Deck 7: Digestive System, Hemiclymphatic System, and Mediastinumdiaphragm

Question 1

Case
-T7-2A OPERATIVE REPORT, APPENDECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Sally Road
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Acute appendicitis
POSTOPERATIVE DIAGNOSIS: Acute appendicitis
OPERATIVE PROCEDURE: Open appendectomy
FINDINGS: The appendix was acutely inflamed but not perforated. There was a little bit of purulent fluid in the pelvis.
PROCEDURE IN DETAIL: After good general endotracheal anesthesia, 10 cc of Marcaine was administered about McBurney's point. A Rockey-Davis incision was made, and dissection was carried down to the sternal oblique fascia. This was incised. Then, using a muscle-sparing technique, the muscle was divided. The peritoneum was identified and incised. The abdomen was entered. The appendix was mobilized and brought up into the wound. The mesoappendix was divided, and the appendix was transected at the base after placing a tie at the base of the appendix. After this, the appendiceal stump was buried using a piece of epiploicae fat that was adjacent and covering it with a serosal stitch. Next, the pull-tip sucker was placed in the pelvis, and a tiny bit of fluid came back. We did not irrigate the abdomen. The peritoneum was then closed. A single suture was placed in the muscle itself to approximate dead space; then the fascia was closed with 3-0, and the skin was closed with 4-0 Vicryl. Steri-Strips and sterile dressings were applied. After the peritoneum was closed, the layers were irrigated in succession as we closed the wound. The patient tolerated the procedure well. The remaining 20 cc of Marcaine were infiltrated into the muscle and the skin. She was returned to the recovery room in good condition.
T7-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 44950 (Appendix, Excision)
ICD-10-CM DX: K35.80 (Appendicitis, acute)
Explanation: An excisional appendectomy was performed and reported with 44950.
The diagnosis is stated to be acute appendicitis (K35.80) in the Postoperative Diagnosis section of the report and in the body of the report (see highlighted area of report below).
REPORT
PROCEDURE IN DETAIL: After good general endotracheal anesthesia, 10 cc of Marcaine was administered about McBurney's point. A Rockey-Davis incision was made, and dissection was carried down to the sternal oblique fascia. This was incised. Then, using a muscle-sparing technique, the muscle was divided. The peritoneum was identified and incised. The abdomen was entered. The appendix was mobilized and brought up into the wound. The mesoappendix was divided, and the appendix was transected at the base after placing a tie at the base of the appendix. After this, the appendiceal stump was buried using a piece of epiploicae fat that was adjacent and covering it with a serosal stitch. Next, the pull-tip sucker was placed in the pelvis and a tiny bit of fluid came back. We did not irrigate the abdomen. The peritoneum was then closed. A single suture was placed in the muscle itself to approximate dead space; then the fascia was closed with 3-0, and the skin was closed with 4-0 Vicryl. Steri-Strips and sterile dressings were applied. After the peritoneum was closed, the layers were irrigated in succession as we closed the wound. The patient tolerated the procedure well. The remaining 20 cc of Marcaine were infiltrated into the muscle and the skin. She was returned to the recovery room in good condition.

Question 2

Case
-T7-2B OPERATIVE REPORT, HEMICOLECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Cecil Graft
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Hepatic flexure tumor
POSTOPERATIVE DIAGNOSIS: Hepatic flexure tumor
PROCEDURE PERFORMED: Right hemicolectomy
HISTORY: This gentleman has a tumor of his hepatic flexure. He has very severe medical problems. The family and the patient wanted to proceed with surgery knowing the huge risks involved.
PROCEDURE: The patient was given a general anesthetic. He had a Swan-Ganz catheter and an arterial line inserted by anesthesia. He was then prepped and draped in the supine fashion. He had had a Foley catheter inserted prior to coming to the operating room. I made a midline skin incision going to the left of the umbilicus. I worked my way into the abdomen and found that there was a very mobile tumor in the hepatic flexure. The liver itself looked fine. There were some adhesions in the right upper quadrant secondary to what I believe is a previous cholecystectomy. I mobilized the right colon along the white line of Toldt and mobilized all the adhesions in the right upper quadrant. I then found that the tumor was right in the hepatic flexure. Once I mobilized the tumor, it was obvious that if this had grown outside of the bowel, it would have eroded right into the duodenum, which was right below it. However, there was no sign that this tumor was outside of the colon. There were no palpable lymph nodes, and it was not stuck to the liver, pancreas, or duodenum. It was freely inside in the bowel. I then mobilized the omentum off of this colon. Then I elected to try to do a segmental colon resection, which I at first thought would be a simpler, easier operation for this gentleman. I used the stapler and went distal and proximal to the tumor, and then I went through the mesentery with right angles. I had my assistant open up the bowel to prove that we had the tumor obviously, but also to make sure we had good margins, which we obviously did. However, once I had this out, I found that I really did not have a lot of right colon left. The blood supply to the right colon was poorer than the blood supply to the terminal ileum, so I elected to just do an extended right hemicolectomy and be done with it. I continued my dissection all the way down and went through the terminal ileum with the stapler and went through the mesentery with Kelly's and removed the rest of the right colon so that he, in fact, did have an extended right hemicolectomy. I tied with Vicryl ties. I then brought the two edges of the bowel together. I had mobilized the omentum off of the bowel. I opened up the bowel along the antimesenteric border on both sides and then brought the two edges of bowel together with GIA-75 stapler. Prior to stapling, I had put a distal and a proximal Vicryl stitch so that I could keep the bowel oriented. Prior to firing the stapler, I made sure that the mesentery of the colon and the small bowel were outside of the stapler. Once I fired the stapler, I looked at the bowel itself, and I found that I had an excellent anastomosis. There was excellent blood supply and no tension at all. I closed the hole first using Allis clamps to bring the two edges of the bowel together, and then I used TL-60 stapler and closed the hole off. This gave me an excellent hemostasis again with excellent blood supply and no tension at all. I closed the mesentery with a running Vicryl stitch. I used Hemaseel around the anastomosis. As mentioned, there were no obvious lymph nodes in the mesentery. The liver itself looked fine. I usually do not use NG tubes with right hemicolectomies, but considering that this gentleman is otherwise so ill, I elected to put an NG tube in. We confirmed it within the correct place in the stomach. I then put omentum over the anastomosis and closed with 2-0 Vicryl stitches. I irrigated out the wound with sterile saline and then closed the skin with staples. Telfa, Toppers, and gauze were applied. The patient tolerated this very well and went to the recovery room in good condition.
PATHOLOGY REPORT LATER INDICATED: See Report 7-2C.
T7-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services: 44160 (Colon, Excision, Partial)
ICD-10-CM DX: C18.3 (Neoplasm, intestine/intestinal, large, hepatic flexure, Malignant, Primary), D12.0 (Neoplasm, cecum, Benign)
Explanation: The procedure indicates a "Right hemicolectomy" and the coder must translate that to "colon excision" to locate the main term in the CPT manual index (colon).
The diagnosis code is as indicated in the pathology report as adenocarcinoma of the hepatic flexure (C18.3). Additionally, there was a polyp in the cecum which is reported with D12.0.

Question 3

Case
-T7-2C PATHOLOGY REPORT
LOCATION: Inpatient, Hospital
PATIENT: Cecil Graft
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PATHOLOGIST: Morton Monson, MD
CLINICAL HISTORY: Right colon resection
SPECIMEN RECEIVED: Right hemicolectomy, hepatic flexure tumor
GROSS DESCRIPTION: Received in a container labeled "extended right colon hepatic flexure" are two segments of colon. One segment includes the cecum and ascending colon and measures 10 cm (centimeter) in length. A segment of terminal ileum measuring 6 cm in length is present. The appendix, which appears normal, is also present and measures 5 cm in length and 0.6 cm in diameter. Abundant mesocolon is present. The specimen is opened and demonstrates a granular green-tan mucosa, which is intact. A small polyp is present in the cecal pouch. This has a nodular appearance and measures 1.3 1 1 cm. The ileocecal valve is unremarkable, and the remainder of the mucosa shows no abnormalities.
A second segment of colon measuring 9 cm in length is present. This has been opened, and a tumor that encircles the majority of the circumference of the lumen is present. The tumor is raised nodular and tan-brown to green. It measures 5 3.5 1.4 cm in greatest dimension. On sectioning, it appears to involve the wall. The specimen is sectioned, and multiple representative portions of the tumor are submitted as 1 to 6. The margins of resection about the tumor are submitted as 7 and 9. The polypoid lesion in the cecum is submitted as 8. The mesocolon is dissected, and lymph nodes are submitted as 10 to 13. Sections of the ileum are submitted as 14, and the appendix is submitted as 15.
MICROSCOPIC DESCRIPTION: The hepatic flexure of the colon demonstrates an invasive tumor consisting of complex glands lined by moderately differentiated pleomorphic epithelial cells. The tumor infiltrates through the muscular wall into the adjacent mesocolon. An abundant mucinous component is present near the deeply invasive portions. The surgical margins of resection are free of tumor. The terminal ileum shows normal morphology. The appendix shows normal morphology. Six lymph nodes of the mesocolon are negative for tumor. The cecum contains a polyp with adenomatous epithelial features.
DIAGNOSIS:
Colon, including cecum, ascending colon, and hepatic flexure, excision: Adenocarcinoma, moderately differentiated, infiltrating through muscular wall into mesocolon (hepatic flexure). Adenomatous polyp (cecum).
Terminal ileum, 6 cm (centimeter): No pathologic diagnosis.
Appendix: No pathologic diagnosis.
Lymph nodes, mesocolic, six: Negative for tumor (no pathologic diagnosis).
COMMENT: The NCCTG modification of Dukes' staging is B2.
T7-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 3

Professional Services: 88309 2 (Pathology, Surgical, Gross and Micro Exam, Level VI) ICD-10-CM DX: C18.3 (Neoplasm, intestine/intestinal, large, hepatic flexure, Malignant Primary), D12.0 (Neoplasm, cecum, Benign)
Explanation: There were 2 specimens submitted for examination: one segment involved the terminal ileum, cecum, and ascending colon. The second segment involved the part of the colon containing the tumor, which was the segment of hepatic flexure. Because there were 2 colon specimens, cecum and ascending colon, 88309 is reported with 2 units.
The tumor was located in the hepatic flexure (C18.3), but other contiguous parts of the colon were removed to allow for good margins and re-anastomosis of the colon. The adenomatous polyp of the cecum is also reported (D12.0).

Question 4

Case
-AUDIT REPORT T7.2 OPERATIVE REPORT, SPLENECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Marie Hill
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Intra-abdominal bleeding; ruptured spleen
POSTOPERATIVE DIAGNOSIS: Intra-abdominal bleeding; ruptured spleen
PROCEDURE PERFORMED: Splenectomy, total
ANESTHESIA: General anesthesia
INDICATION: Patient is a 24-year-old female involved in a one-car accident in which she lost control of her vehicle and went down a ditch and the vehicle rolled twice, landing in an upright position. Patient was only person in the vehicle and was restrained.
Patient has been conscious since paramedics arrived. Tests revealed bleeding in the abdomen. The spleen was suspected.
PROCEDURE: The patient was brought emergently to the operating room and placed under general anesthesia. She was prepped and draped while in the supine position. A left-sided Kocher incision was made.We used the Omni retractor and were able to look way into the abdomen. All of the organs looked intact and clear.We then identified a lot of bleeding in the area of the spleen, and a tear was noted. Under deeper inspection on the backside of the spleen a large tear was present, and decision was made to remove it. We lifted up on the spleen and brought it through the wound. The major vessels were divided. The short gastric vessels were dealt with in the same way. The spleen was then removed in its entirety. The areas were doubly tied, and care was taken to ligate and suture all the major vessels. Bleeding was controlled. We then irrigated and suctioned out the abdominal cavity and closed the wound with #2 Vicryl stitches in a two-layer fashion. We then irrigated out the wound and put in some staples. Marcaine 1.25% was placed in the wound. Telfa, toppers, and gauze were applied. The patient came through the surgery well and went on to the recovery room in good condition.
T7.2:
SERVICE CODE(S): 38115___________________________________________
ICD-10-CM DX CODE(S): S36.09XA___________________________________
INCORRECT/MISSING CODE(S): ____________________________________

Question 5

Case
-T7-1A OPERATIVE REPORT, ESOPHAGOGASTRODUODENOSCOPY
LOCATION: Inpatient, Hospital
PATIENT: Sam Jones
SURGEON: Larry Friendly, MD
ATTENDING PHYSICIAN: Larry Friendly, MD
PREOPERATIVE DIAGNOSIS: Upper gastrointestinal bleed
POSTOPERATIVE DIAGNOSIS:
1. Moderate gastritis with superficial ulcerations in the gastric antrum.
2. Large duodenal bulb ulcer, 1.5 cm (centimeter) in size, not bleeding. No vessel.
3. Large 2-3 cm post bulbar ulcer, not bleeding. No vessel.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy
INDICATION: This is a 63-year-old white male alcoholic who has respiratory failure and pneumonia. This morning he developed bright red blood from his NG tube. His hemoglobin was around 9 and has fallen to 7.8. The endoscopy is indicated to rule out esophageal varices.
PREOPERATIVE MEDICATION: Patient is on a Versed drip.
PROCEDURE: The flexible Pentax video double channel endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 40 cm. Inspection of the esophagus revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The stomach proper was entered, and immediately seen in the antrum was erythema, friability, and some superficial gastric ulcerations, not bleeding. We entered the pylorus and could see a large 1.5-cm moderately deep duodenal bulb ulcer with no vessel or pigmented areas. Beyond this in the post-bulbar ulcer was a large 2-3 cm superficial post bulbar ulceration, not bleeding, without visible vessel. Photographs were obtained. On retroflexion, no lesions were seen. The patient tolerated the procedure well.
IMPRESSION:
1. Moderate gastritis with superficial gastric ulcerations, not bleeding.
2. Duodenal bulb ulcer, 1.5 cm, moderately deep, with no vessel, clot, or pigmented areas.
3. A post-bulbar 2.5 to 3 cm (centimeter) stomach ulceration, superficial, not bleeding.
SUGGESTIONS:
1. Continue IV (intravenous) Protonix.
2. Follow hemoglobins.
T7-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-T7-1B OPERATIVE REPORT, LAPAROTOMY
LOCATION: Inpatient, Hospital
PATIENT: Mary Smith
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Complete small bowel obstruction
POSTOPERATIVE DIAGNOSIS: Complete small bowel obstruction
OPERATIVE PROCEDURE: Laparotomy, adhesiolysis, release small bowel obstruction due to adhesions and internal hernia, and resection of small bowel to colonic fistula
HISTORY: This 47-year-old patient came in with a complete small bowel obstruction. There was a questionable lesion in her large bowel, but it was not obstructing. It is elected to take her to the operating room.
The patient came into the operating room at 2215 hours, and we did not start operating until 2350 hours. Please see anesthesia notes for the preoperative management of the patient during that time.
PROCEDURE: The patient was given a general anesthetic. We put her in stirrups, and she was prepped and draped in the supine fashion. We went through a previous midline incision. There were adhesions stuck right to the abdominal wall. We very carefully took these down. There were a lot of adhesions right against the abdominal wall, but we were able to take all of these down so that we could get at the small bowel. There was very dilated small bowel and then completely collapsed small bowel distally. When we had everything mobilized, we found that there was an internal hernia that was the main problem. There was a piece of small bowel stuck to her transverse colon. Bowel was running in between it. This was a complete obstruction. We very carefully dissected between the small bowel and the transverse colon, but it did not appear to be just adhesions. There was an actual connection that appeared to be a fistula. I used the TLC-55 stapler and came across the fistula going across the small bowel in a Heineke-Mikulicz fashion so that I did not impinge on the diameter of the small bowel. This gave an excellent resection of the fistula. We then identified that she indeed had had a right colon resection with a side-to-side anastomosis.
It appears that all the staples that I was seeing in the left lower quadrant were likely related to her stomach surgery that she had had in the past.
We found no other lesions. We carefully looked at all of the large bowel, and there was really nothing to find in any part of the large bowel. We paid particular attention to the area around the splenic flexure, and there was nothing to feel and there was certainly no distended large bowel. We then found we had an excellent hemostasis, and we had released the bowel obstruction. We then closed with 0 loop nylon. We closed the skin with staples. Telfa, Topper, and then gauze were applied. The patient tolerated this well and will go to ICU (intensive care unit).
T7-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 7

Case
-AUDIT REPORT T7.1 OPERATIVE REPORT, APPENDECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Rachel Wiggins
ATTENDING PHYSICIAN: Leslie Alanda, MD
PREOPERATIVE DIAGNOSIS: Abdominal pain with acute appendicitis
POSTOPERATIVE DIAGNOSIS: Acute appendicitis
ANESTHESIA: General
INDICATIONS: Rachel is a 17-year-old female who has a history and exam consistent with acute appendicitis. Her diagnosis as well as the recommended procedure of an appendectomy was discussed with the patient and her parents.We discussed the other possible diagnoses that could be present. We discussed that some of these are treated medically and some are treated operatively. I would recommend an appendectomy as this is quite suspicious that she indeed has appendicitis.We discussed potential problems with a perforated appendicitis. This is also possible that this has occurred even at this point. I discussed if her appendix appears to be grossly normal that we will still plan to remove her appendix at the time of the operation and then look for other causes of her abdominal pain. If something needs to be done surgically, we will go ahead and proceed with it even if it requires a larger incision or a completely different incision to manage this.We discussed the risk of bleeding and infection.We discussed injury to intestines and other intra-abdominal structures.We discussed wound infections and abscesses that can occur. Her questions were answered. She understands and wishes to proceed with an appendectomy.
PROCEDURE: Rachel was then brought to the operating room and placed in a supine position on the table. After receiving a general anesthetic, she was prepped and draped in a sterile fashion. Incision line was marked out in the right lower quadrant. This was just a little bit above McBurney's point. This was infiltrated with 0.5% Marcaine. We waited a couple of minutes. Incision was then made and carried down through Scarpa's down through the subcutaneous tissues down to the anterior fascia. The anterior fascia was sharply divided. Muscle-splitting incision was carried out down to the peritoneum. This was grasped in a three-step technique, and the peritoneal cavity was entered sharply. The inflamed appendix was identified and brought out through the wound. This did appear to be grossly inflamed, especially the distal aspect of this. It appeared to be fairly early on. The mesoappendix was taken down between clamps, transected, and ligated with 3-0 Vicryl in continuity. The origin of this appendix was then crushed and clamp was moved just distal to this. No Vicryl was used to ligate the origin of the appendix. The appendix was then transected sharply and handed off the table as a specimen. The appendiceal stump was cauterized. A 3-0 silk pursestring suture was placed in the base of the cecum. This was used then to imbricate the appendiceal stump. We also used a Z-stitch of 3-0 silk over this to further "roll this in." Hemostasis was present. This was then returned to the peritoneal cavity. The right lower quadrant and the pelvis were irrigated out with warm normal saline. Clear returns were established. The posterior fascia and peritoneum were closed with a 0 Vicryl in a running fashion. The wound was irrigated out. 0 Vicryl was used to approximate the internal obliques in interrupted fashion. Wound was irrigated out.
The anterior fascia was closed then with interrupted sutures of 0 Vicryl in a figure-of-eight fashion. The wound was irrigated out. Skin was closed with a 4-0 Vicryl in a subcuticular fashion. Steri-Strips and sterile dressings of Telfa and Tegaderm were applied. The patient tolerated the procedure well and went to the recovery room in stable condition.
PATHOLOGY REPORT LATER INDICATED: Acute suppurativa appendix
T7.1:
SERVICE CODE(S): 44960, 49084-51____________________________________
ICD-10-CM DX CODE(S): K37, R10.9___________________________________
INCORRECT/MISSING CODE(S): _____________________________________