HIM1257 Module 04 Worksheet - Coding from Operative Reports
As CPT coding is mastered, it is essential that the steps and process to locate the correct code
is understood and demonstrated. The coding path, including the main term and modifying
terms (or indented terms), is the route to a complete and accurate code.
Accurate and complete coding is integral to the reimbursement of healthcare services.
Oftentimes, the operative report detail is needed to fully code a procedure because the
report detail provides information that requires the addition of other codes to
completely reflect the work of the surgeon.
This assignment asks for the demonstration of the coding path taken to identify correct
codes, and the assignment of codes derived from actual operative reports.
• List the coding path- the main term or keyword, and the modifying terms (or indented
terms). If you are using the 3m encoder, you may screen shot or copy and paste the
history once you have chosen a code. If you are using the book, enter the main
term from the alphabetic index along with any modifying terms that lead you to
the code you have chosen.
• Assign the surgery codes. Determine the correct code(s) after establishing the
complete surgery.
Here is an example to show what the assignment seeks:
Procedure: Extended Radical mastectomy, left breast
Questions for Scenario Answers
1. Demonstrate the correct Coding path from books:
coding path used to • Mastectomy, radical - (this is the index entry in
establish the correct the code book)
codes. (3 points) Coding path with 3m screen shot:
(NOTE: Only the book or the Encoder path is necessary for the
assignment.)
2. Record the correct 19306-LT
code(s).
(2 points)
Continued on next page.
, Instructions: There are six operative report scenarios in this assignment - understand that you
will only be coding for the surgeon. Each scenario has two parts – first you will identify
the correct codes for the completed surgery and second you will demonstrate the coding
path you took to locate the CPT codes. Each scenario is worth 5 pts for a total of 30 pts.
1. Demonstrate the correct coding path used to establish the correct codes. (3 points)
2. Record the correct code(s). (2 points)
Scenario One -
PREOPERATIVE DIAGNOSIS: L5-S1 herniated disc
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION: L5-S1 discectomy and L5 nerve root decompression
INDICATIONS FOR SURGERY: The patient is a 53-year-old male who has a history of low back
pain and left leg pain in the L5 distribution. An MRI shows the presence of a herniated disc
at L5-S1 migrated up impinging the L5 nerve root on the left side. The patient has been
treated conservatively without any improvement.
PROCEDURE: The patient was intubated and placed in prone position. Then an incision
was marked on the lower back and was prepped and draped in a sterile fashion. The
incision was made with a #10 scalpel, Bovie coagulator and down to the fascia. At this
point, the fascia was incised with a #15 blade. A flap of fascia was then retracted with
#2-0 Vicryl and the muscle was gently dissected and retracted with a Taylor retractor.
Under the microscope, a curette was placed between the L5-S1 and x-rays were obtained.
The x-rays showed that the curette was between L5 and S1 until under the microscope
with microdissection, and with the use of a Midas Rex the lamina of L5 was partially drilled
off and yellow ligament was opened, removed, and then the L5 nerve root was identified. A
large, herniated disc was then found, removed and the L5 nerve root was completely
decompressed. At this point, the interspace at L5-S1 was entered and the disc removed
laterally, and then a complete decompression of the L5 into the foramen was
accomplished. At this point, the area was irrigated with antibiotic solution and a paste of
Depo-Medrol, Amicar, and morphine was left in place. The fascia was closed with a #2-0
Vicryl, subcutaneous tissue with a #3-0 Vicryl, and the skin was closed with subcuticular
#4-0 Vicryl.
Questions for Scenario One Answers
1. Demonstrate the correct
coding path used to
establish
the correct codes. (3
points)
Scenario Two -
2. Record the correct 63030
PROCEDURE:
code(s).TUR Bladder tumor
(2 points)CA of the bladder; Status post radiation and systemic chemotherapy POST-OP DIAGNOSIS: CA of
PRE-OP DIAGNOSIS:
the bladder; Status post radiation and systemic chemotherapy ANESTHESIA: General
INDICATIONS FOR PROCEDURE: The patient has infiltrating CA of the bladder. The patient wanted to preserve his
bladder, did not want to have a cystectomy and was given systemic chemotherapy and
As CPT coding is mastered, it is essential that the steps and process to locate the correct code
is understood and demonstrated. The coding path, including the main term and modifying
terms (or indented terms), is the route to a complete and accurate code.
Accurate and complete coding is integral to the reimbursement of healthcare services.
Oftentimes, the operative report detail is needed to fully code a procedure because the
report detail provides information that requires the addition of other codes to
completely reflect the work of the surgeon.
This assignment asks for the demonstration of the coding path taken to identify correct
codes, and the assignment of codes derived from actual operative reports.
• List the coding path- the main term or keyword, and the modifying terms (or indented
terms). If you are using the 3m encoder, you may screen shot or copy and paste the
history once you have chosen a code. If you are using the book, enter the main
term from the alphabetic index along with any modifying terms that lead you to
the code you have chosen.
• Assign the surgery codes. Determine the correct code(s) after establishing the
complete surgery.
Here is an example to show what the assignment seeks:
Procedure: Extended Radical mastectomy, left breast
Questions for Scenario Answers
1. Demonstrate the correct Coding path from books:
coding path used to • Mastectomy, radical - (this is the index entry in
establish the correct the code book)
codes. (3 points) Coding path with 3m screen shot:
(NOTE: Only the book or the Encoder path is necessary for the
assignment.)
2. Record the correct 19306-LT
code(s).
(2 points)
Continued on next page.
, Instructions: There are six operative report scenarios in this assignment - understand that you
will only be coding for the surgeon. Each scenario has two parts – first you will identify
the correct codes for the completed surgery and second you will demonstrate the coding
path you took to locate the CPT codes. Each scenario is worth 5 pts for a total of 30 pts.
1. Demonstrate the correct coding path used to establish the correct codes. (3 points)
2. Record the correct code(s). (2 points)
Scenario One -
PREOPERATIVE DIAGNOSIS: L5-S1 herniated disc
POSTOPERATIVE DIAGNOSIS: Same.
OPERATION: L5-S1 discectomy and L5 nerve root decompression
INDICATIONS FOR SURGERY: The patient is a 53-year-old male who has a history of low back
pain and left leg pain in the L5 distribution. An MRI shows the presence of a herniated disc
at L5-S1 migrated up impinging the L5 nerve root on the left side. The patient has been
treated conservatively without any improvement.
PROCEDURE: The patient was intubated and placed in prone position. Then an incision
was marked on the lower back and was prepped and draped in a sterile fashion. The
incision was made with a #10 scalpel, Bovie coagulator and down to the fascia. At this
point, the fascia was incised with a #15 blade. A flap of fascia was then retracted with
#2-0 Vicryl and the muscle was gently dissected and retracted with a Taylor retractor.
Under the microscope, a curette was placed between the L5-S1 and x-rays were obtained.
The x-rays showed that the curette was between L5 and S1 until under the microscope
with microdissection, and with the use of a Midas Rex the lamina of L5 was partially drilled
off and yellow ligament was opened, removed, and then the L5 nerve root was identified. A
large, herniated disc was then found, removed and the L5 nerve root was completely
decompressed. At this point, the interspace at L5-S1 was entered and the disc removed
laterally, and then a complete decompression of the L5 into the foramen was
accomplished. At this point, the area was irrigated with antibiotic solution and a paste of
Depo-Medrol, Amicar, and morphine was left in place. The fascia was closed with a #2-0
Vicryl, subcutaneous tissue with a #3-0 Vicryl, and the skin was closed with subcuticular
#4-0 Vicryl.
Questions for Scenario One Answers
1. Demonstrate the correct
coding path used to
establish
the correct codes. (3
points)
Scenario Two -
2. Record the correct 63030
PROCEDURE:
code(s).TUR Bladder tumor
(2 points)CA of the bladder; Status post radiation and systemic chemotherapy POST-OP DIAGNOSIS: CA of
PRE-OP DIAGNOSIS:
the bladder; Status post radiation and systemic chemotherapy ANESTHESIA: General
INDICATIONS FOR PROCEDURE: The patient has infiltrating CA of the bladder. The patient wanted to preserve his
bladder, did not want to have a cystectomy and was given systemic chemotherapy and
