Outpatient Case 5 -Patient Name: Ashley Lawson The physician sees…

Outpatient Case 5 -Patient Name: Ashley Lawson The physician sees… Outpatient Case 5 -Patient Name: Ashley LawsonThe physician sees an established patient in the office.  She is a two-year-old girl, Ashley Lawson with a two-day history of a fever to 100.5 degrees, fussiness, fatigue, and a headache.  She also has complained for five days of pain in the left buttock with an area that is swollen and read as of today, with no known injury.  She is a known asthmatic. A detailed history is obtained.  Physical exam reveals a 4 cm to 4 cm abscess over the left upper buttock that is fluctuant, and red, as the only finding on a comprehensive exam. Laboratory done in the office today reveals; Elevated WBC on the automated complete CBC with differential and an abnormal automated urinalysis with microscopy.  A moderate level of medical decision making is used. After obtaining consent, the physician and the staff observer prepare the patient for mild conscious sedation in the procedure room.  The physician injects 5 cc of 2 percent Lidocaine as anesthetic and incises the abscess with a #11 blade straight scalpel.  10 cc of pus is drained, and the area is packed with lodoform gauze.  Culture and sensitivity of the drainage is sent to an outside laboratory for evaluation. Total intra-service time was 30 minutes. The patient was given Ceftin 300 mg b.i.d. for 10 days to treat both the UTI and the abscess and will return to the clinic in two days for a wound recheck.  Diagnoses; Abscess of left buttock. UTI. Codes assigned: (there is no coding of path/lab or venipuncture)N39.0, L02.33, 99215, 10060Are these the correct ICD-10-CM codes?  Are these the correct CPT codes?  Is any coding element missing? Outpatient Case 6 – Physician coding surgery – Patient Name: Stella TrappeThe below is the physician/surgeon documentation of an operative report from a 23-year-old female patient, Stella Trappe.Preoperative Dx: Osteochondroma of the right scapulaPostoperative Dx: SameProcedure: Excision of osteochondroma of right scapulaIndication: This 23-year-old female has noticed a growing lump coming out of the back of her right scapula over the past year.  It has become unsightly and recently has become tender, especially when it’s bumped. CT scan has shown a pedunculated osteochondroma coming off the scapula, right at the base of the spine on the medial border.  There is no thickened cartilage cap, and simple excision should be adequate. Findings: Classic osteochondroma of right scapulaSpecimen Sent: OsteochondromaDescription of Procedure: After induction of adequate general anesthesia and appropriate timeout, the patient was positioned on her left side with the right side uppermost. The right upper extremity was prepped and draped in the standard fashion with the arm free in the field.  We marked out a 4-cm incision over the medial border of her right scapular spine and made this incision through the skin and subcutaneous tissues down to the fascia.  I could palpate the osteochondroma easily. We worked our way down through the fascia and separated a 3-cm-wide section of trapezius over the bump, which let us see the pseudocapsule over the bump.  We then dissected bluntly down around the osteochondroma to its base, where we could feel that is was right at the takeoff of the scapular spine.  The osteochondroma had a well-defined pedunculated stem as we had seen from the CT scan, and with the ¾-inch osteotome, we went around part of it and were able to come from the other side and separate it from the scapula.  There were a couple of rough edges, which were rongeured and smoothed, and then we bone waxed the stalk of the osteochondroma. We removed the excess bone wax. The osteochondroma was inspected and the cartilage cap was seen to be intact.  We then infiltrated the bone in the local area with 0.5 percent Marcaine with epinephrine, of which about 5 mL stayed in the wound.  We also infiltrated the skin edges.  We then closed the trapezius muscle with three 2-0 mattress sutures after a copious round of irrigation and cauterizing a few little bleeders.  The subcutaneous tissue was then approximated with 2-0 inverted mattress Vicryl sutures, and the skin was closed with 3-0 running subcuticular Prolene.  The wound was then dressed in two layers with a 4 x 4 and Tegaderm on the first layer and a bulky dressing on the top, which can be taken off in a couple of days.  The patient was then awakened and taken to the recovery room in satisfactory condition. L. Miles, M. D. Codes assigned for the Dr. Miles: C40.01, 23190Are these the correct codes to be assigned per the clinical documentation?  Health Science Science NursingHIT 205Share QuestionEmailCopy link Comments (0)

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