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CASE 1
DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele separately as it is included in the diagnosis code for the uterine prolapse.) PROCEDURE: Pessary fitting. INDICATIONS: A 75 year-old, gravida 4, para 4,(This information indicates that the patient has had four pregnancies with four term births and the last two babies were quite large.) female with pelvic organ prolapse. She had atrophic vaginitis so we had her use Premarin vaginal cream twice a week for six weeks. She is back for a pessary fitting today. FINDINGS: She has a third-degree cystocele, and after examination we've determined she actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine prolapse. Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal tissues are improved, although still atrophic, but much less thin than prior appointment.
DESCRIPTION OF PROCEDURE - ANSWERS -
N81.
CASE 2
DIAGNOSES:
- Complete procidentia (The stated diagnosis is Complete Procidentia, and this is well supported in the body of the operative note. A review of several medical dictionaries shows the definition of Procidentia, prolapse of an organ or part.)
- Recurrent urinary tract infections (A history of postmenopausal vaginal bleeding, anemia and recurrent urinary tract infection (UTI).)
- Postmenopausal vaginal bleeding (Select codes for the definitive diagnoses.) PROCEDURES:
- Vaginal hysterectomy
- Anterior and posterior colporrhaphy
- Cystoscopy
- Vaginal vault suspension
posterior, parous. Uterus anteverted, normal size. Some tenderness of the adnexa to deep palpation. No cervical motion tenderness. Normal discharge. Pap test was performed.(Pap test is performed.) COLPOSCOPIC PROCEDURE: Speculum was inserted for the
colposcopy. An extra-long, narrow Pederson specul - ANSWERS -
R87.
CASE 4
CHIEF COMPLAINT: Contraceptive placement of IUD (This is the reason for the visit.) INDICATIONS: Ms. Barrett is coming into the office for placement of an IUD. She is a 29-year-old, gravida 1, para 1-0-0-1 (This patient has been pregnant once having recently given birth to her first child who is currently alive.) who is status post a normal spontaneous vaginal delivery of a male infant weighing 4, grams. She has not had intercourse since delivery. She is interested in a Skyla IUD at this time. PROCEDURE: After obtaining consent, the patient is placed in the dorsal lithotomy position. A speculum was placed in the vagina to visualize the cervix. The cervix was cleaned three times with Betadine. Following this, a single-tooth tenaculum was placed on the anterior lip of the cervix. The uterus was sounded to
approximately 6.5 cm. The Skyla IUD 13.5 mg, was then placed in
the usual fashion (This is the inserti - ANSWERS -
J
Z30.
CASE 5
ABC Hospital Indication: 30 year-old G0P0Ab0 (The patient has never been pregnant.) with irregular periods. She is infertile and requires hysterosalpingogram for evaluation to see if there is a cause for the infertility. (Reason for the procedure.) PROCEDURE NOTE: The patient was brought to the outpatient surgical suite. After written consent was obtained and written final verification, the cervix was visualized with a Pedersen speculum, anesthetized with Cetacaine spray and swabbed with three swabs of Betadine scrub and an endocervical prep. A single-tooth tenaculum was placed on the anterior lip of the cervix without problems. An HSG catheter was introduced through the cervix. At this point the balloon was insufflated with 1 ml of normal saline within the cervix, speculum was then removed. Ethiodol contrast, approximately 8 ml, was instilled under fluoroscopic guidance.(This describes the hysterosalping -
ANSWERS -
OB DELIVERY NOTE
Indications: 31 y/o G3P1 at 39 and 4/7 weeks admitted in labor. She has been followed in the OB clinic with 12 normal antenatal visits. Stage I: Patient was admitted with a cervical exam of 3/c/-1. She slowly progressed to 5 cm dilation. She had SROM at 0330 which showed light meconium. She continued to labor and reached the end of stage I at 1000, a period of 10 hours. FHTs showed some periods of reactivity but responded to stimulation. Stage II: Duration of Stage II (from pushing to delivery) was approximately 3 hours. A pediatric team was present. There was slight meconium staining present at delivery. Presentation was OP with right shoulder anterior shoulder. There was no nuchal cord. The cord was clamped x2 and cut and the baby was handed to pediatric team. Gender: Male Weight: 3772 grams. Apgars 8 / Stage III: Placenta delivered spontaneously with gentle traction
and fundal massag - ANSWERS -
O70.
O77.
Z37.
Z3A.
CASE 8
PROCEDURE: D&E
ANESTHESIA: Moderate sedation. INDICATIONS: The patient is a 29 year-old gravida 1 at 20-5/ weeks with multiple fetal anomalies, who desires a termination of pregnancy. She has previously had dilators placed. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, and moderate sedation was administered by the anesthesia team. The patient then placed in the dorsal lithotomy position and was prepped and draped in usual sterile fashion. The dilators were removed. The patient's cervix was dilated to 5- cm. There was a bulging bag that ruptured during vaginal prep. A speculum was attempted to be placed, but the fetus was already delivering into the vagina. The umbilical cord was severed at this time, and no fetal heart beat was noted on ultrasound. Ultrasound guidance was used for the entire procedure. Gentle traction was applied and the fetus delivered intact. There was no -
ANSWERS -59841-
Z33.
O35.9XX
CASE 9
CASE 10
PREOPERATIVE DIAGNOSIS: Severe cervical dysplasia. POSTOPERATIVE DIAGNOSIS: Severe cervical dysplasia. PROCEDURE PERFORMED: Cold knife conization. ANESTHESIA: General. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 25 cc. FLUIDS: 500 cc crystalloid. DRAINS: Straight catheter x 1. INDICATIONS: All risks, benefits and alternatives of this procedure were discussed with the patient and informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. She was prepped and draped in the normal sterile fashion after being placed in the dorsal lithotomy position. Attention was turned to the patient's pelvis where a weighted speculum was placed inside the patient's vagina. The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 10 units of Pitressin and
20 - ANSWERS -
D06.
