Activities will cover the following body systems: Integumentary, Musculoskeletal and

Activities will cover the following body systems: Integumentary, Musculoskeletal and Urinary System. Assignment #1 = 5 points Laparoscopic nephrectomy for patient with cancer Documentation: Partial , radical, with partial ureterectomy , or with nephrectomy with ureterectomy Create a decision tree for coding of the above procedure(s) performed. The beginning of the tree is the laparoscopic nephrectomy. Either of these procedures can be performed to treat the cancer diagnosis. The decision tree will provide a visual presentation of how each of the above procedures would be coded. HIA 3900 Fall 2024 Coding Activities: Chapter 4 Assignment #2 Task : For each case, identify the coding options and what documentation would support the coding decision. Tip: Start with searching the CPT index. 1.Biopsy of oral cavity – 2.Excision of hidradenitis 3.Spinal fusion for patient with scoliosis 4.Excision of lipoma deep (subfascial) in abdominal wall 5.Destruction of lesion of liver HIA 3900 Fall 2024 Coding Activities: Chapter 4 Assignment # 3a OP Report 1 Task: Analyze the details of the operative report and assign the ICD-10-CM diagnosis(es) code(s) and the CPT procedure code(s) Preoperative Diagnosis: Internal derangement left knee Postoperative Diagnosis: Tear of lateral meniscus Operative Procedure: Left knee arthroscopy, partial meniscectomy The arthroscope was inserted through the routine superolateral portal as well as an inferomedial portal for insertion of scope and instruments. The knee joint was then examined in a routine manner. The medial meniscus was intact. The lateral meniscus was partially detached, and this portion was removed. No other defects were noted. The knee was irrigated well using normal saline. The instruments were removed from the knee. Wound closed with 4-0 nylon and dressed. Estimated blood loss 0. Intravenous fluids 1000 cc. Specimen: meniscus. Complications: None HIA 3900 Fall 2024 Coding Activities: Chapter 4 Assignment # 3b Task: Analyze the details of the operative report and assign the ICD-10-CM diagnosis(es) code(s) and the CPT procedure code(s) Op Report #2 Preoperative Diagnosis: Mass, superior aspect of the left breast Postoperative Diagnosis: Benign mass, superior aspect of the left breast Operation: Excision The patient is a female who has had a lump palpable over the superior aspect of the left breast for the past several months. It has been observed in the office. I had done a needle aspiration and did not get any fluid out. After multiple observations, the patient was very concerned about carcinoma and wanted to have this area excised. Surgical Technique: The patient was lying down supine. The left breast was scrubbed with Betadine scrub and paint and draped in the classical fashion. The patient has a transverse incision near where we are feeling this lump, which was about the 11 o’clock position, high up in the superior aspect of the left breast. A transverse incision was made underneath the breast tissue and adipose tissue was completely taken out. Hemostatic was ascertained with electrocoagulation. The wound was closed using interrupted 3-0 Vicryl sutures, the skin was closed with subcuticular running 5-0 Dexon. Benzoin and Steri-Strips and a pressure dressing were applied. All counts were normal. It was the impression of the pathologist that it represented a benign process in the left breast. Coding Activities: Chapter 4 Assignment # 4a Task: Analyze the details of the emergency room (ED) reports and assign only the CPT procedure code(s) Procedure Report (ED) This 3-year-old male was carried into the ED by his mother, who states, “a fish tank fell over on him” cutting his forehead and cheek. No LOC, PERRTL: Patient is alert and oriented. Patient has a 3.5-cmsuperficial laceration over the right eye across forehead and 1.5-cmsuperficiallaceration on right cheek. Local anesthesia was administered, and the wound was irrigated and sutured with 6-0 nylon. Assignment # 4b Procedure Report (ED) The patient was seen in the Emergency Department with a staple embedded in the left index finger. An automatic staple gun impaled a staple into the DIP joint. A 1% lidocaine digital block was performed, and incision was made into the joint and the staple was removed with no complications. He was told to watch for any red streaks, swelling, pain or pus.

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