THE CODING EDGE® ARCHIVES

Table of Contents

Coding Recommendations - Feature Article 10/15/99
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" patient report.

Hint: The following text is, as you would expect, very technical and "dense;" we suggest you print this page for easier use. Your Browser's "File, Print" command should achieve this with no problem. Should you have difficulties printing this -or any other- page, please let us know.

   


  

Admitted: 8/7/99

Discharged: 8/9/99

Brief History: This is the case of a 41-year-old female G4P4-0-0-4 who has had symptomatic uterine bleeding refractory to hormonal therapy. Bleeding has worsened over the past two months. Pelvic ultrasound performed on 7/10/99 revealed the presence of an intrauterine fibroid, new since previous ultrasound of 6/28/98. The patient has hypertension, bilateral carpal tunnel syndrome, asthma and and degenerative joint disease. Past surgeries include carpal tunnel releases and a left knee replacement in 1995 and bilateral tubal occlusion with Hulka clips for voluntary sterilization in 1993. Current medications include Alupent, Fioricet, Hydrochlorothiazide, Vasotec and a multivitamin daily.

Pertinent Physical Examination Findings: Chest and cardiovascular exams were normal. Pelvic exam revealed an 8-week size enlarged uterus that was nontender. No adnexal masses were noted and rectal exam revealed guaiac negative stool.

Laboratory Findings: A preoperative chest x-ray was within normal limits and EKG demonstrated NSR with no ischemic changes. CBC: hematocrit 32.2, white count 6.3, chemistry panel entirely within normal limits and urinalysis was negative.

Hospital Course: The patient was taken to the Operating Room on the morning of 8/7/99 at which time a total vaginal hysterectomy was performed under general anesthesia without complication. Estimated blood loss intraoperatively was 400 cc. Pathology revealed a submucous leiomyoma. Postoperatively she had a Foley catheter and a vaginal packing in place. On the first postoperative day the catheter and packing were removed. The patient was afebrile, lungs were clear, bowel sounds were hypoactive but present, and pain was well controlled. She was advanced to a regular diet which she tolerated well. She did experience a brief episode of orthostatic hypotension with ambulation, and a hematocrit done this day was 24.2 with a hemoglobin of 8.0. The patient therefore received 2 units of packed cells to treat anemia secondary to blood loss at the time of surgery. On postop day #2 repeat H&H were 33.2 and 11.1 respectively. Her vital signs remained stable, she was afebrile, and urine output was excellent. She was discharged home on the 2nd postoperative day in good condition. She is sent home with a prescription for Darvocet 1-2 tabs every 6 hours as needed for pain, iron supplementation and Colace 100 mg b.i.d. to prevent constipation. We reviewed her discharge instructions which included no sexual activity, no lifting over 10 pounds, and no stair-climbing or strenuous physical activity until her postop visit. The patient verbalized understanding of all instructions and will return to my office for her scheduled follow up appointment in 4 weeks.

  

    

Using the above patient report(s), do your own coding and then compare it with our coding recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.
 

 

Please be aware that the Coding Edge® Archive pages are NOT retroactively updated
to reflect possible coding rules and regulation changes made after the publishing date.