Urinary System-Case 2

All Seven I-Abstracting Questions:

1. Are the removal and insertion each reported separately in Case-2?

2. What category from the ICD-10 is referenced to assign the code for the removal of the stent in Case-2?

3. In Case-2 explain why the patient has the stent?

4. The problem with the stent in Case-2 is reported as a _____ using the External Cause code in the ICD-10.

5. Why did the patient in Case-2 initially require a stent?

6. What complication in Case-2 developed from the treatment?

7. What category from the ICD-10 is referenced to assign the code for the radiation in Case-2?

UMA STUDY GUIDE BC3030 Week 3 Please review the following topics in preparation for your week 3 coursework. Objectives for \"Next Step\" Chapter 10-11 (used in conjunction with the ICD-10-CM & CPT-4 code books) Objective 1 o Remember to use the main term in the index of the ICD-9-CM and the appropriate sub-terms for the best code options. Read the guidelines for specific information regarding additional coding and code sequencing. o There may be multiple diagnoses for each patient. Objective 2 o Read and be familiar with the guidelines preceding the specific code range in the CPT-4 code book. o Use the main term in the index of the CPT-4 code book and the appropriate subterm for specific code range. Objective 3 o UPP is urethral pressure profile (CPT Book) o Patient is surrounded by liquid for lithotripsy (CPT Book) o Brachytherapy is a treatment used for prostate cancer (CPT Book) o Pregnancy: Antepartum Care Complications Labor and Delivery Colpocentesis is done to drain abscess in peritoneal cul-de-sac Dysfunctional Uterine Bleeding (DUB) Types of deliveries Cesarean Section o Surgical endoscopies and laparoscopies include diagnostic scope procedures Other topics to study o Use your Language of Medicine text book for additional resource with vocabulary and anatomy found in the medical record o Read the entire chapter and do the practice exercises o Attend live learning labs to improve your coding skills as well as help with Greenway (found in the Student Took Kit on the MyUMA page in Blackboard) 1|P a g e o Attend any of the instructor labs for extra coding tips and help Chapter 8 IEHR Book Internal Communications o Internet (page 175) o Intranet (page 175) o Internal messaging (page 176) o Email priorities (page 176) Importing Documents to the EHR o Importing hard documents (page 177) o Scanners (page 178) o Optical character recognition (page 178) o Bar-coding (page 178) o Resolution (page 178) Master Files and Templates o Master files definition (page 179) o Templates definition (page 179) o Templates (page 179) o Default Values (page 180) Customization o Customization definition (page 180) Using Software to Organize Your Work- Tasks Lists o Task Lists definition (page 182) Using Software as a Reminder o Flags definition (page 183) o Use of flags (page 184) Complete the following scenarios to prepare for you Coding Application test. Steps for correct CPT coding 1. 2. 3. 4. 5. 6. 7. 8. 9. Determine the procedure, test, or service to be coded Identify all terms Locate each main term in the Alphabetic Index Review and select the subterms indented below the main term Note the code number(s) found opposite the selected main term or subterm Verify the code in the Tabular List Review coding notes and coding conventions Determine modifiers when applicable Repeat steps for additional code(s) Steps for correct ICD coding 2|P a g e 1. 2. 3. 4. 5. 6. 7. 8. Identify all terms in the diagnosis Locate each main term in the Alphabetic Index. Refer to any subterms indented under the main term. Follow cross-reference instructions if the needed code is not located under the first main entry consulted. Verify the code in the Tabular List. Read and be guided by any instructional terms in the Tabular List. Assign codes to the highest level of specificity. Code the diagnosis until all elements are completely identified. Maternity Care and Delivery- Case 1 OPERATIVE REPORT LOCATION: Inpatient, Hospital PATIENT: Mary Belle Wilson ATTENDING PHYSICIAN: Andy Martinez, MD SURGEON: Andy Martinez, MD PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean PROCEDURE: Repeat low transverse cervical segment cesarean section ANESTHESIA: Spinal COMPLICATIONS: None FINDINGS: Viable female infant weighing 8 pounds 14.5 ounces, with Apgar's of 9 at 1 minute and 10 at 5 minutes PROCEDURE: The patient was prepped and draped in the supine position with left lateral displacement of the uterine fundus under spinal anesthesia with a Foley catheter indwelling. A transverse incision was made in the lower abdomen, removing the old scar. The fascia was divided laterally. The rectus muscle was divided in the midline. The peritoneum was entered in the sharp manner. An incision was extended vertically. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The uterus was entered in a sharp manner in the lower uterine segment, and the incision was extended laterally with blunt traction. The amniotic fluid was clear. The infant's head was delivered. The infant was then delivered and bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive care nursery staff in apparent good condition. The placenta was manually expressed. The uterus was delivered from the abdominal cavity and placed on wet lap sponges. A dry sponge was used to ensure remaining products of conception were removed. The cervical os (opening) was ensured patent with a ring forceps. The uterine incision was closed with 0 Vicryl interlocking suture in two layers, with the second layer imbricating the first. A figure-of-eight suture was also placed, which was required for hemostasis. The operative site was irrigated. The bladder flap was reapproximated using 2-0 Vicryl continuous suture. The tubes and ovaries appeared normal bilaterally. The uterus was placed back within the 3|P a g e abdominal cavity. The pelvic gutters were irrigated. The anterior peritoneum was reapproximated using 2-0 Vicryl continuous suture. The incision was irrigated. The fascia was closed with 0 Vicryl continuous suture. The incision was irrigated. The skin was closed with staples. All sponges and needles were accounted for at the completion of the procedure. The patient left the operating room in apparent good condition, having tolerated the procedure well. The Foley catheter was patent and draining clear yellow urine at the completion of the procedure. A-Assign the CPT code for Case-1: _________ A-Assign the first-listed ICD-10-CM code for Case-1: _____________ A-Assign the additional ICD-10-CM code for Case-1: _____________ Urinary System-Case 2 Report an external cause code to indicate how the injury occurred. OPERATIVE REPORT LOCATION: Outpatient, Hospital PATIENT: Melissa Cathy Dugeon ATTENDING PHYSICIAN: Ira Avila, MD SURGEON: Ira Avila, MD PREOPERATIVE DIAGNOSIS: Right ureteral stricture. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Cystoscopy, right ureteral stent change. Bimanual examination. ANESTHESIA: IV sedation. CLINICAL NOTE: This lady has a right ureteral stricture secondary to prior treatment for uterine sarcoma. CT scan performed a few months ago showed some straining in the right hemipelvis, although examination at that time failed to demonstrate anything that would be consistent with recurrent tumor. She is scheduled for follow-up CT scan in this regard in 1 week. The patient tells me she has had some nocturia and urgency incontinence recently. There has been no dysuria or hematuria. PROCEDURE: The patient was placed in the lithotomy position after IV sedation. She was prepped and draped in the lithotomy position. The #21French cystoscope was passed into the bladder, and urine collected for culture. Inspection of the bladder demonstrated findings consistent with radiation cystitis, which was previously diagnosed. There is no frank neoplasia. The right ureteral stent was grasped and removed through the urethral meatus, and under fluoroscopic control the guidewire was advanced up the stent and the stent exchanged for a #7 French 26-cm stent in the usual fashion. The patient tolerated the procedure well. She will be discharged with ciprofloxacin. We will also start Detrol LA 4 mg nightly to see if this helps; a 4|P a g e renewal prescription for the next year has been given. Stent change will be arranged in 3 months. Patient was sent home on ciprofloxacin. A-Assign the CPT code for Case-2: ______________ A-Assign the Modifier for Case-2: ___________ A-ICD-10-CM Code: ___Z46.6___ (Admission for) I-Assign the 1st of 4 additional ICD-10-CM codes for Case-2: ___________ I-Assign the 2nd of 4 additional ICD-10-CM codes for Case-2: ___________ A-Assign the ICD-10-CM External Cause code for the complication in Case-2: ___________ A-Assign the ICD-10-CM History of code for Case-2: ___________ All Seven I-Abstracting Questions: 1. Are the removal and insertion each reported separately in Case-2? 2. What category from the ICD-10 is referenced to assign the code for the removal of the stent in Case-2? 3. In Case-2 explain why the patient has the stent? 4. The problem with the stent in Case-2 is reported as a _____ using the External Cause code in the ICD-10. 5. Why did the patient in Case-2 initially require a stent? 6. What complication in Case-2 developed from the treatment? 7. What category from the ICD-10 is referenced to assign the code for the radiation in Case-2? Male Genital System-Case 3 OPERATIVE REPORT LOCATION: Outpatient, Hospital PATIENT: Donald Styel SURGEON: Ira Avila, MD PREOPERATIVE DIAGNOSIS: Left hydrocele, left scrotal mass POSTOPERATIVE DIAGNOSIS: Left hydrocele 513 PROCEDURE PERFORMED: Resection of hydrocele sac, left testicular cord, left scrotum, and resection of left paratesticular mass. CLINICAL NOTE: This is a 78-year-old gentleman who has developed a hydrocele and has a left scrotal mass. We have discussed different options, and he has decided he would like this surgically taken care of. The patient has been marked earlier for surgery. OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the supine position. A midline scrotal incision was made and the testes delivered. Two hydroceles were identified, one of the testis and one of the cord. The hydrocele of the cord was resected. Hemostasis was achieved with electrocautery. The hydrocele sac of the scrotum was also opened and resected. Once opening this, there was a very dark 1.5-cm lesion separate from the epididymis and testis in the region of the testicular cord. This was mobilized, isolated, and resected intact. It did not appear to have a blood supply or be in association with any of the cord or testicular structures. This was sent separately for pathologic identification. Once hemostasis was achieved, the testis was returned to the scrotum. A 1/4-inch Penrose drain was left through a separate stab wound and sutured to the skin with 2-0 Prolene. The 5|P a g e scrotum was closed in two layers with a 3-0 chromic. Dressings applied. Scrotal support applied. The patient was transferred to the recovery room in good condition. Review the medical documentation from Case-3 to answer the following questions. Are the service code(s), modifier(s) and ICD-10-CM code(s) listed below correct for Case-3? I-Briefly explain why the code(s) or modifier(s) are correct or incorrect. What steps did you take to confirm the best code(s) and modifier(s) for Case-3? SERVICE CODE(S): 55040, 55500-51 ICD-10-CM DX CODE(S): N43.3, N43.3 6|P a g e