. Attention was directed to the left heel where, utilizing a 61 blade, a stab incision was made, taking care to identify and retract all vital structures. The incision was deepened to the medial band insertion of the fascia. The fascia was then incised and avulsed from the calcaneus.(The description of the fasciotom is found within the body of the report.) The surgical site was flushed with saline. Next, 1 cc of Depo-Medrol was injected in the operative site. The site was dressed with a light compressive dressing. Excellent capillary refill to all of the digits was observed without excessive bleeding noted. Hemostasis: none Estimated Blood Loss: minimal Injectables: Agent used for local anesthesia was 5.0 cc Marcaine 0.5% with epinephrine. Pathology: No specimen sent. Dressings: Applied Bacitracin ointment. Site was dressed with a light compressive dressing. Condition: Patient tolerated the procedure and anesthesia well. Vital signs were stable. Vascular status was intact to all digits. Patient recovered in the operating room. What are the CPT® and ICD-10-CM codes reported?

28008-LT M72.2

CASE 10 Preoperative diagnosis:1. Chronic hyperplastic rhinosinusitis2. Allergies3. Status post-prior polypectomy and sinus surgeryPostoperative diagnosis: 1. Intranasal and sinus polyps 2. Chronic hyperplastic rhinosinusitisOperative procedure:Left sinusotomy (three or more sinuses) including:• Nasal and sinus endoscopy• Endoscopic intranasal polypectomy• Endoscopic total sinus ethmoidectomy• Endoscopic sphenoidotomy• Endoscopic nasal antral windows, middle meatus, and inferior meatus• Endoscopic removal of left maxillary sinus contents Right sinusotomy (three or more sinuses) including:• Nasal and sinus endoscopy• Endoscopic intranasal polypectomy• Endoscopic total sinus ethmoidectomy• Endoscopic sphenoidotomy• Endoscopic nasal antral windows, middle meatus, and inferior meatus• Endoscopic removal of right maxillary sinus contentsSpecimens sent to pathology:1. Left ethmoid and sphenoid contents for routine and fungal cultures2. Right maxillary contents for routine and fungal cultures3. Left intranasal ethmoid, sphenoid, and maxillary specimens for pathology 4. Right ethmoid, sphenoid, maxillary, and right intranasal contents for pathologyFindings: Complete nasal obstruction by polyps obscuring of all of the normal landmarks. The right middle turbinate was found and preserved. The residual body of the left middle turbinate was found and preserved. There was thickened hyperplastic mucosa throughout the sinuses with some polyps in the sinuses, and the majority of the sinus cavities were filled with glue-like mucopurulent debris. At the end of the case there were no visible polyps, the airway was clear, and the debris had been removed.Procedure: The patient was taken to the operating room, placed in the supine position, and general endotracheal anesthesia was obtained adequately. A pharyngeal pack was placed. The nose was infiltrated with Xylocaine with epinephrine, and cottonoids soaked in 4% cocaine were placed. The procedure was performed in a similar manner bilaterally. The cottonoids were removed.The 30-degree, wide-angle sinus telescope with Endo-scrub and the Stryker Hummer device were used to remove the polyps starting anteriorly and working posteriorly. This led to visualization of the middle turbinates.The middle meati disease was removed. The area of the uncinate process and infundibulum was shaved away and forceps were used to remove portions of bone particle. Using blunt dissection, the agger nasi cells, ethmoid and sphenoid sinuses were entered and the contents removed with forceps and suction. The inferior turbinates were infractured; a mosquito clamp was placed through the lateral nasal wall into the maxillary sinuses through the inferior meatus. That opening was opened with forward and backward biting forceps, sinus endoscopy was performed, and inspissated mucus and debris cleaned out of the sinuses.In a similar manner the sinuses were opened from the middle meatus and the sinuses cleaned. Like before, the ethmoid, sphenoid, and maxillary sinuses were cleaned of debris, and inspissated mucus was suctioned from the frontal recesses.The patient was then suctioned free of secretions, with adequate hemostasis noted. Gelfilm was soaked, rolled, and placed in the middle meati. Telfa gauze was infused with Bacitracin, folded and placed in the nose. Vaseline gauze was placed between the folds of Telfa. The pharyngeal pack was removed. He was suctioned free of secretions, with adequate hemostasis noted, and the procedure terminated. He tolerated it well and left the operating room in satisfactory condition. What are the CPT® and ICD-10-CM codes to report?

31259-50 31267-50-51 J33.0 J33.8 J32.9

CASE 2 PREOPERATIVE DIAGNOSIS: Left vocal cord tumor. PREOPERATIVE DIAGNOSIS: Left vocal cord tumor.(Report this diagnosis if no further positive findings are found in the operative note.) NAME OF PROCEDURE - Direct laryngoscopy with microscope, removal of tumor.(Indication of type of laryngoscopy being performed.) ANESTHESIA: General. COMPLICATIONS: None. SPECIMENS: Left vocal cord tumor to pathology.(Tumor was sent to pathology.) BLOODLOSS: Less than 10 ml. TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. The bed was turned 90 degrees clockwise. The alveolar guard was placed over the upper alveolus to protect the teeth. Appropriate drapes were placed. The anterior laryngoscope was inserted and direct laryngoscopy(Placement of the direct laryngoscope.) was performed with no abnormal findings other than the above-described tumor. The scope was suspended, and using the operating microscope(Operating microscope is used.) the anterior vocal cord tumor was removed. The mucous membrane posterior to the tumor was carefully incised and Reinke's space was entered. Careful dissection allowed mucous membrane elevation off of the anterior vocal cord up to the commissure, with what appeared to be complete excision of the tumor.(Removal of the tumor.) Minimal bleeding was noted. The area was sprayed with Cetacaine spray. The scope was gently removed. The teeth were evaluated and found to be free of injury. The drapes and instruments were removed. The patient was returned to anesthesia for care, allowed to awaken, extubated, and transported in stable condition to the recovery room. The patient tolerated the procedure well. FINDINGS: Patient is a pleasant 77-year-old white female with a history of the above-noted diagnoses. Operative findings included an otherwise normal larynx with the exception of the left anterior vocal cord tumor.(This is confirmation to report a tumor on the vocal cord.) It was fairly soft. What CPT® and ICD-10-CM codes should be used for this procedure?

31541 D49.1

CH 9- CASE 1 Preoperative diagnosis: Malignant neoplasm glottis Postoperative diagnosis: Malignant neoplasm glottis(Diagnosis to report for the procedure.) Procedure: An incision is made low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage. A tracheostomy(This is the performed procedure.) tube is inserted and secured with sutures. The patient tolerated the procedure well and was sent to recovery without complications. What are the CPT® and ICD-10-CM codes reported?

31600 C32.0

CASE 8 Preoperative Diagnosis: Carcinoma, right lung and bronchus intermedius. Procedure Performed: Bronchoscopy. DESCRIPTION OF PROCEDURE: Two liters of oxygen were supplied nasally. The right nostril was anesthetized with two applications of 4% lidocaine and two applications of lidocaine jelly. The posterior pharynx was anesthetized with two applications of Cetacaine spray. The Olympus PF fiberoptic bronchoscope was introduced into the patient's right nostril. The posterior pharynx, epiglottis, and vocal cords were normal. The trachea and main carina were normal. The entire tracheobronchial tree was then visually examined and the major airways. No abnormalities were noted on the left side. There was, however, extrinsic compression of the posterior segment of the right upper lobe. There also appeared to be a submucosal tumor involving the bronchus intermedius between the right upper lobe and right middle lobe. Multiple washings, brushings, and biopsies were taken from the right upper lobe bronchus and bronchus intermedius. The specimens were sent for cytology and routine pathology. The patient tolerated this without complications. The CPT® and ICD-10-CM codes to report are:

31625 31623-51 C34.81

CASE 3 Preoperative Diagnosis 1. Loculated left pleural effusion, chronic Postoperative Diagnosis 1. Loculated left pleural effusion(Report this diagnosis for this procedure.), chronic Procedure Performed: Attempted, ultrasound guided thoracentesis Description of Procedure: The patient was prepped and draped in the sitting position. Using ultrasound guidance(Imaging guidance is performed.) and 1% lidocaine, the thoracic catheter was introduced into the pleural space where we encountered very thick fibrous type pleura.(The placement of the catheter in the pleural cavity to perform the thoracentesis.) The catheter was advanced, and we were unable to aspirate fluid. The catheter was removed. Sterile dressings were applied. Chest x-ray will be obtained for follow-up. Patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes for this procedure?

32555-LT J90

CASE 7 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Procedure Performed: Video-assisted thoracoscopy, lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia were administered, per the anesthesia department. A double-lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the right side up. The chest was prepped in the standard fashion with ChloraPrep, sterile towels, sheets, and drapes. A small incision is made between two ribs and a standard port placement was utilized to gain access to the tho-racic cavity. The endoscope is inserted into the chest cavity. We had excellent isolation of the lung; however, we had poor exposure because there were a number of fibrous adhesions, a few were actually very dense. We immediately evacuated approximately 700 ml of fluid; however, once we entered the chest we encountered a number of loculated areas. We did not break down the adhesions. We gained enough exposure to do a complete talc pleurodesis. After lysing of adhesions, we were confident that we had access to the entire thoracic cavity. Eight grams of talc were introduced into the right thoracic cavity and strategically placed under direct vision. The chest tubes were then placed. The wounds were closed in layers. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

32650-RT J90 C34.91

CASE 4 Preoperative Diagnosis: 1. Mass, right upper lobe. Postoperative Diagnosis: 1. Carcinoma, right upper lobe.(Report this diagnosis if no further positive findings are found in the operative report.) Procedure Performed: VATS, right superior lobectomy. Description of Procedure: Under general anesthesia, after a double-lumen tube intubation, the right lung was collapsed and the right side up is oriented so the patient is in the left lateral decubitus position. We prepped and draped the patient in the usual manner and gave antibiotics. Then two 1 cm incisions were made along the posterior and mid axillary line at the ninth and seventh intercostal spaces. The lung was deflated and a camera was inserted.(VATS.) A longer (6 cm) incision was made along the fourth intercostal space anteriorly. We then freed up some adhesions at the top of the lung, both in the superior area away from the tumor and in the anterior mediastinal area. The tumor seemed to be in the right upper lobe.(Tumor is in the right lung.) The dissection began by ligating the superior pulmonary vein and its branches, and the upper lobe was freed up. The small fissure was incomplete, and I proceeded with the lobectomy. The pulmonary artery branches were then ligated. The bronchus was ligated, as well. The superior branches to the upper lobe were ligated with Endo GIA. The lobe was freed up and sent to pathology. The wound was then closed in layers. A chest tube was placed to suction, and the patient was sent to recovery in stable condition. Pathology confirmed carcinoma.(Indication to report the right lobe of the lung as cancerous.) What are the procedure and diagnosis codes for this procedure?

32663-RT C34.11

CASE 9 Preoperative Diagnosis: Pedestrian in a MVA involving a car, left pneumothorax. Postoperative Diagnosis: Pedestrian in a MVA involved a car, left pneumothorax. Procedure: Bronchoscopy, left VATS, wedge resection. Procedure: Patient was brought into the operating room and placed in supine position. IV sedation and general anesthesia was administered, per the anesthesia department. A single lumen endotrachial tube was placed for bronchoscopy, per anesthesia. Due to the nature of the trauma, we were interested in ruling out a bronchial tear. The bronchoscope was introduced in the mouth and passed into the throat without difficulty. There was no evidence of sanguineous drainage or bronchial trauma noted to the left mainstem. There were copious amounts of secretions noted and removed without difficulty. The right mainstem was also cannulated and found to be free of unexpected trauma. The bronchoscopy was terminated at that time. A double lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the left side up. The chest was prepped in standard fashion with Betadine, sterile towels, sheets, and drapes. A small incision is made along the upper boarder of the fourth rib just below the intercostal space and a standard port placement was utilized to gain access to the thoracic cavity. An endoscope was inserted into the chest cavity. Initially we had excellent exposure with good isolation of the lung. We identified a large bleb at the apex of the lower lobe of the left lung, which was likely to be the source of the chronic air leak. We removed the area of the large bleb at the apex with a wedge resection using thoracoscopic green load for therapeutic correction of the patient's pneumothorax. The wounds were closed in layers. Chest tubes were placed. The patient tolerated the procedure well and was taken to the recovery room. What are the CPT® and ICD-10-CM codes reported?

32666-LT 31622-51 S27.0XXA V03.90XA

CASE 6 Preoperative Diagnosis: 1. Grade 3 squamous cell carcinoma of penis with inguinal lymphatic metastasis Postoperative Diagnosis 1. Grade 3 squamous cell carcinoma of penis with inguinal lymphatic metastasis Procedure Performed: Laparoscopic bilateral pelvic lymphadenectomy Description of Procedure: The patient is placed in supine position with thigh abduction. A 1.5 cm incision was made 2 cm distally of the lower vertex of the femoral triangle. The second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions. The last trocar was placed 2 cm proximally and 6 cm laterally from the first port. Radical endoscopic bilateral pelvic lymphadenectomy was performed.The main landmarks-adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly, were well visualized. The retrograde dissection using a harmonic scalpel was started distally near the vertex of the femoral triangle towards the fossa ovalis, where the saphenous vein was identified, clipped, and divided, towards the femoral artery laterally. After the procedure, one can identify the skeletonized femoral vessels and the empty femoral channel, showing that the lymphatic tissue in this region was completely resected. The surgical specimen was removed through the first port incision. A suction drain was placed to prevent lymphocele, and were kept until the drainage reached 50 ml or less in 24 hours. Patient tolerated the procedure well and was transferred to recovery in stable condition. What CPT® and ICD-10-CM codes are reported?

38571 C77.4 C60.9

CASE 5 Preoperative Diagnoses 1. Sarcoid of lymph nodes(Diagnosis if no further positive findings are found in the operative note.) 2. New onset paratracheal adenopathy(Diagnosis if no further positive findings are found in the operative note.) Postoperative Diagnoses 1. Sarcoid of lymph nodes 2. New onset paratracheal adenopathy Procedure Performed: Mediastinotomy(Indication of what procedure is being performed.) Description of Procedure: The patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia was administered by the anesthesia department. The neck was prepped in standard fashion with betadine scrub, sterile towels and drapes. A standard linear incision was made over the trachea.(Procedure performed with the anterior cervical approach.) We were able to dissect down the pretracheal fascia into the mediastinum without difficulty. The extensive adenopathy was immediately apparent just below the innominate artery on the right paratracheal side. One exceedingly large lymph node was identified and biopsied extensively.(Biopsy performed.) The specimen was sent to pathology. Hemostasis was obtained without difficulty. The region was infused with a marcaine, lidocaine, and epinepherine mixture. The wound was closed in layers. The skin was closed with subcutaneous stitches and covered with Dermabond. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?

39000 D86.1 R59.0

CASE 9 Dear Dr. Smith, Mr. Martin was seen in the office for continued management of his breast cancer. He's having some increasing pain in his breast which is due to the cancer. He is also complaining of neck pain. It does not seem to be worse at night; it seems to be worse with activity. He has no other symptoms. Otherwise his review of systems is unremarkable. He's had no constitutional symptoms. On physical exam, he is alert and oriented. Eyes: EOMI, PERLA, no icterus. The heart had a regular rate and rhythm; S1, S2 within normal limits. The lungs are clear to auscultation and percussion. The abdomen was soft, without masses or organomegaly. He was tender to palpation over the left anterior iliac crest. Otherwise he had no point tenderness over his musculoskeletal system. Neck: Supple. No tenderness, no enlarged lymph nodes in the neck. ASSESSMENT: Adenocarcinoma of the left breast, positive estrogen receptor status. Neck pain. PLAN: The plan is to continue the Tamoxifen at this time. His laboratory studies were reviewed and were essentially unremarkable; however we'll obtain a bone scan to ascertain the extent of his disease. Sincerely, John Smith, M.D. What diagnosis code(s) are reported?

C50.922, G89.3, M54.2, Z17.0, Z79.810

CASE 3 SUBJECTIVE: Low-grade fever at home. She has had some lumps in the abdominal wall and when she injects her insulin; it does seem to hurt there. She stopped four of her medications including Neurontin, Depakote, Lasix, and Premarin, and overall she feels quite well. Unfortunately, she has put on 20 pounds since our last visit. OBJECTIVE: HEENT: Tympanic membranes are retracted but otherwise clear. The nose shows significant green rhinorrhea present. Throat is mildly inflamed with moderate postnasal drainage. Neck: No significant adenopathy. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft, obese, and nontender. Multiple lipomas are palpated. ASSESSMENT 1. Diabetes mellitus, type 1. 2. Diabetic neuropathy. 3. Acute sinusitis. (The definitive diagnoses are reported.) PLAN: At this time, I have recommended the addition of some Keflex for her acute sinusitis.(Provider treated the acute sinusitis.) I have given her a chair for the shower. They will not cover her Glucerna anymore so a note for that will be required.

E10.40, J01.90

HPI: The patient is 67-year-old male who presents with a 5-6 week history of progressive confusion. The majority of the history is obtained from the patient's wife as the patient is somewhat confused and has poor short-term memory. Per the patient's wife he has been having headaches intermittently in his bilateral temporal area over the past week. His left eye has appeared mildly drooped over the past 2-3 days and he has been somewhat unsteady on his feet through he has not fallen. The patient has approximate 7 pound unintentional weight loss over the past month. He denies any fevers, chills, shortness of breath, chest pain, palpitations or recent illnesses. The patient saw his primary care physician for these symptoms and underwent an MRI of the brain yesterday which showed a brain mass concerning for glioblastoma. The patient was admitted today for further workup of this. He denies headache presently, and per his wife, his headaches have been helped with Tylenol and Ibuprofen. There were no exacerbating factors to add to the patient's headaches. Assessment and Plan: 1. Brain mass, concerning for glioblastoma multiforme. We will admit the patient to non-telemetry bed to the pink team. Neurosurgery has been consulted. We will follow their recommendation. 2. Confusion and headaches. 3. Weight loss What ICD-10-CM code(s) is/are reported?

G93.89, R63.4

CASE 4 PREOPERATIVE DIAGNOSIS: Cataract, left eye POSTOPERATIVE DIAGNOSIS: Cataract left eye, Presbyopia(Report the postoperative diagnosis.) PROCEDURE: 1. Cataract extraction with IOL implant 2. Correction of presbyopia(Patient is also diagnosed with presbyopia.) with lens implantation PROCEDURE DETAIL: The patient was brought to the operating room under neuroleptic anesthesia monitoring. A topical anesthetic was placed within the operative eye and the patient was prepped and draped in usual manner for sterile ophthalmic surgery. A lid speculum was inserted into the right infrapalpebral space. A 6-0 silk suture was placed through the episclera at 12 o'clock. A subconjunctival injection of non-preserved lidocaine was given. A peritomy was fashioned from 11 o'clock to 1 o'clock with Westcott scissors. Hemostasis was achieved with the wet-field cautery. A 3-mm incision was made in the cornea and dissected anteriorly with a crescent blade The anterior chamber was entered at 12 o'clock and 2 o'clock with a Supersharp blade. Non-preserved lidocaine was instilled into the anterior chamber. Viscoelastic was instilled in the anterior chamber and using a bent 25-guage needle, a 360-degree anterior capsulotomy was performed using Utrata forceps. The capsulotomy was measured and found to be 5.5 mm in diameter. Using an irrigating cannula, the lens nucleus was hydrodissected and loosened. Using the phacoemulsification unit, the lens nucleus was divided and emulsified. The irrigating/aspirating tip was used to remove the cortical fragments from the capsular bag, and the posterior capsule was polished. Using a curette to polish the anterior capsule, cortical fragments were removed from the anterior lens capsule for 270 degrees. The irrigating/aspirating tip was used to remove the capsular fragments. The anterior chamber and capsule bag were inflated with viscoelastic and using a lens inserter, a Cystalens was then placed within the capsular bag and rotated to the horizontal position. The viscoelastic was removed with the irrigating/aspirating tip and the lens was found to be in excellent position with a slight posterior vault. The wound was hydrated with balanced salt solution and tested and found to be watertight at a pressure of 20 mmHg. Topical Vigamox was applied The conjunctiva was repositioned over the wound with a wet field cautery. The traction suture and lid speculum were removed. A patch was applied. The patient tolerated the procedure well and left the operating room in good condition. What diagnosis code(s) are reported?

H26.9, H52.4

CASE 2 PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss. POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the postoperative diagnosis.) PROCEDURES PERFORMED: 1. Placement of left Nucleus cochlear implant. 2. Facial nerve monitoring for an hour. 3. Microscope use. ANESTHESIA: General. INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis is documented as the indication for thesurgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were described to the patient, who voiced understanding and wished to proceed. PROCEDURE: After properly identifying the patient, she was taken to the main operating room, where general anesthetic was induced. The table was turned to 180 degrees and a standard left-sided post auricular shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested and found to work well. At this time, the previously outlined incision line was incised and flaps were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the area of the round window niche. The lip of the round window was drilled down exposing the round window membrane. At this time, the wound was copiously irrigated with bacitracin containing solution, and the device was then placed into the pocket. A 1-mm cochleostomy was made, and the device was inserted into the cochleostomy with an advance-off stylet technique. A small piece of temporalis muscle was packed around the cochleostomy, and the wound was closed in layers using 3-0 and 4-0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was returned to anesthesia, where she was awakened, extubated, and taken to the recovery room in stable condition. What diagnosis code(s) are reported?

H90.3

CASE 5 Subjective: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on. 0bjective: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. Assessment: Atrial fibrillation, currently stable Plan: 1. Prothrombin time to monitor long term use of anticoagulant. 2. Follow up with me in one month or sooner as needed if she has any other problems in the meantime. Will also check a creatinine and potassium today. What diagnosis code(s) are reported?

I48.91, Z79.01,Z51.81

CASE 1 PROGRESS NOTE This patient is a 50 year-old female who began developing bleeding, bright red blood per rectum(Patient's presenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid(This is reported by the patient, but not documented in the exam or assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is coming from. She is presently concerned because a close friend of hers was recently diagnosed with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is here today for evaluation for a colonoscopy. Physical examination, she appears to be a well appearing 50 year-old, white female. Abdomen is soft, non-tender, non-distended. ASSESSMENT: 50 year-old female with rectal bleeding(Report the code documented in the assessment.) PLAN: We'll schedule the patient for an outpatient colonoscopy. The patient was made aware of all the risks involved with the procedure and was willing to proceed. What diagnosis code(s) are reported?

K62.5

CASE 3 PROGRESS NOTE Chief complaint: Multiple ulcers. Subjective: The patient returns, accompanied by her caregiver who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better. Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin.(The ulcers are healing.) There is no cellulitis. The only uncomfortable area seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits which have distorted the bottom of her foot dramatically. To relieve the left foot pain,(Location of the foot pain. Patient had foot pain likely due to tophaceous deposits which are an indication of gout. This is not a definitive diagnosis documented by the provider. Code the symptom.) a sole nerve block posterior to the lateral malleolus is carried out with a 50:50 mixture of 1% lidocaine with epinephrine and .5% marcaine. Following this, she gets good relief from the pain of the lateral posterior part of the foot. The legs are cleansed with Hibiclens and multi-layer compression wraps are reapplied by the PA. Assessment: Ulcers are on the feet.(Location of the ulcers.) Edema is in the lower extremities. Foot pain is (Report the codes for the definitive diagnoses. Procedure performed for foot pain.) treated with a nerve block. Fantastic course to date, thanks to her caregiver Plan: Continue with wound care as before. Return to the office in six to eight weeks; at which time, assuming everything is going well, we could set up an OR time for panniculectomy. She appears to understand and is willing to proceed. What diagnosis code(s) are reported?

L97.511, L97.521, R60.0, M79.672

CASE 1 Office note: RE: Injection, strapping of foot and ankle. Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat. Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.) Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR, vibration and temp normal. Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed diet, orthotic shoes. Return if need be in 61 days. What diagnosis code(s) are reported?

M77.30

CASE 2 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions werediagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes. Cardiovascular: RRR, no MRGs, no edema. Respiratory: Lungs CTA, normal respiratory effort. GI: NABS, no HSM. Skin: Warm and dry, decreased turgor. Psychiatric: A&OX3 with appropriate affect. Labs: BUN = 99, creatinine = 3.6, HCO3 = 14, K = 5.9. IMPRESSION 1. New, acute renal failure, due to dehydration 2. Underlying stage 3 CKD 3. Mild hypotension (Code the definitive diagnoses documented by the provider.) PLAN 1. Bolus with another liter of NS wide open. 2. Then start D5W with 3 amps of HCO3 at 150 cc/hr. 3. Repeat labs in eight hours. 4. Further diagnostic testing will be ordered if there is no improvement of volume repletion. What diagnosis code(s) are reported?

N17.9, E86.0, N18.30, I95.9

CASE 6 PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus. POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus. CLINICAL HISTORY: The patient is a 2-month-old boy who was born and was IUGR. He did well for the first several weeks; however, he then developed a large head. Mom noticed full fontanelle arid in the last week or so, and they have noticed the eyes have decreased mobility. He tends to stare straight and has some trouble looking up and even to the sides bilaterally, so she reported it to her pediatrician. Pediatrician ordered a CT scan and referred the patient. I saw the patient yesterday in clinic. We ordered an MRI; MRI was done this morning. Initial read shows the congenital hydrocephalus; however, it is not a Dandy-Walker. We had a discussion with the family about risks, benefits, potential complications and also different procedures. We talked about a third ventriculostomy however, given the patient's age and the fact was hydrocephalus, he has elected to go with the shunt, Family is comfortable with this and will bringing him to the OR today for shunting. What diagnosis code(s) are reported?

Q03.9

CASE 7 HPI: 20-year-old female, estimated gestational age 25.3 weeks, who presents with red staining after wiping with toilet paper this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present. ROS: Constitutional: Negative. Headache: Negative. Urinary: Negative. Nausea: Negative. Vomiting: Negative. Past Medical/Family/Social History: Medical History: Negative. Surgical History: Negative. Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies. EXAM: General Appearance: No acute distress. Abdominal: Soft. Non-tender. Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink. No hyphae, BV, or TRICH, and CX not irritated. Cervix: Deferred. Uterus: Fundal height: 24 cm. MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU. Labs reviewed and WNL. Ultrasound: Negative for placenta previa. NOTES: Patient continues with contractions mildly, but does not feel it. Patient given Celestone I/M. D/C and to return tomorrow for repeat Celestone injection. Diagnosis: Threatened premature labor What diagnosis code(s) are reported?

Q47.02, Z3A.25

CASE 4 Subjective: The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches. The patient complains of cephalgia,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes or any smell changes. The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. Assessment: 1. Cephalgia 2. Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan: The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We'll recheck her in one month. What diagnosis code(s) are reported?

R51.9, M99.02, W20.8XXA

CASE 9 PREOPERATIVE DIAGNOSIS: 1. 2 cm transverse laceration of right forehead. 2. 3 cm stellate laceration of right upper eyelid. 3. 3 cm trap door laceration of right lower eyelid. OPERATIVE DIAGNOSIS: OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm. Anesthesia: Local. PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she was thoroughly evaluated by Dr. Tim and is in the process of getting C-spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is linear, deep, but otherwise uneventful. The upper right eyelid laceration is approximately 3 cm in length and the medial aspect of it is somewhat dusky because it is very thin and devoid of vasculature. The lower eyelid laceration is trap door and somewhat deep. It also becomes very thin at the medial aspect; however, there appears to be no duskiness. It seems to be well vascularized. In any event, we chose to immediately repair these with local anesthesia. DETAILS OF OPERATIVE PROCEDURE: Approximately a total of 6 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the three wounds. They were then thoroughly cleansed with soap, and closure was begun on the upper eyelid. We used 6-0 vicryl subcutaneous sutures to attack the flap back into position, and once this was accomplished, we used individual 6-0 Prolene sutures on the skin to complete the closure. Attention was then turned to the right lower eyelid laceration where essentially an identical procedure was done. The wounds were somewhat similar in that they were flaps pedicled to the lateral towards the medial. Again, we used 6-0 vicryl subcutaneous and 6-0 Prolene individual skin sutures. Finally, attention was turned to the forehead laceration which was similarly closed with these same sutures, 6-0 vicryl subcutaneous and 6-0 Prolene on the skin. The wounds were then dressed with Bacitracin ophthalmic. Patient was instructed to keep them moist at all times and to not let crust form. She was also instructed in the appropriate analgesics to be taken orally and given my office number for a follow-up appointment. At the end of the procedure, she was then sent back to x-ray for CT scan of her C-spine. What diagnosis code(s) are reported?

S01.111A, S01.81XA, V00.811A

CASE 5 CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.) MODE OF ARRIVAL: Private vehicle. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain. REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough. All other systems have been reviewed and are negative except as noted. PHYSICAL EXAMINATION: General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance. Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air. HEENT: The head is normocephalic and atraumatic. Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles. Heart: Regular rate and rhythm without murmurs Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand symmetrically. Thorax/Chest Wall: Demonstrates mild tenderness anteriorly and demonstrates distinct tenderness posteriorly along the medial aspect of the scapula. No bruising or ecchymosis is noted on the skin of the chest wall. Patient keeps his right shoulder lowered. There is no deformity noted. There is no tenderness over the right clavicle. No bony deformity is noted there. There is no subcutaneous emphysema of the chest wall. Extremities: Warm and dry without clubbing, cyanosis or edema. Grip strength is 5/5 bilaterally. Patient can flex and extend all fingers without difficulty. He can pronate and supinate at the elbow. He complains of pain in the shoulder when he flexes and extends at the elbow. Normal radial and ulnar pulses are appreciated in the bilateral upper extremities. Capillary refill is brisk. Sensation is normal in all nerve distributions in the bilateral arms. Abdomen: Soft, non-distended. Non-tender. Diagnostics: Two views of the chest, PA and lateral, and three views of the right shoulder were obtained. ED course: The patient received a total of 2 mg of Dilaudid for pain, 1 mg of sublingual Ativan. His arm was placed in a sling This was well tolerated and the patient was discharged home. Medical Decision Making: It appears the patient has an anterior chest wall and a posterior chest wall contusion. The exact reasoning why he has so much difficulty moving the shoulder is unclear at this time, as he is completely neurologically intact from what I can tell. He can adduct and abduct at the shoulder, as I have seen him do it as he was moving around to be examined. X-rays demonstrate no evidence of fracture or dislocation. At this point, I am discharging the patient home, having him use ice packs, doing prescriptions for pain medications and having him return for new or worsening symptoms. IMPRESSION: 1 Anterior and posterior chest wall contusion. 2 Right shoulder injury. (Report codes for the definitive diagnosis.) PLAN: Discharge home. Return for new or worsening symptoms. Sling for comfort. What diagnosis code(s) are reported?

S20.211A, S20.221A, S49.91XA, W23.0XXA, Y92.512

CASE 10 PREOPERATIVE DIAGNOSIS: Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation. POSTOPERATIVE DIAGNOSIS: Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation. ANESTHESIA: Axillary block with general anesthesia. OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes. DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively. A dorsal/posterior approach to the fracture was performed with a standard recommended incision, location and technique. The interval between the extensor carpi radialis brevis and extensor digitorum communis was developed. The extensor pollicis brevis and the abductor pollicis were gently retracted one way or the other to expose the fracture site, and the fracture was just beneath this area. The radial sensory nerve was identified and protected throughout the procedure. The fracture was exposed with minimal soft tissue stripping. The bone holding forceps were placed on either side of the fracture, the overriding fracture was manipulated with gentle traction, and the fracture reduced. This effectively reduced the distal radioulnar joint. A small fragment, Synthes DCP locking plate was utilized to fix the fracture. Eight holes were utilized. Due to the nature of the fracture and the anatomy, there were three screws distal, four screws proximal, and the last hole was at the area of the fracture. Initially to achieve satisfactory bone to plate contact, three lag screws were required and these were placed initially. This was followed by placement of the remaining screws that were utilized proximal and distal to the fracture site to be locking screws. Intraoperative X-rays utilizing the C-arm were performed throughout the procedure to guide fracture reduction and hardware replacement. Final X-rays demonstrated excellent alignment of the fracture in the distal radioulnar joint. Excellent coaptation of the bony surfaces was obtained. Final irrigation of the wound was performed. The wound was closed in layers in a standard fashion. Splints were applied. Total tourniquet time was approximately 60 minutes. The patient tolerated the procedure well and went to the recovery room in satisfactory condition. Sponge and needle count is correct x2. Estimated blood loss is minimal. What diagnosis code(s) are reported?

S52.351A

Emergency Department Visit HPI: The patient presents to the ED with right wrist pain |1|. Just prior to arrival, the patient fell |2| at home |3| and has had a constant moderate pain and swelling since the fall. Exacerbation factors consist of movement palpation. The patient's dominant hand is the right hand. The patient stepped on a lid on the floor, falling onto outstretched right hand |4|. She complains of right wrist pain. She is not anticoagulated, did not striker her head, and denies other complaint or injury. Radiology Results: Minimally displaced fracture involving the distal radial meta-epiphysis |5| extending to the lateral margin of the articular surface for nondisplaced ulnar styloid fracture |6|. Impression and Plan Closed fracture of the wrist _ _Note over view: |1| The right wrist is injured. |2| Injury is the result of a fall. |3| The injury occurred at home. |4| Injury details. |5| The patient has a displaced fracture of the distal radial meta-epiphysis. |6| The patient also has a nondisplaced ulnar styloid fracture. What ICD-10-CM code(s) is/are reported?

S52.591A, S52.614A, W18.31XA, Y92.009

CASE 8 This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed. Past Medical History: Two vaginal deliveries, one in 1965 and another in 1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband. Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact. Neck: Thyroid not palpable. No jugular distention. Carotid pulses are present bilaterally. Breasts: Manual breast exam reveals no masses, tenderness or nipple discharge. The breasts are asymmetrical with no nipple discharge. Abdomen: No masses or tenderness noted. No hernias appreciated. No enlargement of the liver or spleen. Pelvic: Vaginal examination reveals no lesions or masses. Discharge is noted and a sample was collected for testing and sent to an outside laboratory for testing. No bleeding noted. Examination of the external genitalia reveals normal pubic hair distribution. The vulva appears to be within normal limits. There are no lesions noted. A speculum is inserted. There is no evidence of prolapse. The cervix appears normal. A cervical smear is obtained and will be sent to pathology. The speculum is removed and a manual pelvic examination is performed. It appears that the uterus is smooth and no masses can be felt. Rectal examination is within normal limits. Screening occult blood is negative. Uterus is not enlarged. Urinary: Urethral meatus is normal. No masses noted for urethra or bladder. Assessment and Plan: Routine Pap and pelvic; vaginal discharge. Patient had Pap and pelvic examination one year ago. Patient was sent to our in-house lab for blood draw today, and she is to follow-up in one week for lab results. What diagnosis code(s) are reported?

Z01.411, N89.8