The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Exercise 1

Case 11-1
LOCATION: Inpatient, Hospital
PATIENT: Patti Bryan
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Andy Martinez, MD
PREOPERATIVE DIAGNOSIS: Large left ovarian cyst.
POSTOPERATIVE DIAGNOSIS: Large left ovarian cyst.
PROCEDURE PERFORMED: Laparoscopic drainage of left paratubal cyst.
PREAMBLE: The patient is a 27-year-old woman found to have a large left ovarian cyst on ultrasound. This cyst was measuring up to 8 cm, and there was thought to be at least one septation within it. The patient was having increasing problems with irregular menses along with increasing left lower quadrant pain. The decision was therefore made to proceed with laparoscopy with the aim of draining this ovarian cyst.
PROCEDURE: The patient was taken to the operating room and general anesthetic was administered. The patient was then prepped and draped in the usual manner in the lithotomy position, and bladder was drained with straight catheter.
Speculum was placed to allow for visualization of the cervix, which was grasped anteriorly using single-toothed tenaculum. Cohen cannula was then placed to allow for manipulation of the uterus. At this point, gloves were changed and attention was directed toward the abdomen. An umbilical incision was made to allow for insertion of the Veress needle. This was done without incident, and the abdomen was then insufflated with 3 liters of carbon dioxide. A 10-mm trocar was then placed through the umbilical incision without incident.
At this point the pelvis was inspected. Immediately apparent was a large, simple-appearing cyst occupying the majority of the pelvis. In fact, it was impossible to get around the cyst to be able to inspect or identify the remainder of the pelvic organs. At this point a 5-mm trocar was then placed suprapubically. At time of trocar incision, a small puncture was made in the cyst itself. Clear fluid began draining from the cyst cavity. An aspirator was then placed within the cyst cavity, and approximately 150 cc of absolutely clear fluid was drained from the cyst. Puncture site was not bleeding. Once the cyst was deflated, the rest of the pelvis could be inspected. The uterus appeared completely normal. Right ovarian and fallopian tubes were visualized and appeared completely normal. On the left side, the left ovary was completely normal. This cyst was found to arise in the paratubal region and was not ovarian in origin. The cyst was nicely deflated, and as it was paratubal, the cyst was not excised. It was confirmed to be hemostatic. Remaining fluid was then aspirated from the cul-de-sac. The cul-de-sac appeared completely normal. Upper abdomen was inspected and was normal. Appendix was visualized and was also normal. At this point the procedure was terminated. The suprapubic trocar was removed, and good hemostasis was ensured. Abdomen was desulfated, and umbilical trocar was removed. The incisions were then closed using 4-0 Vicryl in a subcuticular fashion. Vaginal instruments were then removed, and cervix was confirmed to be hemostatic.
The patient tolerated the procedure well. There were no complications. Estimated blood loss was minimal.
Pathology Report Later Indicated: No malignancy. Benign ovarian cyst.
CPT Code(s): _________________
ICD-10-CM Code(s): _________________
Abstracting Questions:
1. What approach was utilized for this procedure? _________________
2. Was the cyst removed? _________________