integrated billing and coding exam prep

Terms in this set (247)

This is a 24-year-old female who has been in active labor for the past 17 hours. The hope was that the labor would progress to a vaginal delivery, but the baby has now turned and is breech. After close observation of the baby through monitoring, the decision was made to perform the cesarean section. I have never seen this patient; she is here visiting from out of town. She is three weeks prior to her due date. A low transverse abdominal incision was made with a sharp scalpel. The incision was carried through the subcutaneous tissue and the superficial fascia where the incision extended bilaterally. Fascia was grasped with Kocher clamps and undermined with sharp and blunt dissection using Mayo scissors. Forceps were used to grasp the preperitoneal fascia, which was incised with Metzenbaum scissors until the peritoneal cavity was entered and the incision extended superiorly and inferiorly. The Mezenbaum was used to incise a low uterine segment after the bladder was moved to safety with a bladder retractor. Inferior to the peritoneum was then undermined and the bladder retractor replaced in the flap. The low uterine segment was then incised with a sharp scalpel until the intrauterine cavity was entered. The infant was guided to the incision and delivered from the uterus with fundal pressure. The legs were delivered by flexion of the knees, and arms were delivered by rotation of the body. Then the head was delivered. The baby scored 7 on Apgar at 1 minute and 9 at 5 minutes. Closure of the abdominal incision on the mother was made in layers. Mother and baby were sent to recovery in good condition.

CPT code(s): 59598
This patient is a 42-year-old female
who presents to discuss breast reconstruction. In September 2001, she underwent
a right modified radical mastectomy (acquired
absence of organ) for a 3.7-cm right lobular breast carcinoma. Following
the mastectomy, she proceeded through both chemotherapy and radiation therapy.
The prescribed plan was completed in November 2003. Due to a positive family
history and abnormal mammograms, the patient chose to have a prophylactic
mastectomy of her left breast. Besides the malignancy in her breast, the
patient's medical history was negative.
EXAM: Patient has adequate abdominal
pannus for autogenous reconstruction (repair).
After extensive discussion with the patient regarding surgical reconstruction
options and risks, the patient and her husband decide to proceed with the
reconstruction procedure.
PROCEDURE: Patient was brought into
the surgical suite. After successful administration of general anesthesia, she
was draped in the usual sterile fashion. Under high-power magnification, the
pectoralis major muscle was split along its fiber over the fourth rib.The deep
perichondrium was then incised and the internal mammary artery and veins
identified. An elliptical incision was then made in the lower abdomen,
approximately 2 cm above the umbilicus.The subcutaneous dissection was
performed through the fat down to the level of the rectus abdominis fascia.
Several perforators were identified and preserved as they pierced the rectus
fascia.The fascia was incised and the perforators were dissected through the
rectus abdominis muscle.The first flap was harvested, with the right deep
inferior epigastric vessels visualized as they entered the muscle and divided
at their origin.The perforator flap was brought with its vessels through the
rectus abdominis muscle. No muscle was taken with this flap.The flap was
transferred to the right chest and secured. A second flap was harvested from
the left lower abdomen using the same technique and transferred to the left
chest and secured. Dissection of both the internal mammary artery and vein was
performed after flap harvest to allow for microvascular anastomosis. The
abdominal donor site was closed and all surgery sites were dressed with large
bulky dressings. The patient was transferred to the intensive care unit in good
condition for postoperative monitoring.
The patient had little postoperative
pain or discomfort.
PLAN: Nipple reconstruction will be
done four months postoperatively; nipple/areolar tattooing is planned for
approximately two months after successful nipple reconstruction.
This patient is a 58-year-old male
who presents to my office today with a
chronic ulcer on the plantar aspect of the right foot.
HISTORY: The patient has previously
undergone a pancreas/liver transplant due to the effects of chronic diabetes
mellitus. Over the years, he has developed profound diabetic peripheral
neuropathy that not only affects sensation but motor function also. As a
result, he wears single, upright metal AFOs on both lower extremities. In
addition, he has previously undergone a complete fifth metatarsal resection of
the right foot, a fourth metatarsal osteotomy, and a second metatarsal head
resection because of frequent ulcerations.
This patient is conscientious in
regularly coming in for podiatric care and appears to follow recommendations
with regard to footwear and accommodative orthotic devices. Rocker soles were
prescribed 6 months ago.
EXAM: A newly developed chronic ulcer inferior to the fourth
metatarsal has formed.This is inferior to the area where the patient previously
had an osteotomy.The patient has an elevated fourth metatarsal and does not
appear to have any palpable pressure at this location. At each office visit,
the patient has dried blood within the callus and a shallow ulceration.
Multiple attempts to accommodate this area with his orthotic devices have
failed.
TESTING: Video and computer gait analysis and pressure mapping
software is used to identify pressure distribution points.
Pressure mapping software identifies
localized pressure in the region of the ulcer but the pressure is not any
greater than that found in other parts of the foot. However, the integral
pressures indicates that the sustained amount of pressure in this one region is
much too great. Even though the pressure may not be an extreme amount, the
duration of pressure is causing the problem.
Video gait analysis indicates that
the patient, despite wearing braces, exhibits rapid midstance. The rocker soles
were prescribed to provide a smoother transition of the foot through midstance
into propulsion; however, this is not the case for this patient. This pair of
rocker soles is actually contributing to the rapid flatfoot and subsequently
elevating the pressures on the ulcerated area.The shape of the heel is acting
like a fulcrum, accelerating forefoot loading.
PLAN: Modify
his rocker soles by adding a walking heel. Schedule follow-up visit in
30 days to check status. Hint: Think durable
medical equipment (DME) here.
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