Unit V Homework
For this assignment, you will act as the coding auditor at your local acute care hospital. You have been tasked with reviewing the Current Procedural Terminology (CPT) codes of the outpatient surgery cases for Stan Decodingman, a relatively new coder at your facility.
Remember to review all guidelines and notes in the CPT manual to properly document the feedback to Stan Decodingman. It is important as an auditor that you not only utilize critical thinking to analyze whether the assigned code is correct or incorrect, but that you then synthesize your knowledge to provide the reasoning and evidence when the coding is incorrect.You will utilize this Unit V Homework Worksheet to audit the outpatient surgery cases and the codes assigned by Stan Decodingman. In the Feedback section of each case in the worksheet, you must:
- indicate whether his code is correct or incorrect,
- provide detailed feedback for any noted errors, and
- include the page number in the CPT manual where the proper code information can be found.
Ensure your feedback is clear and concise and all tasks listed above are completed. Once you have audited all five cases, you will save the worksheet and upload it into Blackboard for grading. APA formatting is not required for this assignment.
Unit V Homework Instructions For this assignment, you will act as the coding auditor at your local acute care hospital. You have been tasked with reviewing the Current Procedural Terminology (CPT) cod
Audit Worksheet for Outpatient Surgery Cases Coder: Stan Decodingman Auditor: (your name here) Chart #1 Operative Report Preoperative Diagnosis: Displaced comminuted fracture of the lateral condyle, right elbow Postoperative Diagnosis: Same Procedure: Open reduction, internal fixation Description: The patient was anesthetized and prepped with Betadine. Sterile drapes were applied, and the pneumatic tourniquet was inflated around the arm. An incision was made in the area of the lateral epicondyle through a Steri-Drape, and this was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two planes about 90 degrees. It was possible to manually reduce this quite easily, and the judicious manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. These pins were cut off below skin level. The wound was closed with some plain catgut suture subcutaneously and 5-0 nylon in the skin. Dressing were applied to the patient and tourniquet released. A long arm cast was applied. CPT codes assigned: 24579, 29065 Feedback: (Provide feedback here) Chart #2 Operative Report Preoperative Diagnosis: A 4-mm stone in the right lower pole Postoperative Diagnosis: A 4-mm stone in the right lower pole Procedure: Right extracorporeal shockwave lithotripsy Indications for Procedure: This is a 31-year-old male who recently presented with right renal colic. An x-ray showed a stone in the proximal ureter. He previously underwent a cystourethroscopy, the stone was successfully flushed into the kidney, and a double-J stent was placed in the ureter. Today, he presents for ESWL. An x-ray confirmed location of the stone in the right lower pole. Description of Procedure: The patient was placed onto the treatment table and sedated. He was positioned over the shockwave electrode. Biaxial Fluoroscopy was utilized to position the stone at the focal point of the shockwave generator. The stone was treated with a total of 3.000 shocks. At the conclusion of the procedure, the stone appeared to have garmented nicely, and the patient was discharged to the PACU. CPT code assigned: 52353 Feedback: (Provide feedback here) Chart #3 Operative Report Preoperative Diagnosis: Right inguinal hernia Postoperative Diagnosis: Right inguinal hernia, direct and indirect Procedure: Repair of right inguinal hernia with mesh Description of Procedure: The 43-year-old male was prepped in the usual manner for an initial hernia repair. After satisfactory spinal anesthesia, the inguinal area was draped in the usual sterile manner. A transverse incision was made above the inguinal ligament and carried down to the fascia of the external oblique, which was then opened, and the cord was mobilized. The ilioinguinal nerve was identified and protected. A relatively large indirect hernia was found. However, there was an extension of the hernia, such that one could definitely tell there had been a long-standing hernia here that probably had enlarged fairly recently. The posterior wall, however, was quite dilated and without a great deal of tone and bulging, and probably fit the criteria for a hernia by itself. Nonetheless, the hernia sac was separated from the cord structures, and a high ligation was done with a purse-string suture of 2-0 silk and a suture ligature of the same material prior to amputating the sac. The posterior wall was repaired with Marlex mesh, which was sewn in place in the usual manner, anchoring two sutures at the pubic tubercle tissue, taking one lateral up the rectus sheath and one lateral along the shelving border of Poupart’s ligament past the internal ring. The mesh has been incised laterally to accommodate the internal ring. Several sutures were used to tack the mesh down superiorly and laterally to the transversalis fascia. Then the two limbs of the mesh were brought together laterally to the internal ring and secured to the shelving border of Poupart’s ligament. The mesh was irrigated with gentamicin solution. The subcutaneous tissue was closed with fine Vicryl as was the internal oblique. Marcaine was infiltrated in the subcutaneous tissues and skin. The wound was closed with fine nylon. The patient tolerated the procedure well. CPT code assigned: 49505-RT Feedback: (Provide feedback here) Chart #4 Operative Report Preoperative Diagnosis: Rectal mass, change in bowel habits Postoperative Diagnosis: Rectal prolapse, Colonic polyps, biopsies x 2, significant sigmoid diverticulosis with nonspecific colitis Procedure: Colonoscopy performed to the level of the cecum, 110cm Description of Procedure: The 60-year-old male patient was prepped in the usual fashion, followed by placement in the left lateral decubitus position. I administered 3 mg Versed. Monitoring of sedation was assisted by a trained registered nurses. Next, the Pentax Video Endoscope was passed through the rectal verge after a negative digital examination and advanced to the level of the cecum. The scope was then slowly retracted with a circular tip motion. There was mild nonspecific colitis noted. He did have significant sigmoid diverticulosis and several small polyps just inside the rectum, as well as a large prolapsing mass of mucosa approximately 5 cm inside the rectum. This appears to have prolapsed previously. Two of the small polyps were biopsied using the cold biopsy forceps and sent to pathology for examination. The remainder of the examination was unremarkable. The patient tolerated the procedure well. CPT codes assigned: 45378, 45380 Feedback: (Provide feedback here) Chart #5 Operative Report Preoperative Diagnosis: Fracture of fibula, left Postoperative Diagnosis: Left fibula fracture Procedure: Reduction of fibular fracture Indications and Description of Procedure: This 12-year-old female gymnast felt pain in her leg after hitting the vault at the gym. She is unable to bear any weight on her left leg. Physical examination revealed foot and ankle to be normal. The neurovascular status of the foot is normal. The ankle is nontender and not swollen. Findings are confined to the fibula, 2 inches proximal to the lateral malleolus. There is a point tenderness in this area. An x-ray of the tibia and fibula shows a displaced comminuted fracture of the left fibula, 2 inches proximal to the lateral malleolus. There is point tenderness in this area. An x-ray of the tibia and fibula shows a displaced comminuted fracture of the left fibula. The fracture was reduced, and the patient was put in a short leg splint molded for her from fiberglass, with extensive padding placed over the fracture site. Crutches were provided, and she is instructed not to place any weight on the foot. She was given a supply of Tylenol 3 for pain and will follow up at the clinic in 10 days. CPT code assigned: 27788-LT Feedback: (Provide feedback here)