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[answered] M132 Module 07 Coding Assignment Build the correct ICD 10 P


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M132 Module 07 Coding Assignment

 

Build the correct ICD 10 PCS code based on the documentation in the Operative Report

 

documentation given under each Case Study.

 

1. Case# 1

 

PREOPERATIVE DIAGNOSES:

 

1. Interstitial cystitis.

 

2. Urethral stenosis.

 

POSTOPERATIVE DIAGNOSES:

 

1. Interstitial cystitis.

 

2. Urethral stenosis.

 

Procedures:

 

1. Cystoscopy.

 

2. Urethral dilation and hydrodilation.

 

Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is

 

normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is

 

normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with

 

interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL.

 

The patient was brought to the cystoscopy suite and placed on the table in lithotomy position. The

 

patient was prepped and draped in the usual sterile fashion. A 21 Olympus cystoscope was inserted and

 

the bladder, viewed with 12- and 70-degree lenses. Bladder was filled by gravity to capacity, emptied and

 

again cystoscopy was performed with findings as above. Urethra was then calibrated with 32-French.

 

The patient was taken to the recovery room in stable condition.

 

ICD-10-PCS Code: Click here to enter text. 2. Case #2

 

PREOPERATIVE DIAGNOSIS:

 

1. Atrophic left testis.

 

2. Right spermatocele.

 

POSTOPERATIVE DIAGNOSIS:

 

1. Atrophic left testis.

 

2. Right spermatocele.

 

PROCEDURE PERFORMED:

 

1. Right scrotal exploration, and right spermatocelectomy.

 

2. Left scrotal exploration and left orchiectomy.

 

INDICATIONS: This 55-year-old gentleman was admitted to this Hospital approximately 4 months ago

 

with bilateral testicular pain and swelling and enlargement. Ultrasound revealed a cystic mass of the right scrotum consistent with right hydrocele. On the left side, the patient had severe left epididymitis/orchitis

 

that turned to an abscess with spontaneous drainage. Subsequent ultrasounds revealed essentially no

 

vascular flow to the left testis and the testes gradually became smaller, but it was painful to the patient.

 

The patient requested surgery because of pain in the left side and because of enlargement of the right side,

 

which he states interfered with his sexual

 

activity. The patient was advised that following that spermatocelectomy on the right side, the patient

 

could have recurrence of the spermatocele/bleeding/infection and pain.

 

DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia, the patient was prepped and

 

draped in a supine position. An incision was made in the midline of the scrotum vertically. The right testis

 

was exposed and delivered from the incision. This was done within the sac of the spermatocele.

 

Spermatocele was identified, being adherent to the right epididymis. There was significant adherence and

 

numerous small blood vessels present and adherence of the spermatocele sac to both the testis and the

 

epididymis. Dissection was done sharply. The sac was excised, sent to histology. Care was taken to

 

preserve the blood supply to the right testis. The small bleeding points were cauterized or suture ligated.

 

Hemostasis was also directed towards the scrotal wall. Again, these were controlled by fulguration or

 

suture ligature. The testis was placed back into its anatomic position on the right scrotal sac. A 5/8

 

Penrose nurse drain was left indwelling and brought out a separate stab incision.

 

Attention was then directed to the left scrotal cavity where it was incised, exposing the left testicle with

 

much difficulty because of the abscess formation the patient had. This required total sharp dissection,

 

which we also incurred some numerous bleeding points. These were controlled by cauterization. Finally,

 

the spermatic cord was isolated. It was clamped and spermatic cord cut

 

and the testicle was then removed. The bleeding points were controlled with ties of 2-0 Vicryl. Both

 

scrotal cavities were irrigated thoroughly. As on the right side, a Penrose drain was left indwelling

 

brought out separate stab incision, and then the wound was closed with interrupted sutures of 3-0 chromic

 

catgut. Sterile dressings were applied as well as a scrotal support and the

 

patient taken to recovery room in good condition.

 

ICD-10-PCS Code: Click here to enter text. 3. Case #3

 

Operative Report

 

Preoperative Diagnosis: Vulvar dysplasia.

 

Postoperative Diagnosis: Vulvar dysplasia.

 

PROCEDURE: Partial vulvectomy and vulvar biopsies.

 

ANESTHESIA: General endotracheal anesthesia.

 

PROCEDURE: The patient was prepped and draped sterilely in the lithotomy position. The lesions were

 

at the base of the labia majora bilaterally, extending onto the perineal body. An elliptical incision was

 

made starting about halfway up on the labia minora on the left, bringing it around on the perineal body on

 

the outside and around the hymenal ring on the inside, up to about halfway up the labia on the opposite

 

side. The Bovie cautery was then used to undermine the subcutaneous tissues and the specimen was marked at 12 o?clock and frozen section biopsy submitted to pathology, proven to be dysplasia. I

 

obtained frozen section biopsies from 2, 4 and 6 o?clock, and all were reported as negative for dysplasia.

 

The area was closed with a running, locking 2-0 Vicryl, starting in the midline and working up the right

 

labia and then starting in the midline and working up the left labia. Gentamicin ointment was applied to

 

the incision sites, and the patient was then awakened and sent to recovery in stable condition.

 

ICD-10-PCS code: Click here to enter text.

 


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