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Chapter 17: Practical Application

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    Chapter 17: Practical Application

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    July 2026
    2025/2026
    A+
  • Location: Imaging center, radiologist employed. (Radiologist is employed by the imaging center: the imaging center should report the global component.) STUDY: FEMUR AP AND LATERAL(2 views taken.) REASON: LEFT LEG PAIN LEFT FEMUR: COMPARISON: There are no prior studies for comparison. FINDINGS: There is no fracture or dislocation of the left femur. The femoral head is concentrically seated within the acetabulum without deformity of the femoral head. IMPRESSION: Normal (Findings ...
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Chapter 15-Practical Application

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    Chapter 15-Practical Application

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    6
    July 2026
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  • ANESTHESIA: Laryngeal mask anesthesia. PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye. POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used for coding.) PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right eye. PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye. A limbal peritomy...
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Chapter 14: Application Practice

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    Chapter 14: Application Practice

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    5
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  • 64493-50 M51.36 - Answer PREOPERATIVE DIAGNOSES: 1. LOW BACK PAIN. 2. DEGENERATIVE LUMBAR DISC. POSTOPERATIVE DIAGNOSES: 1. LOW BACK PAIN. 2. DEGENERATIVE LUMBAR DISC. PERFORMED: Bilateral Paravertebral facet joint injection of steroid at the L3-L4 and L4-L5 with fluoroscopic guidance. DESCRIPTION OF PROCEDURE: The patient was transferred to the operative suite and placed in the prone position with a pillow under the abdomen. A smooth IV sedation was given with mi...
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Chapter 9: Practical Application

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    Chapter 9: Practical Application

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  • Preoperative diagnosis: Malignant neoplasm glottis Postoperative diagnosis: Malignant neoplasm glottis(Diagnosis to report for the procedure.) Procedure: An incision is made low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage. A tracheostomy(This is the performed procedure.) tube is inserted and secured with sutures. The patient tolerated the procedure well and was sent to recovery without complications. What are the CPT...
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Chapter 7: Practical Applications

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    Chapter 7: Practical Applications

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  • CASE 1 PREOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. (Indications for surgery.) POSTOPERATIVE DIAGNOSIS: Rapidly enlarging suspicious lesion on patient's right side of forehead. OPERATION PERFORMED: Wide local excision with intermediate closure of the right side of forehead. (An excision with intermediate closure was performed.) INDICATIONS: The patient is a 78-year-old white male who noticed within the last month or so, a rap...
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Chapter 5: Practical Application

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    Chapter 5: Practical Application

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  • CASE 1 Office note: RE: Injection, strapping of foot and ankle. Chief complaint: heel pain(Patient complaint.), 6 months' duration. No inflammation, no heat. Diagnosis: Heel spur.(Definitive diagnosis. The heel pain is a symptom of a heel spur.) Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR, vibration and temp normal. Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed...
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Chapter 8-Practical Application

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    Chapter 8-Practical Application

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  • CASE 1 PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.) FINDINGS PREOPERATIVELY: She had compression fractures at T11 and L1 for which she previously underwent kyphoplasty. She initially had very good results, but then developed back pain o...
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Chapter 5 - Practical Application

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    Chapter 5 - Practical Application

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    July 2026
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  • Case 1 What diagnosis code(s) are reported? - Answer M77.30 Case 2 What diagnosis code(s) are reported? - Answer N17.9 E86.0 N18.30 I95.9 Case 3 What diagnosis code(s) are reported? - Answer L97.521 L97.511 R60.0 M79.672 Case 4 What diagnosis code(s) are reported? - Answer R51.9 M99.02 W20.8XXA Case 5 What diagnosis code(s) are reported? - Answer S20.221A S20.211A S49.91XA W23.2XXA Y92.512 Case 6 What diagnosis code(s) are reported? - Ans...
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Chapter 4: Study Guide Practical Application

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    Chapter 4: Study Guide Practical Application

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    4
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  • CASE 1 PROGRESS NOTE This patient is a 50-year-old female who began developing bleeding, bright red blood per rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid (This is reported by the patient, but not documented in the exam or assessment, so i...
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Chapter 4: Practical Application

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    Chapter 4: Practical Application

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    July 2026
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  • This patient is a 50-year-old female who began developing bleeding, bright red blood per rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her family physician. She states that after a bowel movement she noticed blood in the toilet. She denied any prior history of bleeding or pain with defecation. She states that she has had an external hemorrhoid (This is reported by the patient, but not documented in the exam or assessment, so it is not coded.) that d...
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