Removal of foreign body from third metatarsal joint left foot, open approach. Click here to enter text.
Code the following procedures. The first 15 are brief statements of documentation worth 1 point for each correct code. Each statement requires one code. The last 3 are case studies and are worth five points each. Partial credit for incorrect codes in the case studies may be given at the discretion of the instructor. There is a total of 30 points possible. Place your answers in this word document and submit to the drop box when complete.
1. Removal of foreign body from third metatarsal joint left foot, open approach. Click here to enter text.
2. Incision and drainage of abscess, ankle joint, right. Click here to enter text.
3. Percutaneous biopsy of right gastrocnemius muscle. Click here to enter text.
4. Open repair of ruptured right deltoid muscle. Click here to enter text.
5. Open reduction of a displaced right pisiform fracture. Click here to enter text.
6. Left reverse shoulder replacement, metal on polyethylene. Click here to enter text.
7. Left ureter surgically ligated to prevent further hemorrhage, open approach. Click here to enter text.
8. Extracorporeal shock wave lithotripsy (ESWL) of large bladder stone. Click here to enter text.
9. Retropubic total prostatectomy. Click here to enter text.
10. Laparoscopic bilateral tubal ligation using Falope ring. Click here to enter text.
11. Evacuation of subungual hematoma, fingernailClick here to enter text.
12. Incision of scar contracture of the skin of the left elbowClick here to enter text.
13. Laparoscopic vaginal hysterectomyClick here to enter text.
14. CircumcisionClick here to enter text.
15. Hysteroscopy Click here to enter text.
Case# 1
PREOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
POSTOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
Procedures:
1. Cystoscopy.
2. Urethral dilation and hydrodilation.
Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL.
The patient was brought to the cystoscopy suite and placed on the table in lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 21 Olympus cystoscope was inserted and the bladder, viewed with 12- and 70-degree lenses. Bladder was filled by gravity to capacity, emptied and again cystoscopy was performed with findings as above. Urethra was then calibrated with 32-French. The patient was taken to the recovery room in stable condition.
ICD-10-PCS Code:Click here to enter text
Case #2
PREOPERATIVE DIAGNOSIS:
1. Atrophic left testis.
2. Right spermatocele.
POSTOPERATIVE DIAGNOSIS:
1. Atrophic left testis.
2. Right spermatocele.
PROCEDURE PERFORMED:
1. Right scrotal exploration, and right spermatocelectomy.
2. Left scrotal exploration and left orchiectomy.
INDICATIONS: This 55-year-old gentleman was admitted to this Hospitalapproximately 4 months ago with bilateral testicular pain and swelling andenlargement. Ultrasound revealed a cystic mass of the right scrotum consistentwith right hydrocele. On the left side, the patient had severe leftepididymitis/orchitis that turned to an abscess with spontaneous drainage.Subsequent ultrasounds revealed essentially no vascular flow to the left testisand the testes gradually became smaller, but it was painful to the patient. Thepatient requested surgery because of pain in the left side and because ofenlargement of the right side, which he states interfered with his sexualactivity. The patient was advised that following that spermatocelectomy on theright side, the patient could have recurrence of thespermatocele/bleeding/infection and pain.
DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia, the patientwas prepped and draped in a supine position. An incision was made in the midlineof the scrotum vertically. The right testis was exposed and delivered from theincision. This was done within the sac of the spermatocele. Spermatocele wasidentified, being adherent to the right epididymis. There was significantadherence and numerous small blood vessels present and adherence of thespermatocele sac to both the testis and the epididymis. Dissection was donesharply. The sac was excised, sent to histology. Care was taken to preservethe blood supply to the right testis. The small bleeding points were cauterizedor suture ligated. Hemostasis was also directed towards the scrotal wall.Again, these were controlled by fulguration or suture ligature. The testis was placed back into its anatomic position on the right scrotal sac. A 5/8 Penrosenurse drain was left indwelling and brought out a separate stab incision.
Attention was then directed to the left scrotal cavity where it was incised,exposing the left testicle with much difficulty because of the abscess formationthe patient had. This required total sharp dissection, which we also incurredsome numerous bleeding points. These were controlled by cauterization.Finally, the spermatic cord was isolated. It was clamped and spermatic cord cut
and the testicle was then removed. The bleeding points were controlled withties of 2-0 Vicryl. Both scrotal cavities were irrigated thoroughly. As on theright side, a Penrose drain was left indwelling brought out separate stabincision, and then the wound was closed with interrupted sutures of 3-0 chromiccatgut. Sterile dressings were applied as well as a scrotal support and thepatient taken to recovery room in good condition
ICD-10-PCS Code:Click here to enter text.
Case #3
Operative Report
Preoperative Diagnosis: Vulvar dysplasia.
Postoperative Diagnosis: Vulvar dysplasia.
PROCEDURE: Partial vulvectomy and vulvar biopsies.
ANESTHESIA: General endotracheal anesthesia.
PROCEDURE: The patient was prepped and draped sterilely in the lithotomy position. The lesions were at the base of the labia majora bilaterally, extending onto the perineal body. An elliptical incision was made starting about halfway up on the labia minora on the left, bringing it around on the perineal body on the outside and around the hymenal ring on the inside, up to about halfway up the labia on the opposite side. The Bovie cautery was then used to undermine the subcutaneous tissues and the specimen was marked at 12 o’clock and frozen section biopsy submitted to pathology, proven to be dysplasia. I obtained frozen section biopsies from 2, 4 and 6 o’clock, and all were reported as negative for dysplasia.
The area was closed with a running, locking 2-0 Vicryl, starting in the midline and working up the right labia and then starting in the midline and working up the left labia. Gentamicin ointment was applied to the incision sites, and the patient was then awakened and sent to recovery in stable condition.
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