1
Operative Note Coding Assessment 2 with Step-by-Step Rationale
Question 1:
Operative Report:
Patient: Robert Green
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Left inguinal hernia
Postoperative Diagnosis: Left inguinal hernia
Procedure Performed: Laparoscopic repair of inguinal hernia
Surgeon: Dr. E. Foster
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed in the supine position on the operating table. After
induction of general anesthesia, the abdomen was prepped and draped in
the usual sterile fashion. A 10-mm trocar was inserted into the peritoneal
cavity through an infraumbilical incision, and pneumoperitoneum was
established. Two additional trocars were placed in the lower abdomen under
direct vision.
The hernia sac was identified and reduced. The peritoneum overlying the
hernia defect was incised, and the defect was exposed. A piece of mesh was
introduced and positioned over the defect, secured with tacks. The
peritoneum was then closed over the mesh.
The trocars were removed, and the incisions were closed with sutures. Sterile
dressings were applied. The patient was awakened and extubated in the
operating room and transferred to the recovery room in stable condition.
Which of the following is the correct CPT code for this procedure?
A. 49560
B. 49505
C. 49650
D. 49585
What is the correct ICD-10-CM code for this diagnosis?
A. K40.20
B. K40.30
C. K40.90
D. K40.00
, 2
Question 1:
Operative Report:
Patient: Robert Green
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Left inguinal hernia
Postoperative Diagnosis: Left inguinal hernia
Procedure Performed: Laparoscopic repair of inguinal hernia
Surgeon: Dr. E. Foster
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed in the supine position on the operating table. After
induction of general anesthesia, the abdomen was prepped and draped in
the usual sterile fashion. A 10-mm trocar was inserted into the peritoneal
cavity through an infraumbilical incision, and pneumoperitoneum was
established. Two additional trocars were placed in the lower abdomen under
direct vision.
The hernia sac was identified and reduced. The peritoneum overlying the
hernia defect was incised, and the defect was exposed. A piece of mesh was
introduced and positioned over the defect, secured with tacks. The
peritoneum was then closed over the mesh.
The trocars were removed, and the incisions were closed with sutures. Sterile
dressings were applied. The patient was awakened and extubated in the
operating room and transferred to the recovery room in stable condition.
CPT CODE ANSWER
Answer: C. 49650 (Laparoscopy, surgical; repair of initial inguinal
hernia)
Explanation:
Laparoscopic Procedure Indicators: The mention of "a 10-mm
trocar was inserted into the peritoneal cavity through an infraumbilical
incision, and pneumoperitoneum was established" indicates a
laparoscopic procedure.
Operative Note Coding Assessment 2 with Step-by-Step Rationale
Question 1:
Operative Report:
Patient: Robert Green
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Left inguinal hernia
Postoperative Diagnosis: Left inguinal hernia
Procedure Performed: Laparoscopic repair of inguinal hernia
Surgeon: Dr. E. Foster
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed in the supine position on the operating table. After
induction of general anesthesia, the abdomen was prepped and draped in
the usual sterile fashion. A 10-mm trocar was inserted into the peritoneal
cavity through an infraumbilical incision, and pneumoperitoneum was
established. Two additional trocars were placed in the lower abdomen under
direct vision.
The hernia sac was identified and reduced. The peritoneum overlying the
hernia defect was incised, and the defect was exposed. A piece of mesh was
introduced and positioned over the defect, secured with tacks. The
peritoneum was then closed over the mesh.
The trocars were removed, and the incisions were closed with sutures. Sterile
dressings were applied. The patient was awakened and extubated in the
operating room and transferred to the recovery room in stable condition.
Which of the following is the correct CPT code for this procedure?
A. 49560
B. 49505
C. 49650
D. 49585
What is the correct ICD-10-CM code for this diagnosis?
A. K40.20
B. K40.30
C. K40.90
D. K40.00
, 2
Question 1:
Operative Report:
Patient: Robert Green
Date of Procedure: 08/01/2024
Preoperative Diagnosis: Left inguinal hernia
Postoperative Diagnosis: Left inguinal hernia
Procedure Performed: Laparoscopic repair of inguinal hernia
Surgeon: Dr. E. Foster
Anesthesia: General endotracheal anesthesia
Description of Procedure:
The patient was placed in the supine position on the operating table. After
induction of general anesthesia, the abdomen was prepped and draped in
the usual sterile fashion. A 10-mm trocar was inserted into the peritoneal
cavity through an infraumbilical incision, and pneumoperitoneum was
established. Two additional trocars were placed in the lower abdomen under
direct vision.
The hernia sac was identified and reduced. The peritoneum overlying the
hernia defect was incised, and the defect was exposed. A piece of mesh was
introduced and positioned over the defect, secured with tacks. The
peritoneum was then closed over the mesh.
The trocars were removed, and the incisions were closed with sutures. Sterile
dressings were applied. The patient was awakened and extubated in the
operating room and transferred to the recovery room in stable condition.
CPT CODE ANSWER
Answer: C. 49650 (Laparoscopy, surgical; repair of initial inguinal
hernia)
Explanation:
Laparoscopic Procedure Indicators: The mention of "a 10-mm
trocar was inserted into the peritoneal cavity through an infraumbilical
incision, and pneumoperitoneum was established" indicates a
laparoscopic procedure.
