The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Exercise 2

Case 7-2
LOCATION: Inpatient, Hospital
PATIENT: Sara Milton
ATTENDING/ADMIT PHYSICIAN: Alma Naraquist, MD
SURGEON: Larry P. Friendly, MD
PREOPERATIVE DIAGNOSIS: Abdominal sepsis.
POSTOPERATIVE DIAGNOSIS: Myeloproliferative disorder; sigmoid perforation, pleural effusion, abdominal sepsis.
PROCEDURES PERFORMED
1. Exploratory laparotomy with splenectomy.
2. Sigmoid colectomy with the Hartmann procedure and mobilization of the splenic flexure.
3. Tru-Cut biopsy of liver times two.
4. Placement of right #28 French chest tube.
ANESTHESIA: General.
INDICATIONS: The patient is a 69-year-old female admitted with abdominal pain this past Friday. CT scan showed an infarction of a very large spleen. Over the weekend, she developed increasing pain, then required fluid resuscitation and was found to have question of free air on upright abdominal x-ray. Her abdominal examination was consistent with intraperitoneal catastrophe, and we discussed operative intervention, including splenectomy, possible bowel resection, possible colostomy, and placement of a right-sided chest tube for a very large right pleural effusion, with the patient and her husband. They understood this and wished to proceed.
PROCEDURE: The patient was brought down to the operating room and placed under general anesthesia after an A-line and right CVP line were placed by anesthesia. A midline incision was made with a #10 blade, and dissection was carried down through subcutaneous tissues using electrocautery. The subcutaneous tissue was very edematous. We divided the midline fascia and then opened the peritoneum sharply, allowing entry into the peritoneal cavity. There was hemorrhagic fluid within the peritoneal cavity. We could see a very large spleen. We took down the phrenic attachments as well as the splenic flexure, the peritoneal attachments between right angle clamps, and then identified the splenic vein and splenic artery, and doubly tied these proximally and singly tied them distally before dividing them. We then removed the spleen and sent it to pathology for frozen section, where it was consistent with some type of myeloproliferative disorder going on. We ran the bowel, and found that the sigmoid colon was attached to the mesentery of the proximal jejunum. There was a hematoma here that had ruptured, and in dissecting the hematoma free we could see a small perforation in the sigmoid colon. We debrided the mesentery, debrided the mesenteric abscess, and then divided the sigmoid mesentery between right angle clamps and tied the vascular pedicles with 2-0 silk free ties. We fired a TLC-75 stapler distally across the distal sigmoid colon and then mobilized the splenic flexure and fired it proximally across the descending colon. We sent the sigmoid out for permanent section. After we had freely mobilized the splenic flexure and debrided the abscess cavity, we irrigated with saline until returns were clear. We did two Tru-Cut needle biopsies of the left lobe of the liver and controlled bleeding with electrocautery. The remainder of the bowel appeared normal. We then made a stomal opening in the left lower quadrant by grasping the skin with a Kocher clamp, excising it in an elliptical fashion, dividing the anterior and posterior sheath in cruciate fashion, and delivering the descending colon through the stomal opening. We then closed the midline fascia with a combination of interrupted 0 Vicryl and running 0 PDS. The skin was closed loosely with a few skin clips. We then secured the colon with 3-0 Vicryl sutures. The colon appeared viable. Also the small bowel, which had appeared patchy at first, was quite viable when we had completed the procedure. We then prepped the right chest and we made an incision with a #11 blade. We carried our dissection up over the top of approximately the fourth or the fifth ribs, entered the pleural space with a Kelly clamp, dilated the tract with a Kelly clamp, and then placed a #28 French chest tube. We returned about 900 cc of bloody fluid from the chest. We secured this in place, hooked it up to -20 cm of water suction, and then dressed it. The patient was then left intubated and taken to the surgical critical care unit in critical but stable condition.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. Is the exploratory laparotomy reported separately? _________________
2. Does the Hartmann procedure affect the selection of the colectomy code? _________________
3. Were the procedures performed open or closed? _________________
4. Would "mobilization of splenic flexure" be reported separately? _________________
5. Does the "separate procedure" designation affect the splenectomy CPT code selection? _________________
6. What type of biopsy is a Tru-Cut liver biopsy? _________________
7. What procedure is reported with a CPT code that requires a modifier or modifiers to be appended to the code? _________________
8. Was general anesthesia provided during the procedure? _______________