Ritecode.com Coding and Billing Forum

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American Health Information Management Association - AHIMA

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The Coding Institute

http://www.codinginstitute.com/

This company has both an interesting business model and history. It is owned by Eli Research, which recently purchased the AAPC. Their main niche is a series of specialty newsletters and seminars. They are not an association, but have a series of specialty newsletters they sell.

Their coding specialty newsletters compete with the DecisionHealth Coder Pink Sheets.

www.decisionhealth.com

Comments?

This is an interactive Forum.

Op Reports: Read and print the Op Reports. Leave comments and your coding results. Have an Op Report that you want to see how members code it? Be sure to strip any identifying informatino and post it.

Professional Associations: Let us know if you are getting the optimal value from your professional healthcare association.

Specialty Coding Forum: Post your coding questions.

Post your questions. Be sure to tell your friends about this forum.

Association of Registered Health Care Professionals - ARHCP

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The Medical Management Institute (MMI).

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American Health Information Management Association - AHIMA

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Healthcare Financial Management Association - HFMA

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The American Academy of Professional Coders (AAPC)

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Medical Group Management (MGMA)

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Institute of Certified Healthcare Business Consultants - ICHBC

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Professional Association of Health Care Office Management PAHCOM

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Healthcare Compliance Association

http://www.hcca-info.org/

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Certified Healthcare Business Consultant - CHBC

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The Healthcare Fraud & Abuse Compliance Institute
Certified Compliance Professional (CCP)

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American Association of Medical Assistants (AAMT)

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American Academy of Medical Management - AAMM

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Ritecode.com is a coding and billing consulting firm based in Memphis TN. We have been traing coders and billers since 1992. Since then we have transferred our onsite seminars to the internet. Now we are able to offer twice the product at half the cost.My name is Jeffrey Restuccio and I'm certified as both a CPC and CPC-H with over ten years of experience.

Supporting Ritecode.com helps us provide a list of free services. This is our way of advertising. Please tell your friends.

Please Visit our Online Storefront, with over 75 products, many starting at only $12 at
http://www.ritecode.com/Merchant2/merchant.mvc

Our flagship product is our comprehensive Coding Certification Prep Course.

In addition we sell 120 surgical Op Reports (different from the ones posted on this forum) with detailed explanations and answers organized by difficulty and specialty. They can be ordered in groups of 12.

We sell ten (10) AAPC CEU approved courses at the link below:
http://ritecode.com/Merchant2/merchant.mvc?Screen=CTGY&Store_Code=RPAS&Category_Code=AAPC

To illustrate the quality of our coding and billing products, we have a LOT of FREE stuff related to coding and billing. Compare what ritecode.com offers to any other online training or consulting firm.

*** FREE Surgical Coding Blog - Over 36 actual surgical op reports:
http://health-careconsulting.com/coding_blog/

*** FREE online Medical Abbreviation Database with over 18,900 entries:
http://www.ritecode.com/glossary/glossary.php

*** Coding Certification Prep Course DEMO (The complete Endocrinology Section) at:
http://www.ritecode.com/demo_2003/demo_new_version.html

*** FREE 2007 ICD-9 Updates are now available at:

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*** FREE 2007 CPT Updates are now available at:

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*** FREE 2006 ICD-9 Updates are below:

http://www.ritecode.com/2006_icd-9_course.html

*** FREE 2006 CPT Updates are below:

http://www.ritecode.com/2006_cpt_course.html

*** FREE Coding and Billing Quizzes (240) are below:

http://www.ritecode.com/quizzes/quiz.html

*** FREE Op Reports you can print out and code are at:

http://www.ritecode.com/free_opreports/opreport_free_index.htm

Please Visit our Storefront at
http://www.ritecode.com/Merchant2/merchant.mvc

At $499, the Ritecode.com Prep Course has more information, more sample tests, more definitions and

more links than competing Prep Courses.

See the list of Prep Course Objectives:

http://www.ritecode.com/course_modules/objectives/objectives_prep_course.html

SURGICAL OP REPORT # 31

DIAGNOSIS:Second and third finger burn scar contracture.POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURE:Z-plasty to the left second and third fingers, 6 cm for each z-plasty.

=> Read more!

SURGICAL OP REPORT # 30

DIAGNOSIS:Left arm third-degree burn.
OPERATION:Tangential excision of burn area with split-thickness skin grafting to left arm, sheet graft approximately 400 sq. cm.

=> Read more!

SURGICAL OP REPORT # 29

DIAGNOSIS: Congestive heart failure secondary to severe aortic valve stenosis, moderate mitral valve regurgitation, moderate tricuspid valve regurgitation, chronic atrial fibrillation, large atrial thrombus in left atrial appendage, small atrial thrombus in floor of left atrium.
PROCEDURE:1. Left atrial thrombectomy x2.2. Mitral valve ring annuloplasty for dilated mitral annulus utilizing a #30 Cosgrove partial ring.3. Cryo-MAZE procedure.4. Aortic valve replacement with a #25 bovine pericardial bioprosthesis.5. Tricuspid valve annuloplasty of the De Vega type.

=> Read more!

SURGICAL OP REPORT # 28

DIAGNOSIS: Traumatic ventricular septal defect and traumatic mitral insufficiency.
OPERATION:1. Primary closure of ventricular septal defect.2. Mitral valvuloplasty.

=> Read more!

SURGICAL OP REPORT #27
DIAGNOSIS: Multiple pulmonary nodules.

PROCEDURE:Exploratory thoracotomy and biopsy and multiple wedge resection of right upper and lower lobes.

=> Read more!

SURGICAL OP REPORT # 26

DIAGNOSIS: CAD.
PROCEDURE:1. CABG x3 including LIMA to LAD, saphenous vein graft to PDA, saphenous vein graft to ramus.2. Placement of intraaortic balloon pump percutaneously into right common femoral artery.3. Epiaortic ultrasound.

=> Read more!

SURGICAL OP REPORT #25

DIAGNOSIS: 1. Severe gastroesophageal reflux disease.2. Hiatal hernia.
PROCEDURE: 1. Laparoscopic hiatal hernia repair 2. Laparoscopic Nissen fundoplication

=> Read more!

SURGICAL OP REPORT # 24

DIAGNOSIS: Biliary dyskinesia.
PROCEDURE: Laparoscopy cholecystectomy

=> Read more!

SURGICAL OP REPORT #23

DIAGNOSIS: Morbid obesity.
PROCEDURES:1. Laparoscopic Roux-en-Y gastric bypass.2. Laparoscopic liver biopsy.

=> Read more!

SURGIOCAL OP REPORT #22
DIAGNOSIS: Aneurysm on the juxtarenal abdominal aorta.
PROCEDURE: Repair of aneurysm of the juxtarenal abdominal aorta.

=> Read more!

SURGICAL OP REPORT #21
DIAGNOSIS: Severe right internal common carotid artery stenosis.

PROCEDURE PERFORMED: Right carotid endarterectomy with patchy angioplasty using approximately 8 x 90 mm Dacron patch.

=> Read more!

SURGICAL OP REPORT # 20

DIAGNOSIS: Type IV thoracoabdominal aortic aneurysm.
PROCEDURE:Repair of type IV thoracoabdominal aortic aneurysm.

=> Read more!

SURGICAL OP REPORT # 19

DIAGNOSES: Open chest status post gunshot wound to the heart and open abdomen status post gunshot wound to the abdomen.
PROCEDURE:Exploratory thoracotomy, evacuation of clot and bilateral hemothoraces, closure of clam shell thoracotomy, exploratory laparotomy and irrigation of peritoneal cavity.

=> Read more!

SURGICAL OP REPORT #18

DIAGNOSIS: Partial transection of pancreas, transverse colon injury, proximal duodenal injury, SMV bleeding.
PROCEDURE:Exploratory laparotomy, subtotal pancreatectomy, splenectomy, antrectomy, partial transverse colectomy, proximal duodenal resection, bowel left in discontinuity, open abdomen with temporary closure.

=> Read more!

SURGICAL OP REPORT #17

DIAGNOSES: Bowel discontinuity after subtotal gastrectomy for gastric volvulus secondary to her esophageal hernia.
PROCEDURES: 1. Completion gastrectomy.2. Roux-en-Y esophagojejunostomy.3. Jejunostomy feeding tube.

=> Read more!

SURGICAL OP REPORT #14

DIAGNOSIS: T12-L1 fracture dislocation.
OPERATIONS:1. Left thoracoabdominal exposure, T11-L2.2. Resection left 10th rib.3. Placement of chest tube (Blake drain).

=> Read more!

SURGICAL OP REPORT #11

DIAGNOSIS: Renal failure.
OPERATION: 1. Ex vivo renal artery reconstruction. 2. Live donor kidney transplant.

=> Read more!

SURGICAL OP REPORT #9

DIAGNOSIS: Splenomegaly of unknown origin, rule out lymphoma or other malignancy.

PROCEDURE: 1. Open splenectomy. 2. Mesenteric lymph node biopsy.

=> Read more!

SURGICAL OP REPORT #8

OPERATIVE DIAGNOSIS:1. Cholecystitis.2. Mild pancreatitis.3. No evidence of bile duct obstruction.4. Perforated sigmoid diverticulitis.
OPERATION:1. Open cholecystectomy.2. Operative cholangiogram.3. Sigmoid colectomy with primary anastomosis.4. Placement of feeding jejunostomy.5. Placement of gastrostomy.

=> Read more!

SURGICAL OP REPORT #7

DIAGNOSIS:Pancreatic cancer (junction of head and neck).
OPERATION:1. Diagnostic laparoscopy with liver biopsy.2. Pancreaticoduodenectomy.3. Retroperitoneal lymph node dissection of the porta hepatis. 4. Feeding jejunostomy.5. Celiac plexus block with 100% alcohol (neuroablative).

=> Read more!

SURGICAL OP REPORT #6

DIAGNOSIS: Left lower back wound.
PROCEDURE Irrigation and debridement of left lower back wound.

=> Read more!

SURGICAL OP REPORT #5

DIAGNOSIS: Velopharyngeal insufficiency secondary to abscess soft palate.
PROCEDURE: Pharyngeal flap and split thickness skin graft 2 x 4 cm.

=> Read more!

SURGICAL OP REPORT #4

DIAGNOSIS: Hypertrophic scarring to chin and lower lip, late burn effect, need for scar revision because of failed scar management therapy. Failed conservative scar management therapy.
PROCEDURE: Excision of scar and reconstruction using full thickness skin graft.

=> Read more!

SURGICAL OP REPORT #4

DIAGNOSIS: Hypertrophic scarring to chin and lower lip, late burn effect, need for scar revision because of failed scar management therapy. Failed conservative scar management therapy.
PROCEDURE: Excision of scar and reconstruction using full thickness skin graft.

=> Read more!

SURGICAL OP REPORT #3

DIAGNOSIS: Left small finger proximal phalanx fracture.
OPERATION:Closed reduction and percutaneous pinning of left small finger proximal phalanx fracture.

=> Read more!

SURGICAL OP REPORT #2

DIAGNOSIS :Bilateral hypomastia.
PROCEDURE:Bilateral augmentation mammoplasty.

=> Read more!

SURGICAL OP REPORT # 14

DIAGNOSIS: T12-L1 fracture dislocation.

OPERATIONS:1. Left thoracoabdominal exposure, T11-L2.2. Resection left 10th rib.3. Placement of chest tube (Blake drain).

=> Read more!

SURGICAL OP REPORT # 33

Diagnosis: Hypertensive renal failure requiring hemodialysis

Operation: Insertion of left arteriovenous Gore-tex graft for dialysis access

=> Read more!

Surgical Op Reports
Test your coding skills against other coders with our coding forum. For best results, print and code the Op Report before reading any of the Comments. After you're done, either agree with one of the posted results or feel free to post and explain your coding results.

Print out five or six of the Op Reports and use them for your next AAPC or AHIMA meeting. Again, please leave any comments.

Some of these Op Reports are difficult. Check them out if you want a real challenge. And be sure to leave your comments, pro and con.

Be sure to support the sponsor:

SURGICAL OP REPORT # 34

DIAGNOSIS: Multiparous female desires permanent sterilization.

OPERATION: Laparoscopic tubal ligation with Falope ring on the right and bipolar cautery on the left.

=> Read more!

SURGICAL OP REPORT # 32

DIAGNOSIS: Head and neck carcinoma with nodal metastases; need for long-term intravenous access.

Procedure: Left subclavian Port-A-Cath insertion (9.6-French) under fluoroscopy.

=> Read more!

SURGICAL OP REPORT #36
DIAGNOSIS: 1. Retained T-tubes. 2. Chronic tympanic membrane perforations. 3. Adenoid hypertrophy with chronic adenoiditis.

OPERATION: 1. Bilateral T-tube removal. 2. Bilateral fat pad myringoplasty. 3. Adenoidectomy.

=> Read more!

SURGICAL OP REPORT #38

Code for an open reduction and internal fixation of right scaphoid fracture nonunion with autogenous bone graft from the distal radius and the filling of bone graft donor site with coralline bone graft substitute.

Considered; intermediate

SURGICAL OP REPORT # 35

DIAGNOSIS: Displaced radius fracture, left.

OPERATION: Open reduction and internal fixation of radial shaft fracture.

=> Read more!

DIAGNOSIS: Bilateral carpal tunnel syndrome, left greater than right.

Operation: Release of left carpal tunnel

=> Read more!

CLINICAL PRESENTATION: This 55 year old woman was found less responsive after an altercation. On arrival to the ER, her GCS was 12; no focal neuro deficits; pupils equal and reactive. History of smoking and hypertension.

DIAGNOSTIC STUDIES: Initial cranial CT scan- select views:

Two lesions are evident in these initial CT scans: left side shows a left parietal cystic lesion with perilesional edema; the right side shows a right temporal contusion which is small.

Further diagnostic studies included a MRI scan of the brain- select views shown above. Left: T1weighted image with contrast shows a nodule with a cyst in the left parietal area as does the sagittal T1 weighted image on the right

It was decided to resect the solitary intra-axial lesion in the left parietal area using stereotactic guidance. This lesion was excised completely. The pathology of the lesion was metastatic lung cancer. On post-op day 2, the patient became less responsive and an emergent CT scan was performed.

Considered: Straightforward

OPERATIVE REPORT #10

DIAGNOSIS: Left face melanoma.

OPERATION: Wide resection of left face melanoma (2 x 7 cm resection).

=> Read more!

Yes.

Be sure to strip any and all references to physicians and/or to the patient's name, age or sex. If the coding requires sex or age, you can keep it but be sure to change the age of the patient.

Welcome to the Ritecode.com Coding and Billing Blog.

Please leave your coding answers for the Op Reports listed.

SURGICAL OP REPORT # 16

DIAGNOSIS:Gunshot wound to the back with injury to the left subclavian vein, left thoracoacromial vein, left vertebral vein, thoracic duct, and left upper lobe of the lung.

PROCEDURE:1. Left thoracotomy followed by sternotomy with a trap-door incision. 2. Ligation, left subclavian vein.3. Ligation, left vertebral vein.4. Ligation, left thoracoacromial vein.5. Open cardiac massage with open defibrillation.6. Resection of left upper lobe of lung with nonanatomic segment.

=> Read more!

SURGICAL OP REPORT # 15

DIAGNOSIS:Pericardial effusion - serous fluid.

OPERATION:Extraperitoneal pericardial window.

ANESTHESIA: General endotracheal anesthesia.

FINDINGS:Greater than 100 ml of clear yellow fluid within the pericardial sac. No evidence of blood within the pericardial sac.

PROCEDURE:Patient was brought to the operating room. He was prepped and draped in sterile fashion. We began by demarcating the pertinent landmarks including the xiphoid. We planned our incision in a vertical fashion 5 cm in length below the xiphoid.Scalpel was used to go through the skin and the subcutaneous tissues as well as to the underlying fascia. Once this was accomplished, we used blunt dissection in a cranial direction beneath the sternum. We were able to identify the extraperitoneal diaphragm. This was grasped with two Allis clamps and incised with a Metzenbaum scissors. This revealed the pericardium. The pericardium was grasped with two Allis clamps. It was opened with a Metzenbaum scissors. There was immediate expression of greater than 100 ml of clear serous fluid. This was suctioned. There was no evidence of intrapericardial hemorrhaging. The diaphragm was repaired with a single figure-of- eight stitch using a 3-0 Vicryl suture. This was followed by closure of the fascia with a 1-0 PDS running suture followed by closure of the skin with a 4-0 Biosyn in a subcuticular fashion.Sponge and equipment counts were correct at the end. Patient was brought to the Post Anesthesia Care Unit for recovery prior to disposition to the Surgical Intensive Care Unit.

SURGICAL OP REPORT # 13 (procedure noted on op report has been purposely deleted)

DIAGNOSIS:End stage renal disease without permanent access.

=> Read more!

SURGICAL OP REPORT # 12

DIAGNOSIS:1. End-stage renal disease.2. Malfunctioning peritoneal dialysis catheter, status post laparoscopic revision.

Laparoscopy and catheter removal.

=> Read more!

OPERATIVE REPORT #10

DIAGNOSIS: Left face melanoma.

OPERATION: Wide resection of left face melanoma (2 x 7 cm resection).

=> Read more!

SURGICAL OP REPORT # 1

Right lower extremity tibial fracture, status post ORIF, with open wound.

PROCEDURE: Soleus flap to right pretibial wound, irrigation and debridement of right pretibial wound, split-thickness skin graft to right lower extremity (5 x 12 cm).

=> Read more!

Code for the right transcervical excision of cervical and mediastinal mass (right cranial nerve X)

SURGICAL OPERATIVE REPORT #25

DIAGNOSIS: 1. Severe gastroesophageal reflux disease.2. Hiatal hernia.
PROCEDURE: 1. Laparoscopic hiatal hernia repair, 2. Laparoscopic Nissen fundoplicationANESTHESIA: General endotracheal anesthesia.

=> Read more!

Patient undergoes a cystoprostatectomy with bilateral pelvic Lymphadenectomy with a illeoal conduit diversion or continent diversion (neobladder).

Welcome to our surgical Op Report coding blog !

Please post your comments. We don't edit the coding posts. At some time we may decide which one is "correct." But for the meantime, we will allow both correct and incorrect answers. This is to illustrate that, for the most difficult Op Reports, ask ten certified coders to code it and you might get ten different answers.

We'll see . . .

This is the third post.

It appears on blog B only and in a single category.

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