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The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
Edition 1ISBN: 978-0323430777 Exercise 1
Case 8-1
Assign an external cause code to indicate how the injury occurred.
LOCATION: Inpatient, Hospital
PATIENT: Tara Barron
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant.
POSTOPERATIVE DIAGNOSIS: Same as Preoperative.
PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect.
ANESTHESIA: General.
PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from around the knife as well as the patient's clothing, and prepped with Betadine solution. We extended the incision on either side of the right upper quadrant stab wound 2-3 cm and carried the dissection through subcutaneous tissues using electrocautery. We followed the knife down along its tract and then could see the knife had penetrated the anterior sheath and the rectus fascia by about a quarter inch. We removed the knife and could see the tip was just within the rectus muscle. There was no peritoneal penetration. We then closed the fascia with interrupted 0 Vicryl and closed the skin with vertical mattress 3-0 Ethilon sutures.
All sponge and needle counts were correct. Patient tolerated this well and was taken to recovery in stable condition.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What is the main term in the CPT referenced for this procedure? _________________
2. What is the secondary term in the CPT referenced to report this procedure? _________________
3. Can the repair be reported separately? _________________
4. How far had the knife penetrated? _________________
Assign an external cause code to indicate how the injury occurred.
LOCATION: Inpatient, Hospital
PATIENT: Tara Barron
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Stab wound, right upper abdominal quadrant.
POSTOPERATIVE DIAGNOSIS: Same as Preoperative.
PROCEDURE PERFORMED: Exploration of stab wound, right upper quadrant of abdomen, with closure of fascial defect.
ANESTHESIA: General.
PROCEDURE: The patient was brought to the operating room and placed under general anesthesia; we then removed the jar lid from around the knife as well as the patient's clothing, and prepped with Betadine solution. We extended the incision on either side of the right upper quadrant stab wound 2-3 cm and carried the dissection through subcutaneous tissues using electrocautery. We followed the knife down along its tract and then could see the knife had penetrated the anterior sheath and the rectus fascia by about a quarter inch. We removed the knife and could see the tip was just within the rectus muscle. There was no peritoneal penetration. We then closed the fascia with interrupted 0 Vicryl and closed the skin with vertical mattress 3-0 Ethilon sutures.
All sponge and needle counts were correct. Patient tolerated this well and was taken to recovery in stable condition.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What is the main term in the CPT referenced for this procedure? _________________
2. What is the secondary term in the CPT referenced to report this procedure? _________________
3. Can the repair be reported separately? _________________
4. How far had the knife penetrated? _________________
Explanation
Verified
Verified
The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck
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