Aapc

CASE 1 ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal ...

CASE 1 PREOPERATIVE DIAGNOSIS: Right thyroid follicular lesion. POSTOPERATIVE DIAGNOSIS: Right thyroid follicular lesion.(Diagnosis to report if no further detail is found in the note.) OPERATIVE PROCEDURE: Right thyroid lobectomy.(Planned procedure. Review the operative report to verify this is the procedure performed.) FINDINGS: A large thyroid mass in the inferior aspect of the right thyroid.(The findings confirm the diagnosis.) The right recurrent laryngeal nerve was identified intact an...

CASE 1 DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week f...

CASE 1 Preoperative diagnosis: Transitional cell carcinoma in the bladder. Postoperative diagnosis: Transitional cell carcinoma in the bladder. (This is the diagnosis to report, since the pre and post-operative diagnoses are the same. The operative note is consistent with a tumor on the posterior bladder wall. Pathology is not back yet, but the stated diagnosis is transitional cell carcinoma in the bladder. In the US, 90% of all bladder cancers are transitional cell in origin. This is sometime...

CASE 1 Preoperative Diagnosis: History of rectal carcinoma. Postoperative Diagnosis: History of rectal carcinoma. Procedure Performed: Closure of loop ileostomy with small bowel resection and enteroenterostomy with intraoperative flexible sigmoidoscopy. Description of Procedure: After induction of adequate general endotracheal anesthesia,(General anesthesia.) the patient was carefully positioned in the supine modified lithotomy position in Allen stirrups.(Lying on back with legs in stirrups....

CASE 1 Preoperative diagnosis: Severe two-vessel coronary artery disease and moderate valve aortic stenosis.(There are two separate diagnoses, the coronary atherosclerosis and the aortic valve stenosis.) Postoperative diagnosis: Same. Operation: Triple-vessel coronary artery bypass grafting:(Three vessels were grafted: two veins and an artery. The note goes on to describe the performed procedures.) Left internal mammary artery to the left anterior descending coronary artery, reverse saphenous...

Using the information in the CPB Chapter 10_Case , answer questions 1 and 2. Based on the remittance advice and the payment policy provided, what action is required for this claim? A. The claim was paid correctly. Minor surgeries are not paid when performed with an E/M. B. The claim was paid correctly. The diagnosis does not support both an E/M code and a procedure. C. The claim did not pay correctly. The E/M service should be paid at 100% and the surgical procedure should be discounted. D....

CASE 1 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer.(Report this diagnosis if no further findings are found in the notes.) Procedure Performed: Video-assisted thoracoscopy,(Indication the procedure is being performed by Video Assisted Thoracic Surgery (VATS).) lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position....

CASE 1 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introd...

CASE 1 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. (Indications for surgery.) POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. (An excision with intermediate closure was performed.) INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rapidly enlargin...