Coding an Operative Report Part II: Urinary Male

[Music]

foreign

in this presentation we will discuss

steps to solving a medical coding exam

case study but first I want to introduce

you to the team first up Mr Sandeep

Mr Sandeep coming to you live from Abu

Dhabi he is an AMCI co-lead instructor

next up Miss Eva

coming to you live from the state of

Florida she's also a co-lead instructor

and the intern coordinator and finally

myself Mrs J I'm the curriculum director

at AMCI

now

let's meet the AMCI interns we have Miss

anubama

followed by

Miss Carla

Miss Courtney

Miss Dolly Miss Vivian and Miss Melissa

now that we're all acquainted let's talk

about the goals of the presentation and

we only have one we will review

scenarios from the urinary mail systems

now let's talk about how to solve a

multiple choice case study scenario the

AMCI way for the board exam this is how

we do it we teach you to highlight your

key terms and this key on the right

tells you the colors that you should use

and for what a yellow highlighter should

be used for diagnoses all diagnoses

signs and symptoms

the green will be for procedures so if

you have a green highlighter the green

will be used to highlight only

procedures and pink these are inclusive

or bundled items all right

once you've done your highlighting

you're going to have to document your

inventory that your procedures diagnoses

and select a primary code which

diagnosis is primary which procedure is

primary then you're going to review all

pertinent guidelines

and finally the code that best matches

your inventory list is often the correct

code or a code that is pertinent to a

guideline that will be your best code

all right so here are some do Nots when

you're highlighting you can kind of get

discombobulated so we've compiled some

things that you don't even have to

highlight

number one don't highlight things

observed by The Physician because you

cannot code for them

number two don't highlight closures if a

provider or surgeon is closing up a

surgical site there's no need to

highlight it however if it involves a

skin procedure or skin defect closure

you may definitely have to code that so

if it's closing a surgical site other

than skin defects or wounds or lesions

you do not code it or highlight it also

you don't highlight bleed control

hemostasis because that's pretty

customary and it's bundled into the

procedure code you don't highlight

drains irrigation of the surgical site

nope and you don't highlight

installation and removal of clamps and

trocars because that these are used to

open up or maintain the surgical or

operative site so the physician can view

what they're doing particularly if it's

an open procedure

also you don't highlight dressings and

finally you do not highlight surgical

wrists now that we've gotten that out of

the way I think you're ready to get

started

and I'm going to hand it over to Mr

Sandeep all right Mr Sandeep take it

away okay here we go so ask let me see

if I said this is the third week

sessions uh and please do let us know

how are you feeling so far about quoting

the long scenarios and how our sessions

are helping you in tackling such

challenges please let us know in the

chat and meanwhile let me start uh the

day

I think let me start the session with

the mail uh gender urinary system

scenarios

and we are having our first scenario now

uh let me welcome Miss Carla to read out

the scenario for us miss Carla please

take it away

all right coders

answer a

what are the CPT in ICD

CM codes reported answer a

51530-c67.0

c67.5

c61 answer B

52234

c67.0 c67.5

c61 answer C

52240c67.0 c67.5

c61 answer d

52214

c67.0

c67.5 c61

operative purport pre-operative

diagnosis growth hematuria hematuria

post-operative diagnosis bladder

prostrate tumor operation transurethrial

resection bladder tumor

t-u-r-b-t large

5.3 centimeters anesthesia General

findings the patient had extensive

involvement of the bladder with solid

and

foreign

tumor

completely replacing the Trigon and

extending into the bladder neck and

prostatic tissue

the URI the utero the utero

orifices were not identifiable digital

rectal examination revealed nodular film

mass per rectum procedure distribution

the patient was placed on an operating

room table in the Supine position and

general anesthesia was induced he was

then placed in the lithotomy position

and prepped and draped appropriately

cystoscopy was done which showed

evidence of the urethral trauma due to

the traumatic removal of the Foley

catheter patient stepped on a tubing and

the catheter was pulled out the bladder

itself showed extensive clot retention

there was popularity and necrotic

appearing nodular tissue Mass

extensively involving the Trigon and the

bladder neck and the prostrate area

the reading the urine Tarot

orifices were not identified after

Consulting with the patient's wife and

obtaining an adjustment to the surgical

concept surgical con consent the tumor

was resected from the Trigon

bladder neck and prostate

obvious it did

admit

edematus and hemorrh hemorrhagic

him or

hemorrhagic

tissue was removed

extensive

electrocauterization was done for

bleeding vessels several areas of

necrotic appearing tissue were evacuated

care was taken and avoided extending

resection into the area of the external

sphincter digital rectal examination

revealed the film

The Firm nodular mass in the anterior

rectum no impact the stool was

identified at the end of the procedure

hemostasis appeared good tissue chips

were evacuated from the bladder Foley

catheter was inserted patient was taken

to the recovery room in satisfactory

condition addendum the patient had a

previous partial

prostatectomy and had been found to have

t2b

nomx prostate cancer

on the physical examination today and on

the endoscopic exam it was unclear to

whether as to whether the tumor Mass was

related to the bladder or recurrent

prostate cancer pathology revealed

bladder carcinoma in the Trigon and

bladder neck

and recurrent prostate cancer okay

holders

you all have two and a half minutes

let's get it let's go your time starts

now

and that's time quotas

you know what uh I've been observing

like since we are into the third week of

these group sessions most of them have