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M132 Module 06 Coding Assignment 1. Case Study #1PREOPERAT.docx
M132 Module 06 Coding Assignment
1. Case Study #1
PREOPERATIVE DIAGNOSIS: Carcinoma of the right breast, status post neoadjuvant chemotherapy.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the right breast, status post neoadjuvant chemotherapy.
PROCEDURE PERFORMED: Right modified radical mastectomy, left prophylactic mastectomy
PREOPERATIVE HISTORY: The patient is an unfortunate 37-year-old woman who had a pregnancy associated breast cancer of the right breast with extensive involvement of the breast, clinically a stage III breast cancer. She underwent neoadjuvant chemotherapy with a complete clinical response to therapy with no residual palpable tumor in the breast and no palpable adenopathy. She has elected to undergo a bilateral mastectomy. She will have reconstructive surgery at a later time.
OPERATIVE NOTE: The patient was taken to the operating room. General anesthesia was induced. A Foley catheter was inserted. Her arms were placed on pads. Her legs were placed on pads. Bear hugger was applied and her entire upper torso was sterilely prepped and draped in usual fashion. Symmetric skin sparing mastectomies were planned incorporating the nipple-areolar complex on both sides. We began on the left side. An elliptical incision was made incorporating the nipple-areolar complex, carried down through the skin into the subcutaneous tissue. Flaps were raised circumferentially from the superior aspect to the clavicle, medially to the midline, inferiorly to the inframammary, fold and laterally out to the latissimus dorsi. The breast was then removed from the pectoralis major muscle incorporating the fascia, reflected laterally and truncated. It was marked for orientation, weighed and sent to pathology. Hemostasis was achieved where necessary using electrocautery. There was no evidence of bleeding at the end of the case. Moist laps were placed under the flaps and we moved to the right breast. Again, an elliptical incision was created incorporating the nipple-areolar complex and a little more skin laterally in that breast because the breast was a larger breast on that side. Flaps again were raised from superior infraclavicular and a portion of the breast circumferentially to the midline and subsequently to the inframammary fold and subsequently out to the latissimus dorsi muscle. The breast was removed from the pectoralis major muscle incorporating the fascia, reflected laterally. The clavipectoral fascia was opened and a level I and level II axillary lymph node dissection was performed on both sides, sparing the long thoracic and the thoracodorsal neurovascular bundle, as well as at least 1 intercostal brachial cutaneous nerves. The axillary lymph nodes will be examined for metastasis. There was no palpable adenopathy in level III. The breast and axilla were marked for orientation, weighed and sent to pathology. Irrigation was performed. Hemostasis was achieved where necessary using some Surgiclips and electrocautery. There was no evidence of blee ...
Diagnostic Coding ICD-10-CMAssignment 1.3Diagnostic C.docx
Diagnostic Coding: ICD-10-CM
Assignment 1.3
Diagnostic Coding: ICD-10-CM
W6: Coding
Your Name:
Part 1
Instructions: Review each case and identify the first-listed diagnosis.
1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.
FIRST-LISTED DIAGNOSIS: ________
2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.
FIRST-LISTED DIAGNOSIS: ______
3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.
FIRST-LISTED DIAGNOSIS: _______
4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.
FIRST-LISTED DIAGNOSIS: _____
5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.
FIRST-LISTED DIAGNOSIS: _____
Part 2
Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.
E 6. allergy test a. bronchial asthma
B 7. EKG b. chest pain
A 8. inhalation treatment c. family history, cervical cancer
C 9. Pap smear d. fractured wrist
G 10. removal of ear wax e. hay fever
I_ 11. sigmoidoscopy f. hematuria
J 12. strep test g. impacted cerumen
F 13. urinalysis h. jaundice
H 14. venipuncture i. rectal bleeding
D 15. X-ray, radius and ulna j. sore throat
Part 3
Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)
16.
S: A 53-year-old new patient was seen today for a level 2 visit. The female patient presents with complaints of polyuria, polydipsia, and weight loss.
O: Urinalysis by dip, automated, with microscopy reveals elevated glucose.
A: Possible diabetes.
P: The patient is to have a glucose tolerance test and return in three days for her blood work results and applicable management of care.
Diagnoses
ICD Codes
Polyuria
R35.8
polydipsia
R63.1
weight loss
R63.4
Urinalysis
R81
17.
PREOPERATIVE DIAGNOSIS: Ventral hernia
POSTOPERATIVE DIAGNOSIS: Ventral hernia
PROCEDURE PERFORMED: Repair of ventral hernia with mesh
ANESTHESIA: General
PROCEDURE: The vertical midline incision was opened. Sharp and blunt dissection was used in defining the hernia .
OPSX32SandallOscarMCCG240 Case Scenario OPSX32 Sandall, Os.docx
OPSX32SandallOscar
MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]
Outpatient Surgery
Patient Case Number: OPSX32-Sandall, Oscar
Patient Name: Oscar Sandall DOB: 02-19-72 Sex: M
Date of Service: 05-05-XX Surgeon: Sandra Cullman, MD
Pre-Operative Diagnosis
Right knee complex medial
meniscus tear
Post-Operative Diagnosis
Right knee complex medial meniscus tear and medial plica
Procedure Performed: Knee arthroscopy w/ partial medial meniscectomy, chondroplasty of medial
femoral condyle, excision of medial plica
Anesthesia: General Complications: None
Indication for Procedure:
The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain
for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with
partial medial meniscectomy. The risks, benefits and possible complications from the surgery were
discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding,
neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not
improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is
an increased chance of developing or accelerating any existing arthritis in that knee. The patient also
understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary
embolus and death.
Description of Procedure:
After consent was obtained the patient was taken to the operating room and was administered a general
anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity
was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower
extremity and the tourniquet inflated to 325 mmHg. a superomedial portal was made for the introduction
of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial
portal was made for the introduction of arthroscopic instruments. The findings are as follows:
1. Suprapatellar pouch: Normal
2. Medial plica: Frayed
3. Medial gutter: Normal
4. Lateral gutter: Normal
OPSX32SandallOscar
MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]
5. Patella: Normal
6. Trochlea: Grade I Chondromalacia - Softening Articular Cartilage
7. Medial Femoral Condyle: Grade IIA Chondromalacia - Fissures/Fragmentation Articular Cartilage
<50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50%
8. Medial meniscus: Tear, Complex- Root, Posterior Horn, Body
9. Medial Tibial Plateau: Normal
10. ACL: Normal
11. PCL: Normal
12. Lateral Femoral Condyle: Normal
13. Lateral Meniscus: Normal
14. Lateral Tibial Plateau: Normal
15. Popliteus: Normal
16. Popliteal Hiatus: Normal
A partial medial meniscectomy was performed. Using a combination of an upbiting basket, straight
basket and a 4.2 mm Cuda shaver I removed 50 % of the ro.
Dislocation of Shoulder Joint
A case study on a patient with dislocation of the acromial end of the clavicle
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Massive Haemothorax and Acute Abdomen due to Bullet Injury.pdf
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M132 Module 06 Coding Assignment 1. Case Study #1PREOPERAT.docx
M132 Module 06 Coding Assignment
1. Case Study #1
PREOPERATIVE DIAGNOSIS: Carcinoma of the right breast, status post neoadjuvant chemotherapy.
POSTOPERATIVE DIAGNOSIS: Carcinoma of the right breast, status post neoadjuvant chemotherapy.
PROCEDURE PERFORMED: Right modified radical mastectomy, left prophylactic mastectomy
PREOPERATIVE HISTORY: The patient is an unfortunate 37-year-old woman who had a pregnancy associated breast cancer of the right breast with extensive involvement of the breast, clinically a stage III breast cancer. She underwent neoadjuvant chemotherapy with a complete clinical response to therapy with no residual palpable tumor in the breast and no palpable adenopathy. She has elected to undergo a bilateral mastectomy. She will have reconstructive surgery at a later time.
OPERATIVE NOTE: The patient was taken to the operating room. General anesthesia was induced. A Foley catheter was inserted. Her arms were placed on pads. Her legs were placed on pads. Bear hugger was applied and her entire upper torso was sterilely prepped and draped in usual fashion. Symmetric skin sparing mastectomies were planned incorporating the nipple-areolar complex on both sides. We began on the left side. An elliptical incision was made incorporating the nipple-areolar complex, carried down through the skin into the subcutaneous tissue. Flaps were raised circumferentially from the superior aspect to the clavicle, medially to the midline, inferiorly to the inframammary, fold and laterally out to the latissimus dorsi. The breast was then removed from the pectoralis major muscle incorporating the fascia, reflected laterally and truncated. It was marked for orientation, weighed and sent to pathology. Hemostasis was achieved where necessary using electrocautery. There was no evidence of bleeding at the end of the case. Moist laps were placed under the flaps and we moved to the right breast. Again, an elliptical incision was created incorporating the nipple-areolar complex and a little more skin laterally in that breast because the breast was a larger breast on that side. Flaps again were raised from superior infraclavicular and a portion of the breast circumferentially to the midline and subsequently to the inframammary fold and subsequently out to the latissimus dorsi muscle. The breast was removed from the pectoralis major muscle incorporating the fascia, reflected laterally. The clavipectoral fascia was opened and a level I and level II axillary lymph node dissection was performed on both sides, sparing the long thoracic and the thoracodorsal neurovascular bundle, as well as at least 1 intercostal brachial cutaneous nerves. The axillary lymph nodes will be examined for metastasis. There was no palpable adenopathy in level III. The breast and axilla were marked for orientation, weighed and sent to pathology. Irrigation was performed. Hemostasis was achieved where necessary using some Surgiclips and electrocautery. There was no evidence of blee ...
Diagnostic Coding ICD-10-CMAssignment 1.3Diagnostic C.docx
Diagnostic Coding: ICD-10-CM
Assignment 1.3
Diagnostic Coding: ICD-10-CM
W6: Coding
Your Name:
Part 1
Instructions: Review each case and identify the first-listed diagnosis.
1. Pain, left knee. History of injury to left knee 20 years ago. Patient underwent arthroscopic surgery and medial meniscectomy, right knee (10 years ago). Probable arthritis, left knee.
FIRST-LISTED DIAGNOSIS: ________
2. Patient admitted to the emergency department (ED) with complaints of severe chest pain. Possible myocardial infarction. EKG and cardiac enzymes revealed normal findings. Diagnosis upon discharge was gastroesophageal reflux disease.
FIRST-LISTED DIAGNOSIS: ______
3. Female patient seen in the office for follow-up of hypertension. The nurse noticed upper arm bruising on the patient and asked how she sustained the bruising. The physician renewed the patient’s hypertension prescription, hydrochlorothiazide.
FIRST-LISTED DIAGNOSIS: _______
4. Ten-year-old male seen in the office for sore throat. Nurse swabbed patient’s throat and sent swabs to the hospital lab for strep test. Physician documented “likely strep throat” on the patient’s record.
FIRST-LISTED DIAGNOSIS: _____
5. Patient was seen in the outpatient department to have a lump in his abdomen evaluated and removed. Surgeon removed the lump and pathology report revealed that the lump was a lipoma.
FIRST-LISTED DIAGNOSIS: _____
Part 2
Instructions: Match the diagnosis in the right-hand column with the procedure/service in the left-hand column that justifies medical necessity.
E 6. allergy test a. bronchial asthma
B 7. EKG b. chest pain
A 8. inhalation treatment c. family history, cervical cancer
C 9. Pap smear d. fractured wrist
G 10. removal of ear wax e. hay fever
I_ 11. sigmoidoscopy f. hematuria
J 12. strep test g. impacted cerumen
F 13. urinalysis h. jaundice
H 14. venipuncture i. rectal bleeding
D 15. X-ray, radius and ulna j. sore throat
Part 3
Instructions: Review the following SOAP notes or Operative reports to select the diagnoses that should be reported on the CMS-1500 claim. Then assign ICD-10-CM codes to diagnoses. (The level of service is indicated for each visit.)
16.
S: A 53-year-old new patient was seen today for a level 2 visit. The female patient presents with complaints of polyuria, polydipsia, and weight loss.
O: Urinalysis by dip, automated, with microscopy reveals elevated glucose.
A: Possible diabetes.
P: The patient is to have a glucose tolerance test and return in three days for her blood work results and applicable management of care.
Diagnoses
ICD Codes
Polyuria
R35.8
polydipsia
R63.1
weight loss
R63.4
Urinalysis
R81
17.
PREOPERATIVE DIAGNOSIS: Ventral hernia
POSTOPERATIVE DIAGNOSIS: Ventral hernia
PROCEDURE PERFORMED: Repair of ventral hernia with mesh
ANESTHESIA: General
PROCEDURE: The vertical midline incision was opened. Sharp and blunt dissection was used in defining the hernia .
OPSX32SandallOscarMCCG240 Case Scenario OPSX32 Sandall, Os.docx
OPSX32SandallOscar
MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]
Outpatient Surgery
Patient Case Number: OPSX32-Sandall, Oscar
Patient Name: Oscar Sandall DOB: 02-19-72 Sex: M
Date of Service: 05-05-XX Surgeon: Sandra Cullman, MD
Pre-Operative Diagnosis
Right knee complex medial
meniscus tear
Post-Operative Diagnosis
Right knee complex medial meniscus tear and medial plica
Procedure Performed: Knee arthroscopy w/ partial medial meniscectomy, chondroplasty of medial
femoral condyle, excision of medial plica
Anesthesia: General Complications: None
Indication for Procedure:
The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain
for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with
partial medial meniscectomy. The risks, benefits and possible complications from the surgery were
discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding,
neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not
improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is
an increased chance of developing or accelerating any existing arthritis in that knee. The patient also
understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary
embolus and death.
Description of Procedure:
After consent was obtained the patient was taken to the operating room and was administered a general
anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity
was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower
extremity and the tourniquet inflated to 325 mmHg. a superomedial portal was made for the introduction
of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial
portal was made for the introduction of arthroscopic instruments. The findings are as follows:
1. Suprapatellar pouch: Normal
2. Medial plica: Frayed
3. Medial gutter: Normal
4. Lateral gutter: Normal
OPSX32SandallOscar
MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]
5. Patella: Normal
6. Trochlea: Grade I Chondromalacia - Softening Articular Cartilage
7. Medial Femoral Condyle: Grade IIA Chondromalacia - Fissures/Fragmentation Articular Cartilage
<50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50%
8. Medial meniscus: Tear, Complex- Root, Posterior Horn, Body
9. Medial Tibial Plateau: Normal
10. ACL: Normal
11. PCL: Normal
12. Lateral Femoral Condyle: Normal
13. Lateral Meniscus: Normal
14. Lateral Tibial Plateau: Normal
15. Popliteus: Normal
16. Popliteal Hiatus: Normal
A partial medial meniscectomy was performed. Using a combination of an upbiting basket, straight
basket and a 4.2 mm Cuda shaver I removed 50 % of the ro.
Dislocation of Shoulder Joint
A case study on a patient with dislocation of the acromial end of the clavicle
Inferior Vena Caval Injury - A case report
This patient's shock was reluctant to resuscitation by I/V fluids, blood transfusion and all sorts of effort. I opened his abdomen with taking double bond consent. So he was saved. Thanks God.
Case of TMJ Subluxation
Dr Bhavik Miyani,
Resident Doctor in Department of Oral & Maxillofacial Surgery,
NPDCH, SPU, Visnagar.
Massive Haemothorax and Acute Abdomen due to Bullet Injury.pdf
Massive Haemothorax and Acute Abdomen due to Bullet Injury.
SOJ Anesthesiology & Pain Management
Development of Abdominal Compartment Syndrome in an 82-Year-Old Female Patient Immediately Following A Right Hip Arthroplasty
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M132 Module 06 Coding Assignment 1. Case Study #1PREOPERAT.docx
M132 Module 06 Coding Assignment 1. Case Study #1PREOPERAT.docx
Diagnostic Coding ICD-10-CMAssignment 1.3Diagnostic C.docx
Diagnostic Coding ICD-10-CMAssignment 1.3Diagnostic C.docx
OPSX32SandallOscarMCCG240 Case Scenario OPSX32 Sandall, Os.docx
OPSX32SandallOscarMCCG240 Case Scenario OPSX32 Sandall, Os.docx
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Imaging of tmj in dental radiography and advanced technologies in dental imag...
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The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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Case 5
- 1. Rare injury crush under lift !!!!! – while picking up mobile phone from bottom of lift pit ( buffer area) Time of injury – at around 9 am on 23-012012. Reached our hospital at 1 pm .
- 3. Hb% - 6.6gm (normal-13.5-18 gm )
- 6. LEFT HAEMOTHORAX (moderate) FRACTURE FLOOR of GLENOID AND BLADE SCAPULA LEFT LACERATION CAUDATE LOBE LIVER LACERATION SUPERIOR POLE SPLEEN with HAEMOPEROTONEUM FRACTURE NECK OF FEMUR RIGHT # SUBTROCHANTERIC COMMUNITED – LEFT.
- 7. Total 7 units blood transfusions given along with IV Antibiotics, NSAIDS and IV fluids. Skin tractions- both lower limbs for effective pain management and length maintenance.
- 8. Chest injury: ICD( Inter costal tube drainage) on 24-012012 Total 750ml bloody fluid was drained over 4 days . ABDOMINAL INJURY : Managed conservatively.
- 9. ORTHOPAEDIC injuries: RIGHT SIDE- Neck of femur # fixed with Cancellous screws LEFT SIDE- Sub Trochanteric # fixed with Proximal femoral nailing. Post operative period – uneventful.
- 13. Fracture united AFTER IMPLANT REMOVAL