Coding an Operative Report Part II: Urinary Female

[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 go

ahead and talk about the goals of the

presentation we only have one female

system we will review

scenarios from the female genital system

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's 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

okay on and let's move to the female uh

gender nerve system and let me uh invite

Ms Zoli Mr Ollie this scenario is yours

all right coders what are the CPT and

icd-10-cm codes reported

a 58671 modifier 50

c30.2 B 58600

z30.2

c58615

z30.2 and D

58671 z30.2

anesthesia General with LMA

pre-operative diagnosis patient

requesting sterilization post-operative

diagnosis sterilization procedure

performed tubal ligation with bilateral

fallopian ring application counts needle

sponge and instrument counts were

correct intraoperative medications 0.25

percent marcane with epinephrine

operative findings the left ovary was

mildly adhered to the side of the uterus

the right ovary appeared normal both

tubes appeared normal the upper abdomen

appeared normal there was a small sub

serosal fibroid approximately 1 to 1.5

centimeter on the left upper aspect of

the uterus description of procedure

after informed consent Miss Matthews was

taken to operating suite number four and

a general anesthesia was administered

she was placed in the dorsal lithotomy

position she was thoroughly prepped and

draped in the usual manner a sponge

stick was placed vaginally an

infraumbilical incision was made and a

non-bladed trocar and sheath were placed

proper placement was confirmed and

insufflation was performed a suprapubic

incision was then made and the

suprapubic trocar and sheath were placed

under direct visualization findings were

made as noted above and the right tube

was ligated

with the philope ring and then the left

pictures were taken to document proper

placement all instruments were removed

and gas was allowed to escape the sheets

were removed marking with epineph

epinephrine was were placed again at the

incision sites and they were closed with

monocle in a subcuticular manner the

patient was allowed to emerge from the

anesthesia and was transferred to the

post-anesthesia Care Unit in stable

condition

okay coders your time starts now

thank you

foreign coders two and a half minutes

thank you Miss Dolly reading that

scenario for us and kurus as I've said

before uh don't get intimidated when you

see a long scenario I would also going

to remind you that don't get uh so uh

like feel like this is going to be easy

when you see a small scenario because

these can be a tricky ones so E4 and

sake always I thought this one would be

an easy scenario I thought everyone

would uh come with a correct answer but

I see in the chats this uh mixed

response I can see all the four

alphabets a b c d as well so let's move

on and let's solve the scenario

let's code

so the keywords post-operative diagnosis

patient came for the stabilization the

procedure performed is a tubal ligation

tubal ligation with a bilateral fell

open ring application

general anesthesia was given patient was

placed in a dorsal lithotomy position

infra umbilical incision was made this

is one of the incision made and then

another incision was a suprapubic

incision that was made

the right tube was ligated with fat bow

ring fallow fallopring and then the left

was done all instruments was removed

the correct answer to this mystery

question is option D

let me have a look into the chats let me

see your responses

I think this is going to be an aha

moment

yes I will explain that

foreign

so let's solve the scenario the

procedure performed tubal ligation with

bilateral phelporary fell open ring

insertion diagnosis inventory we are

having sterilization procedure perform

as I said uh you remember I've said like

two incisions was actually made one was

a infra umbilical incision wasn't was a

suprapubic incision this is where the

suprapubic incision was made and this is

what an umbilical incision was made so

uh two incision was made one incision

was used to place the non-bladed truck

cars so truckers are actually the