This assignment is for someone familiar with 3MEncoder and (ICD-10-CM).
Answer the questions in bold for both case studies. There are 13
questions in all.
LOCATION: Inpatient, Hospital
PATIENT: Simon Sulten
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSES 1. Colostomy for obstructing colon cancer. 2. Cholelithiasis.
POSTOPERATIVE DIAGNOSES: Same as Preoperative.
PROCEDURES PERFORMED 1. Takedown colostomy with end-to-end colorectostomy. 2. Open cholecystectomy.
PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. The previous midline was reopened with the #10 blade, and we excised the old scar. We carried our dissection through subcutaneous tissues using electrocautery. Midline fascia was divided sharply. We entered the peritoneal cavity and entered the midline fascia along the length of the incision. We took down numerous filmy adhesions and ran the small bowel from the terminal ileum to the ligament of Treitz, which appeared normal. First, we placed an Omni retractor and exposed the right upper quadrant. We identified the cystic duct and cystic artery and tied them off with 0 silk ties distally before transecting them. We then shelled the gallbladder from its fossa using electrocautery. We placed a pack up by the liver bed. We then identified the rectal stump and dissected this free. We then made an elliptical incision around the colostomy opening and carried our dissection down to fascia, freed up the stoma, and fired our TLC-75 stapler across the descending colon. We then sent the specimen to pathology. We mobilized the left colon along the avascular line of Toldt up and around the splenic flexure. Once we had adequate length we placed a Glassman clamp proximally on the rectum and distally on the descending colon. We then performed a two-layer, hand-sewn, end-to-end anastomosis with an outer layer of 3–0 silk Lembert and inner layer of running 3–0 Vicryl. There was a patent anastomosis, and we could easily milk contents through with no evidence of spilling. We then closed the fascia from the colostomy site with interrupted 0 Vicryl and running 0 PDS. We closed the skin with skin clips.
All sponge and needle counts were correct. The patient tolerated the procedure well and was taken to recovery in stable condition.
Abstracting & Coding Questions:
1. What was the approach?
2. What did the surgeon do with the existing colostomy?
3. What did the surgeon do with the intestinal opening left by removal of the colostomy?
4. What type of diagnosis code was reported for the resection of the colostomy?
5. What is a stoma?
6. What CPT code(s) would be reported for this case?
7. What ICD-10-CM code(s) would be reported for this case?
LOCATION: Outpatient, Hospital
PATIENT: Beth Mahoney
PRIMARY CARE PHYSICIAN: Ronald Green, MD
SURGEON: Mohomad Almaz, MD
PREOPERATIVE DIAGNOSES 1. Chondromalacia, left knee. 2. Torn left medial meniscus per MRI scan.
POSTOPERATIVE DIAGNOSIS: Chondromalacia, left knee.
PROCEDURES PERFORMED 1. Examination, left knee, under anesthesia. 2. Arthroscopy, left knee, with debridement of chondromalacia.
ANESTHESIA: General with endotracheal intubation.
FINDINGS: The patient was found to have significant chondromalacia in all three compartments. She had some bare bone on the femoral trochlear and significant fraying of the articular cartilage on the patella, as well as on the medial femoral condyle. The articular cartilage on the lateral femoral condyle was just frayed slightly, but no large flaps of articular cartilage were raised. She did, however, have some flaps of articular cartilage raised on the floor of the lateral compartment. I could not find any specific meniscal tears, but both medial and lateral menisci had fringe tags, which we removed. The anterior cruciate ligament was intact.
PROCEDURE: Under general anesthesia the patient’s left knee was examined. She had no effusion. The collateral ligaments were intact. Lachman test was negative, as was the pivot shift. McMurray test was negative. We then prepped the patient’s left leg with Betadine and draped it in a sterile fashion. An Esmarch bandage was used to exsanguinate the leg, and a tourniquet on the thigh was inflated to 300 mm Hg. The total tourniquet time was about 35 minutes.
Three portals were used for this procedure. The first was placed along the superior anterolateral aspect of the knee, the second was placed along the inferior anterolateral aspect, and the third along the inferior anteromedial aspect of the knee. We distended the knee with lactated Ringer’s solution. We examined the suprapatellar pouch and the medial and lateral gutters. We immediately noted significant chondromalacia involving the patellofemoral joint. There were large flaps of articular cartilage hanging off the articular surface of the patella and actually an area of bare bone on the trochlea, which was close to the lateral femoral condyle. We used the shaver to trim the articular cartilage, which was hanging from the subchondral bone. We trimmed the leading edge of the fat pad slightly as well.
I then examined the medial compartment and probed the medial meniscus. We could not identify a specific tear of the medial meniscus, although there were multiple fringe tags, which were removed with the shaver. She does have, however, significant chondromalacia involving the weight-bearing surface of the medial femoral condyle. There were flaps of articular cartilage that were loose and just laying on the subchondral surface. We used the shaver to trim these loose bits of articular cartilage. We then examined the notch area and probed the anterior cruciate ligament. It was intact. We then examined the lateral compartment and probed the lateral meniscus. The lateral meniscus was intact, although there were several fringe tags, which were removed. She did have some raised flaps of articular cartilage on the lateral tibial plateau, and these were trimmed with the shaver. The articular cartilage in the lateral femoral condyle appeared to be in relatively good condition with only minor fraying. At this point, we thoroughly irrigated the knee and looked for any remaining loose fragments. We then drained the knee and injected 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine. The hardware was removed and the skin incisions were closed using 4– 0 nylon suture. Sterile dressings were applied under a 6-inch Ace wrap. She was then awakened and taken from the operating room in good condition, breathing spontaneously.
FINAL SPONGE AND NEEDLE COUNT: Correct.
MEDICATIONS: She was given IV Kefzol preoperatively, and she will be continued on Keflex for 5 days postoperatively as well. She will also be started on some aspirin postoperatively.
Pathology Report Later Indicated: Chondromalacia.
Abstracting & Coding Questions:
1. Was this a diagnostic or surgical arthroscopy?
2. What is chondromalacia?
3. Debridement of the chondromalacia is also referred to as
4. Was the diagnosis for the meniscal tear reported?
5. What CPT code(s) would be reported for this case?
6. What ICD-10-CM code(s) would be reported for this case?