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Operative Note Coding Assessment 1 with Step-by-Step Rationale
QUESTION ONE
Operative Report:
Patient Name: John Doe
Date of Birth: 02/14/1970
Date of Surgery: 07/30/2024
Surgeon: Dr. Jane Smith
Preoperative Diagnosis: Acute appendicitis
Postoperative Diagnosis: Acute appendicitis without perforation or
gangrene
Procedure Performed: Laparoscopic appendectomy
Indications: The patient is a 54-year-old male who presented with right
lower quadrant abdominal pain, nausea, and fever. Imaging studies
confirmed the diagnosis of acute appendicitis without perforation or
gangrene.
Procedure Description: After informed consent was obtained, the patient
was taken to the operating room and placed in the supine position. General
anesthesia was administered. The abdomen was prepped and draped in the
usual sterile fashion. A Veress needle was inserted at the umbilicus, and
pneumoperitoneum was established with carbon dioxide to 15 mmHg. A
10mm trocar was inserted at the umbilicus, and a laparoscope was
introduced. Two additional 5mm trocars were placed in the left lower
quadrant and suprapubic region under direct visualization.
The appendix was identified, and the mesoappendix was dissected using
electrocautery. The base of the appendix was ligated with an Endoloop, and
the appendix was transected and removed through the umbilical port. The
peritoneal cavity was irrigated with normal saline, and hemostasis was
achieved. The trocars were removed, and the skin incisions were closed with
absorbable sutures. The patient tolerated the procedure well and was taken
to the recovery room in stable condition.
Specimen: Appendix
Complications: None
Estimated Blood Loss: Minimal
, 2
Disposition: Recovery room in stable condition
Select the correct CPT code for this procedure:
A. 44950 - Appendectomy
B. 44960 - Appendectomy; for ruptured appendix with abscess or generalized
peritonitis
C. 44970 - Laparoscopy, surgical, appendectomy
D. 44979 - Unlisted laparoscopy procedure, appendix
Select the correct ICD-10-CM code for the diagnosis:
A. K35.2 - Acute appendicitis with generalized peritonitis
B. K35.3 - Acute appendicitis with localized peritonitis
C. K35.80 - Unspecified acute appendicitis
D. K35.90 - Acute appendicitis without perforation or gangrene
Operative Note Coding Assessment 1 with Step-by-Step Rationale
QUESTION ONE
Operative Report:
Patient Name: John Doe
Date of Birth: 02/14/1970
Date of Surgery: 07/30/2024
Surgeon: Dr. Jane Smith
Preoperative Diagnosis: Acute appendicitis
Postoperative Diagnosis: Acute appendicitis without perforation or
gangrene
Procedure Performed: Laparoscopic appendectomy
Indications: The patient is a 54-year-old male who presented with right
lower quadrant abdominal pain, nausea, and fever. Imaging studies
confirmed the diagnosis of acute appendicitis without perforation or
gangrene.
Procedure Description: After informed consent was obtained, the patient
was taken to the operating room and placed in the supine position. General
anesthesia was administered. The abdomen was prepped and draped in the
usual sterile fashion. A Veress needle was inserted at the umbilicus, and
pneumoperitoneum was established with carbon dioxide to 15 mmHg. A
10mm trocar was inserted at the umbilicus, and a laparoscope was
introduced. Two additional 5mm trocars were placed in the left lower
quadrant and suprapubic region under direct visualization.
The appendix was identified, and the mesoappendix was dissected using
electrocautery. The base of the appendix was ligated with an Endoloop, and
the appendix was transected and removed through the umbilical port. The
peritoneal cavity was irrigated with normal saline, and hemostasis was
achieved. The trocars were removed, and the skin incisions were closed with
absorbable sutures. The patient tolerated the procedure well and was taken
to the recovery room in stable condition.
Specimen: Appendix
Complications: None
Estimated Blood Loss: Minimal
, 2
Disposition: Recovery room in stable condition
Select the correct CPT code for this procedure:
A. 44950 - Appendectomy
B. 44960 - Appendectomy; for ruptured appendix with abscess or generalized
peritonitis
C. 44970 - Laparoscopy, surgical, appendectomy
D. 44979 - Unlisted laparoscopy procedure, appendix
Select the correct ICD-10-CM code for the diagnosis:
A. K35.2 - Acute appendicitis with generalized peritonitis
B. K35.3 - Acute appendicitis with localized peritonitis
C. K35.80 - Unspecified acute appendicitis
D. K35.90 - Acute appendicitis without perforation or gangrene
