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?

• 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.

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• 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.

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• 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.

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• A lacerated diaphragm tear measuring 2.5 cm is repaired with sutures.

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• 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 The scope is withdrawn, and the incision is closed with sutures.

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• 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.

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• 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.

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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.

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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.

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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 Jackson-Pratt 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.

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• 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.

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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.

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