Answer both discussion questions in your own words. 1 paragraph i.docx

Answer both discussion questions in your own words. 1
paragraph is all that is required.
1. Explain in your own words, the importance of customer-
focused relationship marketing and how it differs from
traditional transactional marketing?
2. Is it true that marketers must play the leading role in all
stages of the of the website development process. Take a
position on this statement and defend your answer fully.
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
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
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
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.
3. Case Study #3
Code only the biopsy for this procedure.
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.
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.
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
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,
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.
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
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.

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.
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
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)
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
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.
1. Select the best response for each question below.
A colostomy was performed from the sigmoid colon to the
abdominal wall.
The section is _________A_______, the body system is
_______B_________the root operation is
__________C________. The body part is ________
D_________. The approach is __________E________. The
device is ___________F__________. The qualifier is
__________G_________.
Answers:
A. Click here to enter text.
B. Click here to enter text.
C. Click here to enter text.
D. Click here to enter text.
E. Click here to enter text.
F. Click here to enter text.
G. Click here to enter text.
2. Using the following table, the correct code for
laparoscopic ventral hernia repair with Paritexmesh is: (Check
one answer)
☐0WU44JZ
☐0WU477Z

☐0WUF4JZ
☐0WUF8KZ
3. When using the root operation Fusion, there are very
specific rules regarding how the device character (sixth
character) is assigned. Use the list of devices listed in the ICD-
10-PCS book for character 6 below:
A Interbody Fusion Device
4 Internal Fixation Device
5 External Fixation Device
7 Autologous Tissue Substitute
J Synthetic Substitute
K Nonautologous Tissue Substitute
Z No device
Complete the following table:
Device Used to Render the Joint Immobile
ICD-10-PCS Device (Character 6)
Interbody fusion device aloneClick here to enter text.
Interbody fusion device with bone graftClick here to enter text.
Bone graft taken from patientClick here to enter text.
Bone graft taken from bone bankClick here to enter text.
Bone graft taken from patient and a donorClick here to enter
text.
Bone graft taken from a donor mixed with synthetic
bindersClick here to enter text.
4. Case Study 1:
Do not code the fluoroscopy or angiogram for this case.

PREOPERATIVE DIAGNOSIS: High-grade asymptomatic right
carotid artery stenosis.
POSTOPERATIVE DIAGNOSIS: High-grade asymptomatic
right carotid artery stenosis.
PROCEDURE PERFORMED: Percutaneous transluminal
angioplasty and stenting of the right internal carotid artery.
(This was done under the Choice protocol.)
ANESTHESIA: Local.
INDICATION: The patient is a 72-year-old gentleman who is 10
years status post head and neck surgery for cancer status post
radiation and has a tracheotomy in place. He has developed a
high-grade asymptomatic right carotid artery stenosis. After
reviewing the risks, benefits and alternatives of his options, he
wished to proceed with carotid artery stenting, due to his high
anatomical risk factors and high risk of nerve injury. He was
enrolled under the Choice post market registry protocol.
After the patient was correctly identified and consented, he was
taken to the cardiac cath lab and placed in supine position. The
right groin was prepped and draped in usual sterile fashion and
anesthetized with 1% local. Using anatomical landmarks, the
right common femoral artery was punctured with a
micropuncture needle in a retrograde fashion. A 0.018-inch wire
was then passed under fluoroscopy into the aorta. The needle
was exchanged out for a 5-French coaxial dilator and
subsequently for a 5-French sheath. Omni flush catheter was
then taken into the arch in an LAO projection and aortogram
was then performed. This demonstrates a mildly to moderately
atherosclerotic aortic arch without any evidence of stenosis. The
origins of the great vessels are identified and these are widely
patent without severe disease. The visualized portions of the
right subclavian, vertebral, left subclavian and left vertebral

arteries are all widely patent without any evidence of severe
disease. The left common carotid artery is patent proximally.
The right common carotid artery arises from the innominate in a
normal variant. The patient was then systemically heparinized
and his ACT was kept over 220 seconds throughout the entire
case. The right common carotid artery was negotiated and then
cannulated with a with a Bernstein catheter. With a catheter in
the common carotid, angiogram was performed which
demonstrates a high-grade atherosclerotic lesion of the proximal
right internal carotid artery MAC with 80-90% stenosis. Distal
to this, the artery is widely patent. The external carotid artery is
identified and is otherwise normal. An angled guide wire was
then advanced deep into the external carotid artery branches and
then the catheter was then tracked into this area. Using an
exchange technique over an Amplatz wire, an 8-French JR
guiding catheter was then advanced through sheath that had
been exchanged into the groin and placed with its tip in the
distal common carotid artery. With the catheter in this position,
a Spider wire embolic protection filter wire was then advanced
very carefully through internal carotid artery lesion and placed
5 cm distal to the area of treatment. The filter wire was
deployed and a follow-up angiogram demonstrates excellent
position without any evidence of embolism or vasospasm. After
making appropriate measurements, an Abbott Xact 6 mm x 30
mm self-expanding stent was then deployed across the lesion
under fluoroscopy with the filter in place. The stent opened and
moved forward slightly but was otherwise in good position.
With the stent completely deployed, a 6 x 20 mm balloon was
then used to post dilate the stent to form full apposition. A
follow-up angiogram was done which demonstrates excellent
treatment of the lesion with less than 20% residual stenosis. The
filter wire is in place and does not appear to have a severe
amount of debris within it. The filter was then retracted and
removed and a cervical carotid angiogram demonstrated wide
patency of the common internal and external carotid arteries.
The AP and lateral views of the unilateral cerebral carotid

demonstrated wide patency with excellent flow through the
MCA distribution and cross filling without any evidence of
embolism or vasospasm. The guiding catheter and sheath were
then removed with direct manual compression held over the
groin for 30 minutes. The patient was given protamine to
reverse the heparin and then loaded with Plavix, given the
placement of the stent. He maintained hemodynamic and
neurological stability throughout the entire case. The wound
was then cleaned, dried and dressed using gauze and Tegaderm.
The patient appeared to tolerate the procedure well. There were
no immediate complications. The patient was taken to recovery
room in stable condition. A total of 70 mL of contrast was used
for the entire case.
· ICD-10-PCS Code: Click here to enter text.
5. Case Study 2:
PREOPERATIVE DIAGNOSES:
1. Left leg claudication.
2. Left superficial femoral artery occlusion and femoropopliteal
occlusive disease.
POSTOPERATIVE DIAGNOSES:
1. Left leg claudication.
2. Left superficial femoral artery occlusion and femoropopliteal
occlusive disease.
PROCEDURE PERFORMED: A left femoropopliteal bypass
(above knee 8-mm PTFE graft with a distal cuff). The patient
was brought to the operating room. General anesthesia was
given. The left leg was prepped and draped in the usual manner.
A vertical incision was made in the groin and the common
femoral profunda and superficial femoral arteries were
dissected.

The femoral artery appeared to be fairly calcified on the back. It
was soft on the front. However, close to the inguinal ligament
after the inguinal ligament was lifted off basically the external
iliac artery was found to be fairly smooth in all directions, and
appeared to be good place to clamp the artery.
The popliteal artery was isolated above the knee through a
medial incision in the thigh. Deep fascia was opened. Popliteal
fossa was entered. Artery was dissected free of its adjoining
veins and was encircled in vessel loops and a tunnel was made.
The patient was heparinized, after which, the popliteal artery
was isolated between clamps and opened longitudinally.
Although it had arteriosclerosis and irregular plaque inside, in
general it appeared to be open. Anastomosis between the cuff of
the graft and the artery was carried out with 6-0 Prolene. The
graft was then pulled through the tunnel into the groin.
The external iliac artery and two profunda arteries were
clamped. A longitudinal incision was made in the common
femoral artery. It appeared that on the back of the artery there
was a popcorn-type of calcification extending into the lumen of
the artery. This popcorn calcification was removed by a limited
endarterectomy and after the artery had been smoothed out on
the inside, the area was thoroughly irrigated. The arteries were
allowed to bleed forwards and backward, after which the graft
was cut at an angle and sutured here as a proximal anastomosis,
as well, a patch over the artery anastomosis was made with 6-0
Prolene. Air was evacuated and the clamps were released to
allow the blood to flow down into the leg.
Palpation showed a strong posterior tibial pulse and faint
dorsalis pedis. These were palpable by hand.
The patient was given protamine. Hemostasis was secured.

Irrigation was done and closure was carried out. Vicryl was
used for deeper tissues. Skin was closed with surgical clips.
Dressings were done. Blood loss was minimal. No transfusion
was given.
6. Case Study 3:
PREOPERATIVE DIAGNOSIS: Recurrent hemoptysis
POSTOPERATIVE DIAGNOSIS: Recurrent hemoptysis
PROCEDURE PERFORMED: Bronchoscopy. Reason for that is
recurrent hemoptysis.
DESCRIPTION OF PROCEDURE: After informed consent
under local and IV sedation, a
bronchoscopy was attempted at the bedside for evaluation of
recurrent hemoptysis. The patient has severe nonischemic
cardiomyopathy. Is here for LVAD evaluation with severe RV
dysfunction as well. His CAT scan did not show any kind of
intraparenchymal or bronchial abnormalities. He had
improvement in his symptoms, but started having another
episode of hemoptysis, which is dark red color. We went in to
evaluate for intrapulmonary source.
Upon inspection of the vocal cords, they opened and closed
without any abnormality. No upper airway abnormality was
found. No blood was found. We went ahead and inspected the
right side as well as the left side. It was completely clean. We
flushed it. There was no evidence of any bloody secretions
come out. Everything looked normal. We terminated the
procedure thereafter.

7. Case Study 4:
PREOPERATIVE DIAGNOSIS: Lipodystrophy of the abdomen.
POSTOPERATIVE DIAGNOSIS: Lipodystrophy of the
abdomen.
OPERATION PERFORMED: Suction-assisted lipectomy of the
abdomen.
ANESTHESIA: General.
BLOOD LOSS: Minimal.
COMPLICATIONS: None.
SPECIMENS: None.
INDICATIONS: The patient is a 23-year-old white male who is
relatively thin but has mild to moderate fatty prominence of the
central abdomen as well as the lateral abdomen focally. He
presents for suction-assisted lipectomy of these sites.
DESCRIPTION OF PROCEDURE: The patient was seen in the
preoperative area where, in the standing position, the abdominal
skin was wiped with alcohol and marked with a marking pen for
surgery. The patient was brought into the operative room and
placed supine on the operating room table and administered
general anesthesia successfully. A total of 5 mL of 50:50
mixture of 1% lidocaine with epinephrine with 0.25% Marcaine
with epinephrine was infiltrated into the site of liposuction,
access site incisions.

The abdomen was prepped and draped in the usual sterile
fashion. Stab incision was performed with #15 blade, which
was dilated with a hemostat in the high lateral flank superior
margin of the umbilicus and in the groin on each side.
Tumescent solution, which is the standard mixture of 20 mL of
lidocaine, 1 mL adrenaline and a liter of warm normal saline
was injected throughout the subcutaneous plane. Suctioning
was then performed after a wait of 10 minutes plus with the 3
mm triport cannula throughout the anterior and lateral abdomen
with shorter cannulas being used for the upper abdomen. All
sides were remarkably thinner. Good smooth contour. Total
infiltration amount was 1100 mL. Total output 950 mL, which
appeared to be about 50% to 60% fat by volume.
Incisions were closed with #5-0 Prolene interrupted sutures x2.
Incisions were clean, dried and dressed with broad Band-Aid
dressings, gauze pads and abdominal binder. The patient
tolerated the procedures well with no apparent complications.
The patient was then extubated in the operating room and
transferred to the recovery room in a satisfactory condition.
Postoperatively, following the procedure, I spoke to the patient
in regards to procedure and postoperative care.
Find the correct code and explain your rationale for each case
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
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
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.
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.
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.
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:

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