___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
1. OPD6986 OPD6986 MEDICAL RECORD
Age: 68 Sex: Male DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAG-
K62.3 NOSIS: PROLAPSE RECTUM. PROCEDURES: REDUCTION OF PROLAPSED
45900 RECTUM UNDER ANESTHESIA. POSTOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM. SURGEON: M.D. ANESTHESIA: GENERAL VIA FACE MASK.
The diagnosis is pro-
ANESTHESIOLOGIST: RUNG-TAN Andrews ESTIMATE BLOOD LOSS: NIL.
lapsed rectum. Anoth-
DRAINS: NONE. IV FLUIDS: LACTATED RINGER'S COMPLICATIONS: NONE.
er name for this pro-
INDICATIONS: This is a male with history of constipation who presented to
lapse is procidentia. In
the ED with prolapse rectum that was not reducible by self. PROCEDURE:
the ICD-10-CM Alpha-
The patient was brought into the operating room and laid supine on the
betic Index, look for
operating table. After anesthesia was induced, the patient was placed in
Prolapse, rectum (mu-
the lithotomy position. A rectal exam was carried out digitally, and the
cosa)(sphincter) K62.3.
anal sphincter was noted to be lax. The prolapsed rectum was noted to
Verify all coding se-
be viable with no ulceration or ischemia, it was easily reduced back into
lections in the Tabular
the pelvis. A small Vaseline tampon was placed in the anal canal and the
List. The correct prima-
buttocks were taped together to discourage re-prolapse. The patient was
ry diagnosis coding is:
then returned back into the supine position. The patient was awoken in
K62.3.
the operating room and taken to the recovery room. Sponge, needle,
and instrument counts were correct at the end of the case. Electronically
The procedure per-
signed by: MD 1/1/20XX
formed is reduction of
rectal prolapse under
anesthesia. In the CPT
Alphabetic Index, look
for Prolapse, Rectum
45130-45135, 45900,
46753. Verify all coding
selections in the Tabu-
lar List. CPT 45900 is
for reduction of pro-
lapsed rectum under
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
anesthesia. The correct
CPT coding is: 45900.
2. OPD7007 OPD7007 MEDICAL RECORD
SEX: Male AGE:38 DATE OF SERVICE: 01/01/20XX DIAGNOSIS: Chronic
J35.01 Tonsillitis ANESTHESIA: GENERAL DESCRIPTION OF PROCEDURE: The pa-
42826 tient was brought into the operating room and placed supine on the
operating room table. General anesthesia was administered. An orotra-
The patient is diag-
cheal tube was placed by the anesthesiologist. The operating room table
nosed with chronic ton-
was then turned to the left 90 degrees and the patient's head and neck
sillitis. Look In the
region was prepped and draped in the usual fashion for bilateral tonsil-
ICD-10-CM Alphabetic
lectomy. A shoulder roll was placed. A Crowe-Davis mouth retractor was
Index for Tonsillitis/
inserted and a head drape was positioned. The patient's eyes were also
chronic J35.01. Verify
protected. Upon opening the Crowe-Davis mouth retractor, there was no
all code selection in the
evidence of bifid uvula or submucous clefting. Red rubber catheters were
Tabular List. The cor-
then passed through the nose into the oral cavity to retract soft palate
rect Primary ICD 10 CM
anteriorly. Straight Allis clamps were used to grasp the tonsils at the
coding is: J35.01.
superior pole and retract the tonsils inferomedially. Using the Coblation
device on coagulation settings. The tonsils were dissected out of the
The surgeon performs
tonsillar fossae from superior to inferior along the tonsil capsule. Once
a tonsillectomy on
the tonsils were removed from the fossae, adequate hemostasis was
a 38-year-old patient.
obtained in the tonsillar fossae using the Coblation device on coagulation
Look in the CPT® code
settings. Copious amounts of saline were irrigated into the oral cavity
book Index for Ton-
and orogastric suction was then passed to evacuate stomach of its se-
sils/ Excision (Tonsillec-
cretions. Naropin 0.5% was also infiltrated into the anterior and posterior
tomy) 42825, 42826.
tonsillar pillars approximately 3 mL was used in total. Upon releasing the
Verify code selection.
Crowe-Davis mouth retractor for one minute and opening there was no
The correct CPT coding
evidence of bleeding. The patient was then turned back around to the
is: 42826
anesthesiologist for extubation. Upon awakening from extubation, there
seemed to be bleeding arising from the nose.
3.
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
OPD7033 OPD7033 MEDICAL RECORD
RADIOLOGY REPORT Location: Valley Hospital PATIENT: Hedy Smith SEX:
G93.40 F AGE: 75 DATE OF EXAM: 1/1/20XX REFERRING PHYSICIAN(S): Robert
70551-26 Thompson M.D. PROCEDURE: MRI BRAIN WITHOUT CONTRAST COM-
PARISON: CT study dated 08/30/20XX. INDICATIONS: Encephalopathy.
Encephalopathy is a
Question of a pineal cyst. TECHNIQUE: Sagittal FLAIR; axial T1, FLAIR, fast
group of conditions
spin echo T2, and diffuse weighted images were obtained. FINDINGS:
that can cause brain
The ventricles are normal size for age. There is no shift. No abnormal
dysfunction. Possible
extra-axial fluid collections. On the T2 weighted images, there are some
etiologies include in-
scattered areas of bright signal in the white matter tracts superiorly.
jury, drugs, exposure
These are probably old gliosis changes. No signs of any extra-axial
to certain chemicals,
fluid collections. No new masses are seen. There are no signs of any
or underlying systemic
expanding mass lesions in the pineal region. There is no abnormal signal
diseases (such as cir-
change to suggest any new ischemia or new hemorrhage. CONCLUSION:
rhosis and liver failure).
1. Encephalopathy. Electronically signed by S. Smith MD1/1/20XX
The indexing pathway
for it in the ICD-10 is
Encephalopathy, which
is G93.40.
The procedure per-
formed was magnet-
ic resonance imaging
(MRI) of the brain with-
out contrast. In the
CPT book, the index-
ing pathway is Magnet-
ic Resonance Imaging
-> Diagnostic -> Brain,
which leads to code
range 70551 - 70555.
70551 is the only code
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
for an MRI without
contrast. The proce-
dure was performed at
the hospital that owns
the equipment, so only
the professional com-
ponent would need to
be reported with mod-
ifier 26. The final code
selection is 70551-26.
4. OPD6984 OPD6984 MEDICAL RECORD
SEX: MALE Age: 62 DATE OF OPERATION: 01/1/20XX PREOPERATIVE DI-
T18.3XXA AGNOSIS: SMALL BOWEL OBSTRUCTION. PROCEDURES: EXPLORATORY
44020 LAPAROTOMY, SMALL BOWEL ENTEROTOMY, REMOVAL OF FOREIGN OB-
JECT AND CLOSURE. POSTOPERATIVE DIAGNOSIS: BEZOAR OBSTRUCT-
The diagnosis is small
ING THE ILEOCECAL VALVE. SURGEON: M.D. FIRST ASSISTANT: ESTIMATE
body obstruction due
BLOOD LOSS: 20 CC. IV FLUIDS: 2 LITERS. WOUND: CONTAMINATED.
to a bezoar (foreign
DISPOSITION: POSTOPERATIVELY, THE PATIENT REMAINED INTUBATED
body). Look in the
AND WAS TRANSFERRED TO THE SURGICAL ICU. INDICATIONS: This is a
ICD-10-CM Alphabetic
male who presented in the operating room with approximately a two-day
Index for Bezoar/intes-
history of nausea, vomiting, abdominal distention, and inability to pass
tine T18.3. When veri-
flatus or stool. Radiographic examination showed dilated bowel gas
fying code selection in
pattern. CAT scan that was done through the emergency room showed
the Tabular List, we see
extensive dilation of most of the entire length of the small bowel with a
this code requires a 7th
collapsed colon. There was no area of obvious perforation nor free air
character. When there
in the entire CAT scan. The scan showed small bowel obstruction at the
is no 5th or 6th char-
level of the ileocecal valve in this patient without a history of previous
acter, a placeholder X
abdominal surgery. The decision was then made to take the patient to
is used as the 5th and
the operating room and perform exploratory laparotomy. The patient was
6th characters. The 7th
then explained the risks and benefits of the procedure and consented for
character is A for active
an exploratory laparotomy, possible bowel resection, possible ostomy.
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
1. OPD6986 OPD6986 MEDICAL RECORD
Age: 68 Sex: Male DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAG-
K62.3 NOSIS: PROLAPSE RECTUM. PROCEDURES: REDUCTION OF PROLAPSED
45900 RECTUM UNDER ANESTHESIA. POSTOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM. SURGEON: M.D. ANESTHESIA: GENERAL VIA FACE MASK.
The diagnosis is pro-
ANESTHESIOLOGIST: RUNG-TAN Andrews ESTIMATE BLOOD LOSS: NIL.
lapsed rectum. Anoth-
DRAINS: NONE. IV FLUIDS: LACTATED RINGER'S COMPLICATIONS: NONE.
er name for this pro-
INDICATIONS: This is a male with history of constipation who presented to
lapse is procidentia. In
the ED with prolapse rectum that was not reducible by self. PROCEDURE:
the ICD-10-CM Alpha-
The patient was brought into the operating room and laid supine on the
betic Index, look for
operating table. After anesthesia was induced, the patient was placed in
Prolapse, rectum (mu-
the lithotomy position. A rectal exam was carried out digitally, and the
cosa)(sphincter) K62.3.
anal sphincter was noted to be lax. The prolapsed rectum was noted to
Verify all coding se-
be viable with no ulceration or ischemia, it was easily reduced back into
lections in the Tabular
the pelvis. A small Vaseline tampon was placed in the anal canal and the
List. The correct prima-
buttocks were taped together to discourage re-prolapse. The patient was
ry diagnosis coding is:
then returned back into the supine position. The patient was awoken in
K62.3.
the operating room and taken to the recovery room. Sponge, needle,
and instrument counts were correct at the end of the case. Electronically
The procedure per-
signed by: MD 1/1/20XX
formed is reduction of
rectal prolapse under
anesthesia. In the CPT
Alphabetic Index, look
for Prolapse, Rectum
45130-45135, 45900,
46753. Verify all coding
selections in the Tabu-
lar List. CPT 45900 is
for reduction of pro-
lapsed rectum under
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
anesthesia. The correct
CPT coding is: 45900.
2. OPD7007 OPD7007 MEDICAL RECORD
SEX: Male AGE:38 DATE OF SERVICE: 01/01/20XX DIAGNOSIS: Chronic
J35.01 Tonsillitis ANESTHESIA: GENERAL DESCRIPTION OF PROCEDURE: The pa-
42826 tient was brought into the operating room and placed supine on the
operating room table. General anesthesia was administered. An orotra-
The patient is diag-
cheal tube was placed by the anesthesiologist. The operating room table
nosed with chronic ton-
was then turned to the left 90 degrees and the patient's head and neck
sillitis. Look In the
region was prepped and draped in the usual fashion for bilateral tonsil-
ICD-10-CM Alphabetic
lectomy. A shoulder roll was placed. A Crowe-Davis mouth retractor was
Index for Tonsillitis/
inserted and a head drape was positioned. The patient's eyes were also
chronic J35.01. Verify
protected. Upon opening the Crowe-Davis mouth retractor, there was no
all code selection in the
evidence of bifid uvula or submucous clefting. Red rubber catheters were
Tabular List. The cor-
then passed through the nose into the oral cavity to retract soft palate
rect Primary ICD 10 CM
anteriorly. Straight Allis clamps were used to grasp the tonsils at the
coding is: J35.01.
superior pole and retract the tonsils inferomedially. Using the Coblation
device on coagulation settings. The tonsils were dissected out of the
The surgeon performs
tonsillar fossae from superior to inferior along the tonsil capsule. Once
a tonsillectomy on
the tonsils were removed from the fossae, adequate hemostasis was
a 38-year-old patient.
obtained in the tonsillar fossae using the Coblation device on coagulation
Look in the CPT® code
settings. Copious amounts of saline were irrigated into the oral cavity
book Index for Ton-
and orogastric suction was then passed to evacuate stomach of its se-
sils/ Excision (Tonsillec-
cretions. Naropin 0.5% was also infiltrated into the anterior and posterior
tomy) 42825, 42826.
tonsillar pillars approximately 3 mL was used in total. Upon releasing the
Verify code selection.
Crowe-Davis mouth retractor for one minute and opening there was no
The correct CPT coding
evidence of bleeding. The patient was then turned back around to the
is: 42826
anesthesiologist for extubation. Upon awakening from extubation, there
seemed to be bleeding arising from the nose.
3.
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
OPD7033 OPD7033 MEDICAL RECORD
RADIOLOGY REPORT Location: Valley Hospital PATIENT: Hedy Smith SEX:
G93.40 F AGE: 75 DATE OF EXAM: 1/1/20XX REFERRING PHYSICIAN(S): Robert
70551-26 Thompson M.D. PROCEDURE: MRI BRAIN WITHOUT CONTRAST COM-
PARISON: CT study dated 08/30/20XX. INDICATIONS: Encephalopathy.
Encephalopathy is a
Question of a pineal cyst. TECHNIQUE: Sagittal FLAIR; axial T1, FLAIR, fast
group of conditions
spin echo T2, and diffuse weighted images were obtained. FINDINGS:
that can cause brain
The ventricles are normal size for age. There is no shift. No abnormal
dysfunction. Possible
extra-axial fluid collections. On the T2 weighted images, there are some
etiologies include in-
scattered areas of bright signal in the white matter tracts superiorly.
jury, drugs, exposure
These are probably old gliosis changes. No signs of any extra-axial
to certain chemicals,
fluid collections. No new masses are seen. There are no signs of any
or underlying systemic
expanding mass lesions in the pineal region. There is no abnormal signal
diseases (such as cir-
change to suggest any new ischemia or new hemorrhage. CONCLUSION:
rhosis and liver failure).
1. Encephalopathy. Electronically signed by S. Smith MD1/1/20XX
The indexing pathway
for it in the ICD-10 is
Encephalopathy, which
is G93.40.
The procedure per-
formed was magnet-
ic resonance imaging
(MRI) of the brain with-
out contrast. In the
CPT book, the index-
ing pathway is Magnet-
ic Resonance Imaging
-> Diagnostic -> Brain,
which leads to code
range 70551 - 70555.
70551 is the only code
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
,___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
Practicode Cases Part 1
Study online at https://quizlet.com/_ijotm0
for an MRI without
contrast. The proce-
dure was performed at
the hospital that owns
the equipment, so only
the professional com-
ponent would need to
be reported with mod-
ifier 26. The final code
selection is 70551-26.
4. OPD6984 OPD6984 MEDICAL RECORD
SEX: MALE Age: 62 DATE OF OPERATION: 01/1/20XX PREOPERATIVE DI-
T18.3XXA AGNOSIS: SMALL BOWEL OBSTRUCTION. PROCEDURES: EXPLORATORY
44020 LAPAROTOMY, SMALL BOWEL ENTEROTOMY, REMOVAL OF FOREIGN OB-
JECT AND CLOSURE. POSTOPERATIVE DIAGNOSIS: BEZOAR OBSTRUCT-
The diagnosis is small
ING THE ILEOCECAL VALVE. SURGEON: M.D. FIRST ASSISTANT: ESTIMATE
body obstruction due
BLOOD LOSS: 20 CC. IV FLUIDS: 2 LITERS. WOUND: CONTAMINATED.
to a bezoar (foreign
DISPOSITION: POSTOPERATIVELY, THE PATIENT REMAINED INTUBATED
body). Look in the
AND WAS TRANSFERRED TO THE SURGICAL ICU. INDICATIONS: This is a
ICD-10-CM Alphabetic
male who presented in the operating room with approximately a two-day
Index for Bezoar/intes-
history of nausea, vomiting, abdominal distention, and inability to pass
tine T18.3. When veri-
flatus or stool. Radiographic examination showed dilated bowel gas
fying code selection in
pattern. CAT scan that was done through the emergency room showed
the Tabular List, we see
extensive dilation of most of the entire length of the small bowel with a
this code requires a 7th
collapsed colon. There was no area of obvious perforation nor free air
character. When there
in the entire CAT scan. The scan showed small bowel obstruction at the
is no 5th or 6th char-
level of the ileocecal valve in this patient without a history of previous
acter, a placeholder X
abdominal surgery. The decision was then made to take the patient to
is used as the 5th and
the operating room and perform exploratory laparotomy. The patient was
6th characters. The 7th
then explained the risks and benefits of the procedure and consented for
character is A for active
an exploratory laparotomy, possible bowel resection, possible ostomy.
___________________________________________________________________________________________________________________________________
____)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))_________________________________________________________________________________________________
Practicode Cases Part 1.pdf!#()*_*$_!*$__________________________)(&)$*&!)($)(*&&*^(&(#()))))))))))))))))))))))))))))))____________________________________
