The document contains multiple surgical case studies detailing various operations performed on patients with different medical conditions. Key procedures include subtotal parathyroidectomy for tertiary hyperparathyroidism, endoscopic ultrasound with fine-needle aspiration for pancreatic head mass, cardiac catheterization and biopsy post-cardiac transplantation, and tracheostomy for respiratory failure. Additional cases include cochlear implant surgery and spinal cord stimulator implantation for chronic pain management, each with preoperative and postoperative diagnoses and anesthesia details recorded.

1. M132 Module 05 Coding Assignment
1. Case Study #1
PREOPERATIVE DIAGNOSIS: Tertiary hyperparathyroidism.
POSTOPERATIVE DIAGNOSIS: Tertiary
hyperparathyroidism.
OPERATION PERFORMED: Subtotal parathyroidectomy.
ANESTHESIA: General. Fifteen mL of 0.5% Marcaine with
epinephrine for local anesthesia.
DESCRIPTION OF OPERATION: The patient was intubated
with the nerve monitor endotracheal tube. A shoulder roll was
placed and the neck was prepped and draped in the usual
manner. A transverse cervical incision was made, and local
anesthesia was infiltrated prior to the incision and as we
finished the closure. The initial incision was deep and beyond
platysma. Crossing anterior jugular vein branches were doubly
ligated with 2-0 silk ties and divided. The superior subplatysmal
flap was brought to the thyroid notch and the inferior flap to the
sternal notch. Strap muscles were divided at the midline and
separated.
The right strap muscles were lifted off the right thyroid gland
and mobilized slowly the right thyroid gland medially. The
nerve at the base of the neck was identified. There were two
inferior thyroid artery branches that were ligated with 2-0 silk
ties and divided. Middle thyroid vein was ligated with 2-0 silk
tie and divided. The thyroid gland was mobilized medially. The
right upper parathyroid gland was found at the mid aspect of the
posterior thyroid gland. It was intrathyroidal. It was slowly

2. removed from the thyroid gland, clipped the feeding vessels and
the right upper parathyroid gland was totally excised. The nerve
was noted to be functional at the end of this excision.
The superior vascular bundle was doubly ligated with 2-0 silk
ties and divided allowing for further mobilization of the gland
medially. We were unable to find a parathyroid gland at that
level. We then subsequently freed the lower pole of the thyroid
gland and we started identifying the thymus tissue and pulled it
out of the chest. There was a right neck lymph node that was
submitted for frozen section and this was benign. We then
identified a right lower parathyroid gland. I clipped the distal
half and this was confirmed to be parathyroid tissue. The
proximal half of the parathyroid gland was left intact.
The left strap muscles were lifted off the left thyroid gland. The
middle thyroid vein was ligated with 3-0 silk ties and divided
and the thyroid gland was then mobilized medially. The nerve
was found at the base of the neck and traced towards the larynx.
The left upper parathyroid gland was identified, found to be
posterior to the mid aspect of the thyroid gland, and it measured
1.5 x 0.8 cm. We freed it from the nerve and from the thyroid
gland and this was confirmed to be parathyroid tissue. The
small vascular pedicles were clipped and the left upper
parathyroid gland removed. The nerve was noted to be
functional at this point.
We ligated the superior thyroid vascular pedicle. This was done
with 2-0 silk ties x2 and with a 3-0 silk suture ligature. We
mobilized the gland medially, and not finding any parathyroid
tissue superiorly, we then addressed our attention inferiorly
where the thymus was pulled out and we identified a left
inferior parathyroid gland. This was found to be anterior to the
nerve. This gland was noted to be 1.1 x 0.9 x 0.8 cm. This was
removed in its entirety. The vascular pedicles were clipped. At
this point, both nerves were noted to be functional, and with

3. assurance of hemostasis, we commenced closure. Running 4-0
Vicryls were used to approximate the strap muscles at the
midline, interrupted 4-0 Vicryls were used to approximate the
platysma, 5-0 Monocryl was used for the subcuticular skin
closure. Local anesthesia was infiltrated. Dermabond was
placed. The patient tolerated the procedure well. Sponge and
needle counts were correct. Blood loss was minimal. The patient
was taken to recovery room, extubated and in stable condition.
ICD-10-PCS Code: Click here to enter text.
2. Case Study #2
PREOPERATIVE DIAGNOSIS: Obstructive jaundice.
POSTOPERATIVE DIAGNOSIS: Pancreatic head mass.
SURGICAL PROCEDURES: EUS with FNA.
After informed consent was obtained, the patient received
sedation with IV 10 mg Versed and IV 200 mcg of fentanyl for
adequate sedation. The linear echoendoscope was first passed
through the mouth down the esophagus to the extent of the
duodenal bulb. The scope could not pass beyond the duodenal
bulb into the descending duodenum due to the nature of her
anatomy. The celiac axis was first scanned from the stomach
and was grossly normal with no lymphadenopathy seen. The
body and tail of the pancreas were scanned from the stomach at
which point that the pancreatic duct was seen to be very
irregular in nature and also dilated to approximately 5-6 mm.
The parenchyma appeared very atrophic as well of the pancreas
in the body and tail. No lymphadenopathy seen near. The scope
was then advanced to the duodenal bulb through the pylorus into
the duodenal bulb at which point a pancreatic head mass was
seen. This mass appeared was very vague to differentiate from

4. the normal pancreatic parenchyma, but appeared to be roughly 3
x 2 cm when scanned from the duodenal bulb. There appeared to
be no invasion of the superior mesenteric artery and no invasion
of the portal vein. There was seen a clean plane between these 2
structures. The percutaneous drain appeared to be extending
into this mass. From the duodenal bulb, 3 biopsies were taken
with the 22-gauge FNA needle. Three passes made through the
duodenal wall of the pancreatic head lesion and sent for
cytology, and cell block. There was maybe one 2 mm lymph
nodes seen at this level, but again no definite vascular invasion
was seen. The scope was then removed and the procedure
complete.
ANESTHESIA TYPE: Conscious sedation.
ESTIMATED BLOOD LOSS: Minimal.
SPECIMENS REMOVED: FNA of the pancreatic head mass x3
with a 22 gauge needle through the duodenal wall.
FINDINGS: Pancreatic head mass measuring roughly 3 x 2 cm.
Local collaterals seen, but no apparent invasion of the
confluence, the portal vein or the superior mesenteric artery.
Unable to pass the scope into duodenum for a full evaluation of
this lesion.
COMPLICATIONS: None.
RECOMMEND: Await cytology results.
ICD-10-PCS Code: Click here to enter text.
3. Case Study #3
Code only the biopsy for this procedure.

5. PROCEDURE: Right heart cardiac catheterization and
endomyocardial biopsy
procedure.
REASON FOR PROCEDURE: The patient is status post
orthotopic cardiac
transplantation and is undergoing hemodynamic evaluation and
surveillance
allograft biopsy for rejection.
The patient was admitted to the catheterization lab. His right
neck was prepped
and draped in the usual sterile fashion. Using 2% lidocaine the
skin was
anesthetized. Using the Seldinger technique, the right internal
jugular vein
was easily entered. Good blood flow was obtained. A short
sheath was placed
over a wire. The wire was removed. Through the sheath, the
Swan was floated to
the right atrium, right ventricle, pulmonary artery, pulmonary
capillary wedge
positions. Pressure was measured. PA saturation and
thermodilution cardiac
output was measured. The Swan was withdrawn using a wire for
guidance. The
short sheath was exchanged for a long biopsy sheath with its tip
in the right
ventricle. The wire was removed through the biopsy sheath. A
bioptome was
placed and endomyocardial biopsy specimens from the right
ventricle were obtained. The biopsy sheath and bioptome were
removed and good hemostasis was obtained using manual
compression. The patient tolerated the procedure well. There
were no complications. He was discharged from the
catheterization lab in good condition.

6. Mean right atrial pressure 12. RV 32/10. PA 37/14. Mean PA
25. Pulmonary
capillary wedge pressure 18. Cardiac output 3.78. Cardiac index
2.18. PA
saturations 16%.
IMPRESSION: Mild pulmonary hypertension with lower PA
saturation. Patient's
creatinine today is 1.4 and he may be significantly volume
depleted, but overall
stable. Allograft biopsy results pending.
ICD-10-PCS Code: Click here to enter text.
4. Case Study #4
PREOPERATIVE DIAGNOSIS: Respiratory failure, intracranial
hemorrhage.
POSTOPERATIVE DIAGNOSIS: Respiratory failure,
intracranial hemorrhage.
PROCEDURE PERFORMED: Tracheostomy.
ANESTHESIA TYPE: General.
ESTIMATED BLOOD LOSS: 10 mL.
HISTORY: This is a 58-year-old female who presented to the
trauma center several days ago with isolated head trauma. She
has been on the ventilator and unable to support her ventilation
without a mechanical ventilator. She is thus unable to be

7. weaned from a ventilator and thus in need of a tracheostomy.
She also is unable to swallow and thus will need a PEG
placement. Due to the fact that there is no endoscope
functioning at this time we have decided to do the PEG at a
later time. The risks and benefits were explained to the family
and they consented to the procedure.
PROCEDURE: The patient was brought to the operating room
and had SCDs placed prior to induction of anesthesia. She had
preoperative antibiotics given prior to any incision. She had
come down with the ET-tube and this was hooked up to the
ventilator by the anesthesia staff. She was prepped and draped
in normal sterile fashion and the anatomic landmarks of the
thyroid cartilage and sternal notch were identified, as well as
the cricothyroid membrane. About 1 fingerbreadth below the
cricothyroid membrane, incision was made down to the level of
the subcu tissue. Bovie electrocautery was used to dissect down
through the platysma. Any venous bleeders were identified and
tied off with silk suture. Right angles were used and a suture
ligature was placed with silk suture around the end of the
isthmus and this was transected in the midline. We then had
good exposure of the trachea. We identified the third tracheal
ring. We had the ICU staff deflate the balloon and we placed
stay sutures laterally on both sides of the third tracheal ring.
This was carried down from skin to the tracheal ring back up to
the skin. We then reinflated the balloon and then when we were
ready we deflate the balloon again and made a square incision
around the third tracheal ring and removed this portion in a
square fashion. We brought our ET-tube out proximally just
proximal to this and used a tracheal spreader to dilate the
trachea. We then placed a #8 Shiley tracheostomy tube without
any difficulty and the balloon was inflated. We then hooked our
tracheostomy to the ventilator and received good end tidal C02.
The patient was oxygenating at 100% and her tidal volumes
were equivalent to what they were preop with the ET-tube.
There were no signs of bleeding and good, hemostasis was,

8. achieved. The skin around the tracheostomy incision was closed
in running fashion and the tracheostomy was secured in four
places with nylon suture. The Vicryl stay sutures were secured
to the chest wall with Steri-Strips. The patient tolerated the
procedure well and was taken to ICU in stable condition.
ICD-10-PCS Code: Click here to enter text.
M132 Module 04 Coding Assignment Answers
1. Case Study #1
PREOPERATIVE DIAGNOSIS: Sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Sensorineural hearing loss.
OPERATION: Right cochlear implant, Nucleus Contour
Advance multi-channel device, right facial nerve monitor.
ANESTHESIA: General endotracheal.
FINDINGS: Complete insertion, normal anatomy, Nucleus
Contour Advance placed.
SURGICAL PROCEDURE: The patient was brought to the
operating room and placed in the supine position. A general
endotracheal anesthetic was administered. The right ear was
examined and there was no evidence of ear infection. The area
of the anticipated incision was shaved and infiltrated with
lidocaine 1% with epinephrine
1 :100,000. The right ear and face were prepped and draped in
the standard sterile fashion. Bipolar pin electrodes were placed
in the orbicularis oris and oculis with ground electrodes in the
left shoulder.
An extended postauricular incision was created and brought
down to the subgaleal level. Flaps were elevated and periosteal

9. incisions were designed. The mastoid was widely exposed. A
recess was created to accommodate the receiver/stimulator case.
Mastoidotomy was then performed. The area of the aditus was
identified and the short process of the incus exposed. The facial
recess was opened. The promontory was identified. The stapes
and area of the oval window was exposed as was the round
window niche. A cochleostomy was performed. Holes were
created at the lateral aspect of the receiver/stimulator recess and
the mastoidotomy. The wound was irrigated copiously with
sterile saline and hemostasis was achieved with suction cautery.
The device was then introduced into the field and secured in the
recess. 3-0 Nurolons were used to secure the device. The ground
electrode was placed deep to the temporalis fascia. The
electrode array was inserted and a complete insertion was
obtained with an advance off stylet technique. The
cochleostomy was packed with soft tissue from the lateral
incision. The stylet was removed.
The wound was then closed in 3 layers using 3-0 chromic to
approximate the periosteal layer, 4-0 chromic to approximate
the galea layer, and 5-0 Monocryl in a running subcuticular
fashion.
ICD-10-PCS Code: Click here to enter text.
2. Case Study #2
DIAGNOSIS: Low back pain, lumbar facet arthropathy, lumbar
radiculopathy, failure of conservative management.
PROCEDURE: Neural modulation with a spinal cord stimulator
implant under fluoroscopic guidance.

10. INTERIM HISTORY: Patient is well known to me. She has had
conservative management with injections and medication from
other pain physicians. At this time, the patient is unable to
return to work because of the persistent pain, and she had a
spinal cord stimulator trial which gave her significant relief so
we are going ahead with the spinal cord stimulator implant. The
patient understands the risks and benefits of this. Patient
understands if she has any side effects, she has to reach me or
reach the emergency room.
DESCRIPTION OF PROCEDURE: After taking informed
consent, with the patient in prone position the back was prepped
aseptically and draped aseptically. The patient was then
spontaneously breathing and communicating throughout the
procedure. Under AP view of fluoroscopy, L1 interspinous
process was identified. Local was infiltrated using 3 mL of 1%
lidocaine and 4 mL of 1% preservative-free Marcaine using a
2S-gauge needle. Number 14-gauge epidural needle was then
advanced under continuous AP and then under continuous
lateral fluoroscopy to reach the epidural space by loss-of-
resistance technique. Once reaching the epidural space, on
aspiration no CSF or heme, no paresthesia at any point. An 8-
contact Bionics lead was then advanced with the help of the
navigation. I was able to place the needle right in the middle of
the spine and the posterior epidural space. There was no CSF or
heme at any point, no paresthesia at any point. This was
confirmed both with the lateral and AP view. The needle was
then advanced to T8-T9 level. At this level, the patient had
good paresthesia and there was good coverage of all her painful
parts. Continuous fluoroscopic pictures were taken during this
procedure with the help of the Bionics rep, The stimulator was
analyzed, had good coverage and normal impedance. Once the
patient appreciated good paresthesia and good coverage of all
her painful spots, the lead was anchored by extending the
incision at the paraspinal area around Ll-2, and the lead was

11. anchored in the spinal canal with 2-0 silk. At this time, the
procedure was taken over by Dr. X who did the pocket for the
generator. The patient was discharged uneventfully.
(Code only the Spinal Cord Stimulator Implant for this case)
ICD-10-PCS Code: Click here to enter text.
3. Case Study #3:
PREOPERATIVE DIAGNOSIS:
1. Left chest wall mass.
2. Ovarian cancer.
POSTOPERATIVE DIAGNOSIS:
1. Left chest wall mass.
2. Ovarian cancer.
PROCEDURE PERFORMED:
1. Bronchoscopy with evaluation of bronchial tree tube.
2. Left video-assisted thoracoscopy.
3. Resection of anterior chest wall mass with resection of

12. pleura.
PROCEDURE: After proper consent was obtained the patient
taken to and placed on
operating room table in supine position. General sedation was
administered by oral endotracheal tube. The bronchoscope was
inserted. Right upper lobe, middle lobe and lower lobe were
normal. No endobronchial lesions seen. Scope was inserted in
left upper lingula lobe segments were normal. The patient was
placed in a right lateral decubitus position. Left chest prepped
and draped in normal sterile fashion. Incision made and the
thoracoscope inserted. Under direct vision additional lateral
port placed. Dissection was then carried down. The mass
identified within chest wall. It was confined to the pleura. This
appeared to be a large plaque, approximately 10 x 4 cm.
Separate satellite mass was present. Using the Bovie
electrocautery, the pleura was then dissected from the chest
wall. The entire chest wall mass was resected including the
pleural lesion. It was then placed in EndoCatch, removed and
sent to Pathology. No other areas were seen on the pleura.
Meticulous hemostasis obtained. Chest tube placed to the apex
and anchored with heavy silk. Lung re-expanded no significant
air leak. Wound then closed in layers with absorbable suture.
Chest tube anchored with heavy silk. Dermabond sterile
bandage placed on the wound.
The patient tolerated procedure well, in stable condition.
ICD-10-PCS codes: Click here to enter text.
M132 Module 02 Coding Assignment
Find the correct code and explain your rationale for each case

13. study below.
1. Case Study:
PREOPERATIVE DIAGNOSIS:
1. Gangrene right foot.
POSTOPERATIVE DIAGNOSIS:
1. Gangrene right foot.
OPERATION:
1. Right below the knee amputation.
ANESTHESIA: General LMA.
PROCEDURE: The patient was brought to the operative suite
where a general LMA anesthesia was induced.
A Foley catheter was inserted. The right foot was s secluded in
an isolation bag and the right lower extremity circumferentially
prepped and draped in its entirety. Beginning on the right side
the skin was marked with a marking pen 4 fingerbreadths below
the tibial tuberosity anteriorly with a long posterior flap. The
skin was incised circumferentially and the anterior musculature
sharply divided exposing the tibia The tibia was cleaned with a
periosteal elevator and then transected with the Stryker saw.
The fibula was exposed and transected with the bone cutter and
the amputation completed by sharply incising the posterior
musculature. Bleeding vessels were ligated with 2-0 silk
Ligature. There appeared to be adequate bleeding at this level
for primary healing. The tibia was then cleaned with a bone rasp
and the fibula with a rongeur. The wound was irrigated and
ultimately closed without significant tension utilizing

14. interrupted 2-0 vicryl sutures for reapproximation of the fascia
and skin staples for reapproximation of the skin.
The right side was dressed with sterile gauze fluff dressings and
a Kerlix roll. Estimated blood loss throughout the procedure
was approximately 150 mL. The patient received one unit
intraoperatively of packed cells because of preoperative anemia.
She was transported in stable condition to the recovery room.
Code: Click here to enter text.
2. Case Study:
PROCEDURE: Open reduction and internal fixation of bilateral
tibial plateau fractures.
INDICATIONS: This 23-year old was involved in a serious
accident and sustained bilateral tibial plateau fractures
DESCRIPTION OF OPERATION: The patient was brought to
the operating room and placed on the operating room table in
the supine position. General anesthesia was induced, and after
this both lower extremities were prepped and draped in the
usual sterile fashion. Attention was first directed towards the
left tibial plateau. A standard lateral procedure to reduce the
lateral tibial plateau fracture was performed. After a
submeniscal arthrotomy was performed, the joint was visualized
via the lateral approach. The posterolateral fragments were
reduced and the lateral tibial plateau was elevated, restoring the
articular surface. K-wires were placed to provisionally hold this
reduction. C-arm fluoroscopy was used to confirm good
reduction of the joint surface. Next, a 6-hole lateral plateau
locking plate from the Stryker sets was selected. This locking
plate was advanced down the tibial shaft. Screws were placed to
secre the plate to the bone. Four screws were placed in the
distal shaft fragments and 4 locking screws in the proximal
fragment. A kickstand screw was also placed in the locking

15. mode. After all screws were placed, x-rays exhibited good
reduction of the fracture, as well as good placement of all
hardware. Next, the wound was thoroughly irrigated with
normal saline. The meniscal arthrotomy was closed with the 0
PDS suture, including the capsule. Next, the IT band was closed
with 0 Vicryl suture, followed by 2-0 Vicryl sutures for the skin
and staples. Attention was then directed toward the right tibial
plateau. A similar procedure was performed on the right side.
Then, the lateral approach to the lateral tibial plateau was
performed, exposing the fracture. The incision was
approximately 4 cm on the right side. A 6-hole LISS plate was
advanced down the tibial shaft. Four screws were placed in the
distal fragments followed by four screws in the locking mode
and proximal metaphyseal fragment. Excellent fixation was
obtained. The C-arm fluoroscopy was used to confirm excellent
reduction of the fracture on both the AP and lateral fluoroscopic
images. Next, the wound was thoroughly irrigated and closed in
layers. Sterile dressings were applied All wounds were dressed
with sterile dressing and the patient was placed into knee
immobilizers. The patient was then awakened from anesthesia,
and transferred to recovery. The patient will be
nonweightbearing for approximately three months on bilateral
lower extremities. The patient will receive DVT prophylaxis
during this time.
ICD-10-PCS Code: Click here to enter text.
3. Case Study:
PREOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. History of previous pelvic surgery and ovarian cyst.
POSTOPERATIVE DIAGNOSES:
1. Pelvic pain.
2. History of previous pelvic surgery and ovarian cyst.

16. OPERATION PERFORMED: Laparoscopic adhesiolysis.
SURGEON: Susan Smith, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Less than 10 mL.
URINE OUTPUT: 70 mL.
IV FLUIDS: 750 mL.
DESCRIPTION OF OPERATION: After informed consent was
obtained, the patient was taken to the operating room. She was
placed in the dorsal supine position and general anesthesia was
induced and prepped and draped in the usual sterile fashion. A
Foley catheter was placed to gravity and speculum was placed
in the posterior and anterior vagina and the cervix was grasped
with a single-toothed tenaculum. A Hulka clamp was then
inserted through the cervix into the uterus for uterine
manipulations and the tenaculum was removed and attention
was then turned to the abdomen.
A supraumbilical incision was made with a scalpel and elevated
up with towel clamps. A long Veress needle was then placed
and CO2 gas was used to insufflate the abdomen and pelvis. A
10-12 trocar and sleeve were then placed and confirmed via the
laparoscope. The dense greater omental adhesions to the
anterior abdominal wall were noted immediately. At this time,
we were not able to see into the pelvic region. A second 5 mm
trocar and sleeve were placed in the left mid quadrant under
direct visualization. The ligature device was then placed
developing a plane between the omentum and the anterior
abdominal wall.

17. The adhesiolysis took place and it took approximately 25
minutes to release all of the omental adhesions from the anterior
abdominal wall. We were then able to visualize the pelvis and a
blunt probe was placed through the port. The ovary was
visualized and photos were taken with no evidence of any
ovarian cyst or ovarian pathology or of pelvic endometriosis.
The uterus also appeared normal and the left tube and ovary
were surgically absent. The appendix was easily visualized and
noted to be noninflamed, normal in appearance, and there were
no adhesions in the right lower quadrant. The upper abdominal
exam was unremarkable. The procedure was terminated at this
time. The ports were removed. CO2 gas was allowed to escape.
The incisions were closed with 4-0 Vicryl suture. The Hulka
clamp was removed. The vagina was noted to be hemostatic.
The patient's anesthesia was awakened from anesthesia, the
Foley catheter was removed, and she was taken in stable
condition to the recovery room.
ICD-10-PCS Code: