AAPC - Chapter 12 Practical Applications

CASE 1 Preoperative diagnosis: Transitional cell carcinoma in the bladder. Postoperative diagnosis: Transitional cell carcinoma in the bladder. (This is the diagnosis to report, since the pre and post-operative diagnoses are the same. The operative note is consistent with a tumor on the posterior bladder wall. Pathology is not back yet, but the stated diagnosis is transitional cell carcinoma in the bladder. In the US, 90% of all bladder cancers are transitional cell in origin. This is sometimes referred to as urothelial carcinoma.) Procedure: Cystoscopy; Excision bladder tumor -1 cm. Bilateral retrograde pyelogram. Cytology of bladder. Anesthesia: General. (Anesthesia, local or general, is usually not reported by the physician performing the procedure. This information is for documentation quality purposes only.) Estimated Blood Loss: 10 cc. Complications: None. Counts: Correct. Indications: The patient is a 58 year-old male status post partial cystectomy for transitional cell carcinoma of the bladder. He understood the risks and benefits of today's procedure, and elected to proceed. Procedure Description: The patient was brought to the operating room, placed on the operating room table, and placed in the supine position. After adequate LMA anesthesia was accomplished he was put in the dorsal lithotomy position and prepped and draped in the usual sterile fashion.