Question 1

Case
-T10-1C OPERATIVE REPORT, CYSTOSCOPY
LOCATION: Outpatient, Hospital
PATIENT: Martin Glass
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: History of vesical neck contracture, post radical prostatectomy
POSTOPERATIVE DIAGNOSIS: Same, with foreign body removal
PROCEDURE PERFORMED: Cystoscopy, foreign body removal from vesical neck
ANESTHESIA: General
PROCEDURE: Please see the preoperative note for indications of the procedure as well as full informed consent. The patient underwent general anesthetic, was put in the dorsolithotomy position, and was prepped and draped in the usual fashion. Cystoscopically the bladder neck was sitting fairly open at this point, having had a catheter in through the weekend. Findings revealed a couple of small staples from the stapled superficial venous complex to have eroded through the anastomosis. These were plucked out using a cold cup biopsy forceps. He tolerated the procedure well.
T10-1C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

Professional Services: 52310 (Cystourethroscopy, Removal, Foreign Body) ICD-10-CM DX: T85.692S (Complication[s], suture, permanent, mechanical, specified NEC), N32.0 (Contraction/contracture/contracted, vesical, neck or urethral orifice)
Explanation: The service was a cystourethroscopy for the removal of a foreign body and is reported with 52310.
The diagnosis is as stated as contraction (N32.0) and complications of nonabsorbable surgical material (staples T85.692S).
Code T85.692S describes a mechanical complication of a permanent suture (staple). The 7th character "S" indicates a sequelae of a previous procedure.

Question 2

Case
-T10-2C TRANSRECTAL ULTRASOUND
LOCATION: Outpatient, Hospital
PATIENT: John Ibarra
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Possible recurrent prostate cancer
POSTOPERATIVE DIAGNOSIS: Possible recurrent prostate cancer
PROCEDURE: Transrectal ultrasound and biopsy of
prostatic nodule
CLINICAL NOTE: This gentleman had a radical prostatectomy by me 6 months ago. His prostate-specific antigen is now 0.1 ng/ml (nanograms per milliliter). He had a repeat prostate-specific antigen a few weeks after this at the VA. This showed an undetectable prostate-specific antigen level. On rectal examination, though, there is a little nodule in the prostatic fossa.
PROCEDURE: Patient was placed in the left lateral position. Ultrasound probe was introduced. The nodule could not be identified by ultrasound. There is no palpable mass. Bladder neck was open. Images were not obtained.
Probe was removed with digital guidance, and nodes were biopsied twice. Patient tolerated the procedure well. I will contact him when results are available.
If the biopsy is benign, I think we will try and write the abnormal prostate-specific antigen off to laboratory error given the fact that he has had a normal one since then. We will schedule him for prostatic-specific antigen and follow-up in 3 months.
PATHOLOGY REPORT LATER INDICATED: Benign prostatic tissue specimen
T10-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

Professional Services: 55700 (Prostate, Needle Biopsy), 76872-26 (Ultrasound, Rectal) ICD-10-CM DX: N40.0 (Enlargement/enlarged, prostate), Z85.46 (History, personal [of], malignant neoplasm [of], prostate)
Explanation: The prostate was transrectally biopsied and reported with 55700. The ultrasound of the prostate was a diagnostic exam and performed independent of the biopsy and is reported separately with 76872. Note that the ultrasound probe was removed and then the physician used his finger to identify the site and guide the biopsy. This means that the biopsy was performed without ultrasound guidance; therefore, 76942 is not appropriate. The -26 modifier is added when reporting the professional service.
The pathology report indicates benign prostatic tissue specimen. Therefore, the indication for biopsy would be coded, which is a little nodule in the prostatic fossa (N40.0). When referencing "Nodule, prostate" in the Index of the ICD-10-CM the coder referred to "Enlargement, prostate," N40.0. When referencing this code in the Tabular, the code accurately reports the condition stated in this report. This patient also has a history of prostate cancer (Z85.46).

Question 3

Case
-AUDIT REPORT T10.1 OPERATIVE REPORT, RESECTION
LOCATION: Outpatient, Hospital
PATIENT: Donald Styel
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left hydrocele, left scrotal mass
PATIENT: Left hydrocele
PROCEDURE PERFORMED: Resection of hydrocele sac, left testicular cord, left scrotum, and resection of left paratesticular mass.
CLINICAL NOTE: This is a 78-year-old gentleman who has developed a hydrocele and has a left scrotal mass. We have discussed different options, and he has decided he would like this surgically taken care of. The patient has been marked earlier for surgery.
OPERATIVE NOTE: The patient was given a general endotracheal anesthetic, prepped, and draped in the supine position. A midline scrotal incision was made and the testis delivered. Two hydroceles were identified, one of the testis and one of the cord. The hydrocele of the cord was resected. Hemostasis was achieved with electrocautery. The hydrocele sac of the scrotum was also opened and resected. Once opening this, there was a very dark 1.5-cm lesion separate from the epididymis and testis in the region of the testicular cord. This was mobilized, isolated, and resected intact. It did not appear to have a blood supply or be in association with any of the cord or testicular structures. This was sent separately for pathologic identification. Once hemostasis was achieved, the testis was returned to the scrotum. A 1/4-inch Penrose drain was left through a separate stab wound and sutured to the skin with 2-0 Prolene. The scrotum was closed in two layers with a 3-0 chromic. Dressings applied. Scrotal support applied. The patient was transferred to the recovery room in good condition.
10.1:
SERVICE CODE(S): 55040, 55500-51_________
ICD-10-CM DX CODE(S): N43.3, N43.3______
INCORRECT/MISSING CODE(S): ________________________________________

Accepted Answer

Incorrect/Missing code(s): 55500, 54512, LT, N43.3, N509
Explanation: The Operative report clearly states that there were two distinct hydroceles, one from the scrotum and one on the testicular cord. The first procedure was for the excision of the hydrocele located in the scrotum and would be coded with CPT code, 55040 with the modifier -LT to indicate that the procedure was of the left testicle. There was also a hydrocele of the testicular cord reported with 55500. Code 55500 is a "separate procedure" and is therefore bundled with 55040. When removing these hydroceles, a mass/lesion was found in the scrotum in the region of the testicular cord. The lesion was separate from and not in association with the epididymis, testis, or testicular cord. This was resected and is reported with 54512. Modifier -51 is appended to indicate multiple procedures during the same session.
The diagnosis would be the hydrocele, N43.3. This code covers both the hydrocele of the testis and of the spermatic cord. The diagnosis code N50.9 would also be used to report the mass of the scrotum.

Question 4

Case
-T10-1A OPERATIVE REPORT, LYMPHADENECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Jack Ehnke
SURGEON: Ira Avila, MD
ATTENDING PHYSICIAN: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate, with elevated PSA (prostate specific antigen)
POSTOPERATIVE DIAGNOSIS: Recurrent adenocarcinoma of the prostate
ANESTHESIA: General
PROCEDURE: Please see the preoperative note for indications of the procedure as well as full informed consent. The patient underwent a general anesthetic and was put in a modified frog-leg position. Anesthesia preparation included a central venous line, arterial line, and epidural catheter. After this was achieved, a midline incision was made between the umbilicus and symphysis pubis. This was deepened down through skin and generous subcutaneous tissue to the midline. The retropubic space was entered and developed. The pelvic lymphadenectomy was then performed. This was carried along the usual lines. The lateral extension was the external iliac vein. Tissues surrounding that vein were brought down and around the muscle wall to include the obturator group, preventing injury to the obturator artery, vein, and nerve. Proximally we went to the circumflex iliac branches, including the node of Cloquet, and then used clips across the trunks of the lymphatics. Distally or proximally on the patient, we proceeded to the bifurcation of the iliac vein, ending the dissection at that point. Again, the lymphatic trunks were clipped. Each package was delivered and sent to Pathology for frozen section analysis. With the result of negative nodes, we proceeded with surgical removal of the prostate. This was performed in standard fashion. The Thompson retractor was used with modifications under padded retractors throughout the procedure. This allowed adequate exposure. The margin between the lateral and endopelvic fascia was opened in anteromedial fashion to the puboprostatic ligaments, which were opened. The patient's size was fairly good, and he had a large prostate so the visualization in the apical area of the prostate was not so great. We finger dissected along the superficial venous complex, reaching the apex of the prostate on each side. The McDougall clamp was placed through the fascia under the superficial venous complex but anterior to the urethra. Space was created there. A TIA-46 stapler was used to staple across the superficial venous complex. The urethra was exposed and opened anteriorly. Sutures at 10 and 2 o'clock were placed, 2-0 chromic, outside to in. The rest of the urethra was mobilized after the catheter was brought up and out of the wound and used for traction device after it was cut. The urethra was incised, and sutures were placed at the 4 and 8 o'clock positions likewise. Apex of the prostate was mobilized using sharp and blunt dissection, carrying it down to the lateral pelvic fascial leaves. These were separated using sharp and blunt dissection off the lateral aspect of the prostate. Clips were used for the small bleeding vessels encountered. The lateral pedicle was then mobilized between clamps and ligated with 0 chromics, each side. Care was again taken to avoid the neurovascular bundle apparatus. The prostate was mobilized anteriorly, and the Denonvilliers' fascia was opened over the seminal vesicles. Those were dissected posteriorly. The bladder neck was then incised down just behind the prostate. Because of the large median lobe on the prostate, we had to open the bladder neck somewhat more than normal. We exposed the trigone but did not approach it. The prostate was dissected posteriorly off the bladder neck using sharp and blunt dissection. The seminal vesicles were then approached anteriorly, as was the ampulla of the vas. Each was cross-clamped and ligated. Final hemostasis was achieved at this point with the prostate removed. We everted the urothelium and closed the bladder neck slightly. We then brought the sutures concomitantly from inside to out, at 2, 10, 4, and 8 o'clock. An 18-silicone catheter was placed in the bladder, and the sutures were tied down. Hemovac drains were placed, and the wound was closed with a double-stranded running nylon. Skin clips were placed, and the drains were secured. He tolerated the procedure well overall.
PATHOLOGY REPORT LATER INDICATED: Adenocarcinoma neoplasm, prostate, benign lymph nodes
T10-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

The answer of Case
-T10-1A OPERATIVE REPORT, LYMPHADENECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Jack...

Question 5

Case
-T10-2A OPERATIVE REPORT, EXCISION OF CAROTID BODY TUMOR
LOCATION: Inpatient, Hospital
PATIENT: Emma Apolio
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Right neck carotid body tumor
POSTOPERATIVE DIAGNOSIS: Carotid body tumor on frozen section
PROCEDURE PERFORMED: Excision of right neck carotid body tumor
ANESTHESIA: General
INDICATIONS FOR SURGERY: The patient is a 67-year-old Caucasian female who was found to have a mass in her right neck on CT (computerized tomography) scan. Angiography was done, and this showed the mass in the area of the bifurcation of the internal and external carotid artery, consistent with a carotid body tumor. The patient was taken to the operating room for excision.
PROCEDURE: The patient was prepped and draped in the usual manner. A right neck incision was made on the anterior border of the sternocleidomastoid muscle. Dissection was carried down to the common carotid artery. The facial vein was ligated with 0 silk suture doubly ligated on each end before division. There were a couple of other small veins that were ligated with real silk sutures and divided. The common carotid artery was then dissected free from surrounding tissues, and a vessel loop was placed around the artery in a figure-of-eight fashion. Dissection was then carried up onto the external carotid artery, and the external carotid artery was isolated with a vessel loop. The next two branches off the external carotid artery were also isolated. The internal carotid artery was dissected out and also isolated with a vessel loop. The hypoglossal nerve was identified and dissected and retracted superiorly. Next, the tumor was approached by dissecting along the external carotid artery and taking all the small vessels that entered into the tumor. The vessels were ligated with 3-0 and 4-0 silk sutures and divided. After this was done, the dissection was carried out on the internal carotid artery, and this dissection was also carried superiorly. Finally, the superior-most pole was the only thing remaining; a small segment was left and was clamped with a right-angle clamp, and the tumor was released from the superior pole. The right-angle clamp tissue was tied with 0 silk suture and doubly ligated, and the clamp was removed. The dissection was carried down proximally, and there was what appeared to be a nerve entering the carotid body tumor at the base. Photographs were taken of the carotid body tumor during the operative procedure. The final attachment was then clamped, divided, and tied with 2-0 silk suture. The specimen was sent for frozen section. Frozen section returned the diagnosis of carotid body tumor. The operative area was thoroughly irrigated. Hemostasis was complete. The incision was then closed in layers using running 3-0 Vicryl suture for the platysma and a 4-0 Vicryl subcuticular stitch for the skin. Steri-Strips were applied. The patient tolerated the operation and returned to recovery in stable condition.
PATHOLOGY REPORT LATER INDICATED: See T10-2B.
T10-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

The answer of Case
-T10-2A OPERATIVE REPORT, EXCISION OF CAROTID BODY...

Question 6

Case
-T10-1B OPERATIVE REPORT, URETEROSCOPIC STONE EXTRACTION
LOCATION: Outpatient, Hospital
PATIENT: Don Dwell
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Left ureteral calculus
POSTOPERATIVE DIAGNOSIS: Left ureteral calculus
PROCEDURE PERFORMED: Left ureteroscopic stone extraction under fluoroscopic control
CLINICAL NOTE: The patient is a 50-year-old gentleman with intermittent left renal colic and left distal ureteral stone that has not passed spontaneously.
PROCEDURE: The patient was given a general endotracheal anesthesia, prepped, and draped in the lithotomy position. A 21-French cystoscope was passed into the bladder under direct vision. The urethra was normal. The bladder was normal. The prostate was not obstructed. A guidewire was then advanced up to the left ureter beyond the stone under fluoroscopic control. The patient was ureteroscoped without prior ureteral dilation using a 7-French rigid scope. The stone was visualized, grasped within a 0-tip basket, and withdrawn intact. Repeat ureteroscopy showed no evidence of ureteral abrasion or edema. It was decided not to stent the patient. The bladder was drained. The scope was withdrawn. B and O suppository was placed rectally. The patient was transferred to the recovery room in good condition. We will schedule him for renal ultrasound, KUB (kidney, ureter, bladder), and follow-up in 3 months' time. The stone will be shown to the patient and then sent for analysis.
PATHOLOGY REPORT LATER INDICATED: Benign calculi
T10-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

The answer of Case
-T10-1B OPERATIVE REPORT, URETEROSCOPIC STONE EXTRACTION
LOCATION: Outpatient,...

Question 7

Case
-T10-2B PATHOLOGY REPORT
LOCATION: Inpatient, Hospital
PATIENT: Emma Apolio
SURGEON: Gary Sanchez, MD
ATTENDING PHYSICIAN: Gary Sanchez, MD
PATHOLOGIST: Grey Lonewolf, MD
CLINICAL HISTORY: Patient has right carotid body mass and history of thyroid cancer.
SPECIMEN RECEIVED: Carotid body tumor with FS (frozen section)
GROSS DESCRIPTION: The specimen is labeled with the patient's name and "right carotid body mass" and consists of a 3.5 2.8 1.4 cm (centimeter) red-brown tissue weighing 8.5 g (gram). The tumor is inked black. Cut sections show a solid red-brown center. The specimen is submitted in 5 cassettes.
INTRAOPERATIVE FROZEN SECTION DIAGNOSIS: Right carotid body tumor:
Paraganglioma (carotid body tumor), as per Dr. Lonewolf.
MICROSCOPIC DESCRIPTION: Permanent sections confirm the frozen section diagnosis of carotid body tumor. The lesion appears relatively well circumscribed, partially surrounded by a hyalinized fibrous capsule. The tumor is composed of nests (Zellballen) of polygonal cells with areas of trabeculae of fibrous tissue. The tumor cells have abundant granular eosinophilic cytoplasm and predominantly round to ovoid nuclei showing some focal pleomorphism and hyperchromatism. Mitoses are scant. Vascular invasion is not seen.
DIAGNOSIS: Right carotid body mass: Carotid body paraganglioma.
COMMENT: It is almost impossible histologically to judge the clinical source of a carotid body tumor by its histology, even though most of these tumors are seldom malignant. Mitoses, nuclear pleomorphism, and even vascular invasion are unreliable markers of malignancy. Close clinical follow-up is needed as these tumors may recur.
T10-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Accepted Answer

The answer of Case
-T10-2B PATHOLOGY REPORT
LOCATION: Inpatient, Hospital
PATIENT: Emma Apolio
SURGEON:...

Question 8

Case
-AUDIT REPORT T10.2 OPERATIVE REPORT, PROSTATECTOMY
LOCATION: Inpatient, Hospital
PATIENT: Jonathon Wend
SURGEON: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Carcinoma of the prostate
POSTOPERATIVE DIAGNOSIS: Carcinoma of the prostate
PROCEDURE PERFORMED: Radical retropubic prostatectomy, plastic
repair of bladder neck, bilateral pelvic
lymph node dissection.
CLINICAL NOTE: This gentleman was found to have adenocarcinoma of the prostate after presenting with a rising PSA and abnormal digital rectal examination.
OPERATIVE NOTE: The patient was given an epidural anesthetic. Unfortunately, analgesia was incomplete, and therefore he was converted to a general endotracheal anesthetic. A
20-French catheter was inserted into the bladder and a lower abdominal midline incision made. The Omni retractor was used for exposure. Bilateral pelvic lymphadenectomy was performed. The obturator nerves were identified and spared. There was no gross abnormality of the lymph nodes, and therefore they were sent for permanent section. The superficial venous complex was identified, cauterized, and divided. The endopelvic fascia was opened bilaterally. The puboprostatic ligaments were divided sharply. The dorsal venous complex was then surrounded with a McDougal clamp, ligated distally with #1 silk and oversewn proximally with 2-0 chromic. It was then divided using electrocautery. The urethra was incised anteriorly, the catheter withdrawn, clamped, divided and the urethra divided posteriorly. A left nerve-sparing procedure was performed, and the nerves were dissected off the prostate under direct visual guidance. The right neurovascular bundle was taken widely using clips and chromic ties. Lateral pedicles were taken with 0 chromic ties. The bladder neck was opened anteriorly, then divided posteriorly after the ureteric orifices were identified. The seminal vesicles were clipped and divided near their bases. A small amount of seminal vesicle tissue was left on the right-hand side. The ampullae of the vas were also clipped and divided. Hemostasis was achieved with 2-0 chromic suture ligatures. The bladder neck was then closed in a tennis racquet fashion using 2-0 chromic and the mucosa everted using 4-0 chromic. The urethra was re-anastomosed to the bladder neck using 2-0 Monocryl sutures over a 20-French Foley catheter in the usual fashion. A Jackson-Pratt drain was left through a left lower quadrant stab wound and sutured to the skin with 2-0 Prolene. The fascia was closed with #1 Vicryl, subcutaneous tissue with 3-0 Vicryl, and skin with 4-0 subcuticular Dexon and Dermabond. Estimated blood loss was 750 cc. Sponge and needle counts were reported as correct. The patient remained hemodynamically stable intraoperatively.
PATHOLOGY REPORT LATER INDICATED: Malignant, primary prostate cancer
T10.2:
SERVICE CODE(S): 55840, 51800-51, 38770-51-50
ICD-10-CM DX CODE(S): D07.5______________
INCORRECT/MISSING CODE(S): ______________________________________

Accepted Answer

The answer of Case
-AUDIT REPORT T10.2 OPERATIVE REPORT, PROSTATECTOMY
LOCATION: Inpatient,...

Exam 10: Urinary, Male Genital, and Endocrine Systems