Deck 11: Female Genital System and Maternity Caredelivery

Question 1

Case
-T11-2A OPERATIVE REPORT, CESAREAN SECTION
LOCATION: Inpatient, Hospital
PATIENT: MaryBelle Wilson
ATTENDING PHYSICIAN: Andy Martinez, MD
SURGEON: Andy Martinez, MD
PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean
POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean
PROCEDURE: Repeat low transverse cervical segment cesarean section
ANESTHESIA: Spinal
COMPLICATIONS: None
FINDINGS: Viable female infant weighing 8 pounds 14.5 ounces, with Apgars of 9 at 1 minute and 10 at 5 minutes
PROCEDURE: The patient was prepped and draped in the supine position with left lateral displacement of the uterine fundus under spinal anesthesia with a Foley catheter indwelling. A transverse incision was made in the lower abdomen, removing the old scar. The fascia was divided laterally. The rectus muscle was divided in the midline. The peritoneum was entered in the sharp manner. An incision was extended vertically. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The uterus was entered in a sharp manner in the lower uterine segment, and the incision was extended laterally with blunt traction. The amniotic fluid was clear. The infant's head was delivered. The infant was then delivered and bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive care nursery staff in apparent good condition. The placenta was manually expressed. The uterus was delivered from the abdominal cavity and placed on wet lap sponges. A dry sponge was used to ensure remaining products of conception were removed. The cervical os (opening) was ensured patent with a ring forceps. The uterine incision was closed with 0 Vicryl interlocking suture in two layers, with the second layer imbricating the first. A figure-of-eight suture was also placed, which was required for hemostasis. The operative site was irrigated. The bladder flap was reapproximated using 2-0 Vicryl continuous suture. The tubes and ovaries appeared normal bilaterally. The uterus was placed back within the abdominal cavity. The pelvic gutters were irrigated. The anterior peritoneum was reapproximated using 2-0 Vicryl continuous suture. The incision was irrigated. The fascia was closed with 0 Vicryl continuous suture. The incision was irrigated. The skin was closed with staples. All sponges and needles were accounted for at the completion of the procedure. The patient left the operating room in apparent good condition, having tolerated the procedure well. The Foley catheter was patent and draining clear yellow urine at the completion of the procedure.
T11-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 59510 (Cesarean Delivery, Antepartum Care) ICD-10-CM DX: O34.219 (Delivery, cesarean [for] previous, cesarean delivery), Z37.0 (Outcome of delivery, single, liveborn)
Explanation: The service was a cesarean delivery that included the antepartum care, delivery, and postpartum care and is reported with 59510.
The diagnosis is cesarean delivery in a woman who previously delivered by means of cesarean, reported with O34.219. Z37.0 reports the outcome of delivery as single liveborn.

Question 2

Case
-T11-2B OPERATIVE REPORT, AMNIOCENTESIS
LOCATION: Inpatient, Hospital
PATIENT: Patricia Garrison
ATTENDING PHYSICIAN: Andy Martinez, MD
SURGEON: Andy Martinez, MD
PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 32 plus weeks.
2. Insulin-dependent diabetes.
3. Diabetic nephropathy.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 32 plus weeks.
2. Insulin-dependent diabetes.
3. Diabetic nephropathy.
PROCEDURE PERFORMED: Amniocentesis
ANESTHESIA: NONE
INDICATIONS: The patient is a 26-year-old woman with a complicated pregnancy, who has been on bedrest because of diabetic nephropathy. Due to the fact that the fetus might be in a hostile environment, we felt that accelerated pulmonary maturity might be a possibility; therefore, at this time, we elected to go with amniocentesis to help us manage her pregnancy. She had been fully informed of the risks and benefits of the procedure prior to proceeding.
DESCRIPTION OF PROCEDURE: Ultrasound scanning was done by the technologist, and placenta was posterior. We prepped the abdomen and draped it. We used a sterile covered ultrasound transducer with guide and located a pocket of fluid (do not report the ultrasound guidance). The 20-gauge needle was inserted. As we got into the uterus, the baby moved into the area; therefore, the needle was immediately withdrawn. The fetus was palpated a little bit, and we stimulated the baby and it moved out of the area. We then repositioned the transducer, and we were able to drop into the pocket of amniotic fluid and withdraw 20 cc of clear yellow amniotic fluid. The fluid was sent for maturity studies. The patient tolerated the procedure without difficulty.
T11-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services: 59000 (Amniocentesis)
ICD-10-CM DX: O24.113 (Pregnancy, complicated by, diabetes [mellitus], pre-existing, type 2), E11.21 (Diabetes/diabetic, type 2, with, nephropathy), Z79.4 (Long term [current] drug therapy [use of], insulin)
Explanation: The service is an amniocentesis reported with 59000.
The diagnosis O24.113 indicates the maternal diabetes is complicating pregnancy.
One code reports diabetes with nephropathy, E11.21.
Code Z79.4 is reported to indicate the long-term use of insulin (see the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.15.h.).

Question 3

Case
-AUDIT REPORT T11.2 DISCHARGE SUMMARY
INDICATION: The patient is a 22-year-old gravida 1 who underwent spontaneous rupture of membranes and presented to her primary obstetrician. She developed intermittent repetitive late decelerations and was transferred to our facility for lack of cesarean coverage where she was originally admitted. On a low dose of Pitocin, the baby had reactive tracing, but when Pitocin was increased because she was not progressing in labor, the baby, again, began to develop repetitive variables, and she was offered cesarean section for delivery of the infant. She underwent Cesarean section of a viable 5 pound 13.7 ounce infant with Apgars of 7 at 1 minute and 9 at 9 minutes with the cord around the neck times one and she returned to recovery in stable condition. By later on postoperatively day zero, she was ambulating with active bowel sounds. She was passing flatus by postoperative day one and tolerating a regular diet. She remained afebrile with stable vital signs. She continued to do well, and by postoperative day two, she requested discharge.
DISPOSITION: Discharge to home.
CONDITION AT DISCHARGE: Good.
FOLLOW-UP with her primary OB physician for staple removal and postoperative care.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg 1-2 p.o. q.4h. p.r.n.
2. Ibuprofen 600 mg 1 p.o. q.6h. p.r.n, dispense 30 with no refills.
3. Iron sulfate 1 p.o. b.i.d., take with food.
DISCHARGE HEMOGLOBIN: 9.5.
PATHOLOGY: No pathologic diagnosis.
T11.2:
SERVICE CODE(S): 99239__________________________________
ICD-10-CM DX CODE(S): O42.92, O62.0, Z37.0________________
INCORRECT/MISSING CODE(S): ________________________________________

Answer 3

Incorrect/Missing code(s): 99238
Explanation: The hospital discharge service is reported based on the amount of time spent discharging the patient. Since no time is stated for this discharge service, the lowest level of service, 99238, is reported. Since the attending (Dr. Martinez) did not perform the C-section the discharge visit would not be considered part of the global package and should be reported with code 99238. The diagnoses at discharge includes, delivery complicated by premature rupture of the membrane, failure to progress, and a code for the out-come of delivery (single liveborn).

Question 4

Case
-T11-1A OBSTETRICAL ULTRASOUND
LOCATION: Inpatient, Hospital
PATIENT: Patricia Garrison
ATTENDING PHYSICIAN: Andy Martinez, MD
RADIOLOGIST: Morton Monson, MD
EXAMINATION OF: Limited OB (obstetrics) ultrasound
CLINICAL SYMPTOMS: Twin gestation of vertex/breech at 36 weeks; please check position
LIMITED OB ULTRASOUND: FINDINGS: A twin gestation is identified. Twin A lies to maternal right and is in longitudinal lie and breech presentation according to technologist's sheet. Twin B lies to maternal left and is in longitudinal lie in cephalic presentation. Twin B appears to be the presenting twin. Fetal heart rate for baby A is 148 beats per minute, and for baby B, 154 beats per minute. No further evaluation was performed on today's exam.
T11-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 5

Case
-T11-1B OPERATIVE REPORT, CESAREAN SECTION
LOCATION: Inpatient, Hospital
PATIENT: Patricia Garrison
ATTENDING PHYSICIAN: Andy Martinez, MD
SURGEON: Andy Martinez, MD
PREOPERATIVE DIAGNOSES:
1. Twin intrauterine pregnancy at 36 weeks 4 days.
2. Vertex/breech combination.
POSTOPERATIVE DIAGNOSES:
1. Twin intrauterine pregnancy at 36 weeks 4 days.
2. Vertex/breech combination.
PROCEDURE PERFORMED: Primary low transverse cesarean section
ANESTHESIA: Spinal
SURGICAL INDICATIONS: The patient is a 26-year-old gravida 2, para (to bring forth) 1, at 36 weeks 4 days who presented in active labor with vertex/breech combination. After counseling with the patient, the decision was made to proceed with delivery by C-section.
OPERATIVE FINDINGS: The first twin weighed 2794 g (gram) and was a male infant, with Apgar scores of 6 at 1 minute and 8 at 5 minutes. The second child was a male weighing 3203 g, with Apgar of 6 at 1 minute and 9 at 5 minutes. There were two separate sacs with fused placenta. The amniotic fluid was clear on both twins. Tubes and ovaries were normal. The appendix was retrocecal.
OPERATIVE DESCRIPTION: After induction of subarachnoid anesthesia, Foley catheter was placed as well as Venodynes, and the patient was then prepped and draped. The abdomen was opened through a Pfannenstiel incision. The bladder flap was opened transversely with scissors and the bladder dissected down bluntly with the hand. A small incision was made in the myometrium of the lower uterine segment, and then entry into the uterus was accomplished bluntly with a Kelly clamp. A finger was introduced into the uterus to guide a bandage scissors for a low transverse incision. The first infant was then delivered without difficulty, and the mouth and nose were suctioned with bulb syringe, cord was clamped and cut, and infant handed to ICN (intensive care; neonatal) staff. The second sac was then ruptured with Allis clamp, and the infant was delivered breech without difficulty. This infant was then suctioned and handed off. The placenta was delivered manually. The cords were tagged appropriately for pathology. Uterus was closed in two layers, first with a running locked 0 Vicryl followed by a running horizontal Lembert 0 Vicryl. The pelvis was irrigated with saline. The uterine incision was reinspected and was felt to be dry. With sponge and needle counts correct, attention was directed toward the closure. The peritoneum was loosely approximated in the midline with three mattress sutures of 2-0 Vicryl. The fascia was then closed with running 0 Vicryl using two strands, one from either side to the middle and tied independently. The skin was closed with staples, and a sterile dressing was applied. Blood loss estimation was difficult due to the large amount of amniotic fluid, but we estimated approximately 1200 cc. Specimen to pathology: Placenta. Final sponge and needle counts were correct.
PATHOLOGY REPORT LATER INDICATED: Benign tissue
T11-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-AUDIT REPORT T11.1 OPERATIVE REPORT, CESAREAN SECTION
LOCATION: Inpatient, Hospital
PATIENT: Lisa Logan
ATTENDING PHYSICIAN: Andy Martinez, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS:
1. Spontaneous rupture of the membranes.
2. Failure to progress.
POSTOPERATIVE DIAGNOSIS:
1. Spontaneous rupture of the membranes.
2. Failure to progress.
PROCEDURE PERFORMED: Primary low transverse cesarean section.
ANESTHESIA: Epidural with Duramorph.
ESTIMATED BLOOD LOSS: 700 cc
PATIENT: Lisa Logan
FLUIDS: 3000 cc crystalloid
URINE OUTPUT: 90
COMPLICATIONS: None
FINDINGS: A single viable male infant, Apgar's 7 at 1 minute, 9 at 5 minutes, weight 2656 gm (5 pounds 13.7 ounces).
PROCEDURE PERFORMED: Primary low transverse cesarean section.
ANESTHESIA: Epidural with Duramorph.
INDICATIONS: Lisa is a 22-year-old, G1, who presented to her primary obstetrician with ruptured membranes at 38 weeks and was found to have intermittent late decelerations. She was transported here. Pitocin was used to attempt to cause cervical change; however; despite nine hours of attempting to adjust Pitocin without causing late deceleration, she remained at 3 to 4, 90 and 0. The baby began to experience late decelerations, and patient elected to proceed with cesarean. Risks and benefits of surgery were discussed with the patient.
FINDINGS AT THE TIME OF SURGERY: Included single viable male infant, left occiput transverse position, with cord around the neck 1, normal tubes and ovaries, normal uterine contour.
TECHNIQUE: The patient was taken to the operating room, where epidural anesthesia was dosed. She was prepped and draped in a normal sterile fashion, and anesthesia was found to be adequate. A Pfannenstiel skin incision was made with the scalpel and carried through to the underlying fascia, which was nicked in the midline, and the fascial incision was extended bilaterally with Mayo scissors. The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and the underlying rectus muscles were dissected off with sharp dissection. The inferior aspect of the fascial incision was likewise grasped with Kocher clamps, tented up, and the underlying rectus and pyramidalis muscles were dissected off with sharp dissection. The rectus muscles were separated in the midline, and the incision was extended superiorly and inferiorly, with good visualization of the bladder. The peritoneum was grasped with hemostat, tented up, and entered sharply. The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder. The rectus muscles were separated in the midline. The bladder blade was inserted. The vesicouterine peritoneum was grasped with pickup, entered sharply, and the incision was extended bilaterally with Metzenbaum scissors. The bladder flap was created digitally. The bladder blade was reinserted. The uterus was transcribed in a transverse manner with the scalpel and extended with bandage scissors. The fetus in left occiput posterior presentation was delivered into the incision, and the fetus was bulb suctioned on the abdomen after delivery. Cord gases were cut and sent. The fetus was handed to NICU after the cord was clamped and cut. The placenta was extracted manually. The uterus was exteriorized, cleared of clots and debris, and the angles of the uterine incision were grasped with ring forceps, and the incision was closed with 0 Vicryl in a running locked fashion, a second imbricating layer was used to achieve hemostasis. The bladder flap was closed with 2-0 Vicryl in a running fashion. The posterior cul-de-sac was copiously irrigated. The uterus was replaced within the abdominal cavity. The pelvic cavity was then copiously irrigated and cleared of clots and debris. Then, the rectus diathesis was closed with 2-0 Vicryl in a running fashion. The fascia was closed with 0 Vicryl in a running fashion, using two sutures beginning at the angles and meeting in the midline. The subcuticular space was closed with 2-0 Vicryl interrupted sutures. The skin was reapproximated with staples. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct, and she was taken to recovery in stable condition.
T11.1:
SERVICE CODE(S): 59510_________________
ICD-10-CM DX CODE(S): O42.92__________
INCORRECT/MISSING CODE(S): ________________________________________