Coding an Operative Report Part II: Nervous System

[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 it's time

to review the goals of the presentation

we only have one that is the nervous

system we will dissect scenarios from

the nervous 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 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 intro

cars 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

next we are moving into the nervous

system chapter

and let me invite Miss Vivian to the

stage to read this scenario for us let's

move on take it away

all right what are the CBT and icd-10-cm

codes

a61304-606.4 xoa V 89.2 xxa

b61312-606.4 x 0 a for v89.2 xxa

c61314-606.4 X 0 a

V 89.2 xxa or D 61313

S 0 6.4 x 0 a v 89.2 x x a

pre-operative diagnosis acute epidural

hematoma post-operative diagnosis as

above anesthetic agent General

endotracheal operation left craniotomy

for evacuation of epidural hematoma

emergence indications the patient

presented with the history of a motor

vehicle accident he presented to the

emergency department neurologically

intact and Urgent CT scan revealed a

large epidural hematoma and the patient

was taken emergently to the operating

room for evacuation

procedure techniques description of

findings condition of patients the

patient was brought to the operating

room and after induction of adequate

general anesthesia was prepped and

draped to the usual sterile fashion for

a left frontal temporal parietal

craniotomy

a curvilinear incision was made

beginning just the anterior to the left

ear curving posteriorly then upward and

interiorly to enact the hairline just

off the midline the resulting muscular

cutaneous flap was then reflected

anteriorly

multiple holes were then placed and

connected using the high speed drill to

create a large free Bone flap

this was removed from the remediate

operative Fields directly beneath the

bone flap was a large well-formed clot

which delivered itself from the epidural

space a bleeding point was found in the

region of the middle meningeal artery

this was carefully and thoroughly

coagulated using bipolar cauterization

a small opening was then made in the

dura to ensure that there was not an

underlying blood clot there was not this

opening was primarily closed using four

zero neural on additional meticulous

hemostasis was then obtained the bone

flap was then replaced and held in place

using multiple kls fixation devices

skin was then reapproximated using 2-0

vehicle for the subcutaneous tissues and

five zero monocle for the skin

the patient was then awakened from

anesthesia at which time his vital signs

were stable

and he was neurologically improved from

pre-operatively

estimated blood loss was 100 cc

specimens none lab orders none

diagnostic procedures ordered none

complications none okay quarters your

time begins now

minutes is done and

let's solve the scenario

we have a little bit more time so I will

quickly go through this scenario

keywords pre-operative diagnosis

post-operative diagnosis same as a

pre-operative diagnosis which is acute

epidural hematoma

the procedure performed is left

craniotomy for evacuation of epidural

hematoma

patient indication the patient had a

history of motor vehicle accident

general anesthesia was given

and a frontal temporal parietal

craniostomy was performed this is the

one per surgery which is performed

frontal temporal parietal craniotomy

a curvy linear incision was made to the

anterior anterior to the left ear

muscular cutaneous flap was a reflected

anteriorly multiple birth holes were

made to create a large bone flap

and directly beneath the bone flap

uh cloth which was delivered itself to

the epidural space

so the blood clot is in the epidural

space coagulated using the bipolar

quarterizations opening was then removed

uh opening was then made into made in

the Jura to ensure that there was no

underlying blood clot

and this opening was closed with a four

hyphen 0 neurol on the bone flap was

then replaced and held into place so the

correct answer to this question is going

to be option b

okay I was just looking into the chats

let's solve this one

the procedure imagery as I said it's a

left frontal temporal right till