cpt 10 CODING

Anonymous
timer Asked: Nov 14th, 2016

Question description

1.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.


2.QUESTION 2

  1. 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

    SERVICE CODE(S): ___________________________________________________
    ICD-10-CM DX CODE(S):
    ______________________________________________

3.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.



SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S):
______________________________________________

Tutor Answer

(Top Tutor) Studypool Tutor
School: UC Berkeley
Studypool has helped 1,244,100 students
flag Report DMCA
Similar Questions
Hot Questions
Related Tags
Study Guides

Brown University





1271 Tutors

California Institute of Technology




2131 Tutors

Carnegie Mellon University




982 Tutors

Columbia University





1256 Tutors

Dartmouth University





2113 Tutors

Emory University





2279 Tutors

Harvard University





599 Tutors

Massachusetts Institute of Technology



2319 Tutors

New York University





1645 Tutors

Notre Dam University





1911 Tutors

Oklahoma University





2122 Tutors

Pennsylvania State University





932 Tutors

Princeton University





1211 Tutors

Stanford University





983 Tutors

University of California





1282 Tutors

Oxford University





123 Tutors

Yale University





2325 Tutors