Unit 8 Live Seminar
Medical Coding II
•
Read Case 2, pp. 140–143 in Scott. Answer the following questions:
Obesity is a co-morbidity that will affect MS-DRG assignment. It is important
to also code the body mass index (BMI). Is the BMI noted in the
documentation, and, if so, what is this patient’s BMI? Per the Operative
note, “bleeders were controlled.” Is there any documentation that further
clarifies this? If so, where is the bleeding coming from? If not, what will the
coder do?
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A patient is found to have a cyst-like lesion per MRI of the mediastinum.
This is to be removed. An incision is made by the physician from the
shoulder blade to the spinal column of the thoracic area. Muscles are
retracted, and the rib cage is exposed. After gaining access to the thoracic
cavity, the physician identified the cyst and removed it. The specimen is
sent to pathology. The wound is closed in layers
.
• 39200
•
•
A 45-year-old male has an acute diaphragmatic hernia. After adequate
general anesthesia, an abdominal incision is made in the epigastric region.
A moderate amount of abdominal tissue is protruding through the hernia into
the diaphragm. These contents are moved back into proper placement.
The opening of the diaphragm is closed with sutures.
• 39540
•
Via transabdominal approach, the physician overlaps diaphragm tissue to
ensure that the diaphragm s in the correct position and the eventration or
partial protrusion is corrected.
• 39545
• A lacerated diaphragm tear measuring 2.5
cm is repaired with sutures.
• 39501
•
A patient is being seen to confirm the diagnosis of sarcoidosis. An
endoscopic examination of her mediastinum is done under general
anesthesia. After making an incision in the area of the sternum, the scope is
inserted. The trachea, bronchi, and lymph nodes are examined. A lymph
node biopsy is taken. The scope is withdrawn, and the incision is closed
with sutures.
• 39400
•
A patient had the signs and symptoms consistent with a perforated viscus.
After discussion, the patient consented to suture repair of the gastric ulcer.
The patient was placed in a supine position. After adequate anesthesia,
attention was turned to the anterior abdominal wall. A midline incision was
made. Gross contamination was visualized. This was suctioned out. The
gastric ulcer was visualized, and copious irrigation with 3 liters of warm
saline was performed. All gross evidence of contamination was gone.
Checking was done, hemostasis was throughout, and the skin incision was
closed.
• 43840
•
A patient presented with a lesion of the lip; due to the patient’s history of
smoking, it was determined to remove the lesion and send it to analysis to
rule out carcinoma. After adequate anesthesia, a wedge incision was done
of the lower lip to remove the lesion. The defect was closed with a small flap
and sutures.
• 40510
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A patient with the diagnosis of carcinoma of the stomach presented for a
hemigastrectomy. With the patient in the supine position and after adequate
level of general anesthesia, the abdomen was prepped and draped in usual
sterile fashion. An upper midline incision was made to access the abdominal
cavity. The abdominal ligament was retracted to the right side of the
incision. The stoma was mobilized. The duodenum was divided away from
the stomach. The tumor was identified. The stomach tumor was transected
with cautery, and a specimen was sent for evaluation by pathology. The
distal margin of the remaining stomach was cleaned. Staples were used to
close the curvature area of the stomach. The abdomen was closed with
running Prolene for the fascia. The skin was closed with staples.
• 43611
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An 18-year-old patient has a history of chronic tonsillitis. Under general
anesthesia, the physician separated the tonsils from the tonsil bed by blunt
and sharp dissection followed by the snare. No gross bleeding was found.
The adenoids were extracted by the adenotome followed by the sharp
curette. Again, no gross bleeding was found. The patient had minimal blood
loss
.
• 42821
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A 72-year-old male patient presented to the emergency department with a 14-hour
history of acute right inguinal pain and obstructive symptoms. Examination found a
tender nonreducible mass in the right groin. He consented to surgical intervention via
exploration and correction of possible hernia. After adequate anesthesia, the patient
had an oblique preperitoneal incision through the fascia. The peritoneal cavity was
entered. A strangulated loop was found along with the femoral hernia. The lower edge
of the inguinal ligament was grasped with clamps, and interrupted Prolenes were
used to close the femoral defect using Coopers ligament repair. The defect was
closed up to the edge of the external iliac vein. Once the repair was completed, the
wound was irrigated with saline. The bowel was inspected and appeared to be totally
revascularized, with no evidence of necrosis and no need for resection. The femoral
hernia sac was reduced and resected using electrocautery. The abdominal wall was
closed with interrupted polypropylene sutures for the anterior wall fascia. A JacksonPratt drain was brought out through a separate stab wound. The subcutaneous tissue
was closed with interrupted 3-0 Vicryl, and the skin was closed with staples.
• 49553
•
A patient with chronic cholelithiasis presented for a cholecystectomy. An
infraumbilical incision was made, and a trocar was inserted into the
abdominal cavity. After insufflation of the cavity, the laparoscope was
inserted through the trocar. Two additional incisions were made to place
trocars— one on the right side and one on the left. The gallbladder was
identified. It was noted to be slightly enlarged and grayish in color. Multiple
stones were palpable inside the gallbladder. Tissue surrounding the
gallbladder was dissected. The cystic duct and artery were clipped and then
cut. The gallbladder was dissected from the liver bed and removed through
the umbilical trocar site. Careful irrigation of the cavity was done. The
patient had minimal blood loss.
• 47562
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A 19-year-old patient presented to the hospital with a history of bloody
stools of three weeks duration. The patient was prepped for a
sigmoidoscopy. The sigmoidoscope was passed without difficulty to about
40 cm. The entire mucosal lining was erythematosus. There was no friability
of the overlying mucosa and no bleeding noted anywhere. No pseduopolyps
were noted. Biopsies were taken at about 30 cm; these were thought to be
representative of the mucosa in general. The scope was retracted; no other
abnormalities were seen.
• 45331