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HIM1257 Module 04 Worksheet -Coding from Operative Reports 2025/2026, Assignments of Computer Programming

University of LeedsComputer Programming

HIM1257 Module 04 Worksheet -Coding from Operative Reports 2025/2026/HIM1257 Module 04 Worksheet -Coding from Operative Reports 2025/2026

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2024/2025

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HIM1257 Module 04 Worksheet - Coding from Operative Reports
As CPT coding is mastered, it is essential that the steps and process to locate the correct code is
understood and demonstrated. The coding path, including the main term and modifying terms
(or
indented terms), is the route to a complete and accurate code.
Accurate and complete coding is integral to the reimbursement of healthcare services. Oftentimes,
the
operative report detail is needed to fully code a procedure because the report detail
provides information that requires the addition of other codes to completely reflect the work
of the surgeon.
This assignment asks for the demonstration of the coding path taken to identify correct codes, and
the
assignment of codes derived from actual operative reports.
• List the coding path- the main term or keyword, and the modifying terms (or indented
terms). If you are using the 3m encoder, you may screen shot or copy and paste the history
once you have
chosen a code. If you are using the book, enter the main term from the
alphabetic index along with any modifying terms that lead you to the code you have
chosen.
•
Assign the surgery codes. Determine the correct code(s) after establishing the complete
surgery.
Here is an example to show what the assignment seeks:
Procedure: Extended Radical mastectomy, left breast
Questions
for
Scenario
Answers
1. Demonstrate the correct
coding path used to establish
the correct codes. (3
points)
Coding path from books:
•
Mastectomy, radical - (this is the index entry in the
code book)
Coding path with 3m screen shot:
(NOTE: Only the book or the Encoder path is necessary for
the
assignment.)
pf3
pf4
pf5
pf8
pf9
pfa

Partial preview of the text

Download HIM1257 Module 04 Worksheet -Coding from Operative Reports 2025/2026 and more Assignments Computer Programming in PDF only on Docsity!

HIM1257 Module 04 Worksheet - Coding from Operative Reports

As CPT coding is mastered, it is essential that the steps and process to locate the correct code is understood and demonstrated. The coding path, including the main term and modifying terms (or indented terms), is the route to a complete and accurate code. Accurate and complete coding is integral to the reimbursement of healthcare services. Oftentimes, the operative report detail is needed to fully code a procedure because the report detail provides information that requires the addition of other codes to completely reflect the work of the surgeon. This assignment asks for the demonstration of the coding path taken to identify correct codes, and the assignment of codes derived from actual operative reports.

  • List the coding path- the main term or keyword, and the modifying terms (or indented terms). If you are using the 3m encoder, you may screen shot or copy and paste the history once you have chosen a code. If you are using the book, enter the main term from the alphabetic index along with any modifying terms that lead you to the code you have chosen.
  • Assign the surgery codes. Determine the correct code(s) after establishing the complete surgery.

Here is an example to show what the assignment seeks:

Procedure: Extended Radical mastectomy, left breast Questions for Scenario Answers

  1. Demonstrate the correct coding path used to establish the correct codes. ( points) Coding path from books: - Mastectomy, radical - (this is the index entry in the code book) Coding path with 3m screen shot: (NOTE: Only the book or the Encoder path is necessary for the assignment.)
  1. Record the correct code(s). (2 points)

19306-LT

Continued on next page.

radiation and a follow up cystoscopy. The patient showed areas of tumor and is brought in for resection. PROCEDURE: After induction of general anesthesia, the patient was placed in the dorso-lithotomy position. Genitalia were prepared and draped in the usual manner. External genitalia revealed phimosis. Urethra was prepared. A metal Van Buren sounds up to 30 was passed by the urethra into the bladder without any difficulty. A #28 resectoscope was introduced and again a raw irregular area about 5.5 cm in the posterior left lateral wall and near the dome was seen again. The rest of the bladder showed no tumor. Bladder mucosa was congested, hyperemic and irritated probably from the radiation. Ureteral orifices were normal. At this time the area of about 5.5 to 6 cm was completely resected and dissection was done fairly deep. The base was thoroughly cauterized. The tissue was sent for pathological examination. Also urine cytology was obtained at the beginning of the procedure. No active bleeding was noted. Bladder was emptied and resectoscope was removed. A #20 Foley catheter was introduced and left indwelling. Bimanual rectal examination was grossly unremarkable without any masses. The patient tolerated the procedure well and general anesthesia well and left the OR in good condition Questions for Scenario Two Answers

  1. Demonstrate the correct coding path used to establish the correct codes. (3 points)
  2. Record the correct code(s). (2 points) Scenario Three PREOP DIAGNOSIS: History of severe menorrhagia. POSTOP DIAGNOSIS: Same. OPERATION: D and C. PROCEDURE: Prior to D and C, the patient was admitted with a history of vaginal bleeding since approximately 2-1-12. The patient was admitted with a hemoglobin of 6.5. She was noted to be tachycardic and had hypotensive changes in her blood pressure. She was admitted and transfused with two units of blood, brought to the operating room. At the time of exam under anesthesia, she was noted to have a uterus, which I believed symmetric. The uterus, however, was difficult to outline due to her obesity and the position of the uterus. The uterus was slightly retroflexed. Uterine cavity sounded to 4 inches and was symmetric at the time of the procedure. Moderate amount of tissue was obtained, which was sent for permanent section. There was nothing present at the time of D and C, however, to suggest either polyps or uterine fibroids. Bleeding was fairly well controlled at the close of the procedure. The patient awoke from anesthesia and left the operating room in good condition. I will have the patient return for four week follow up and then on a p.r.n. basis. With traction of the cervix, the patient did have good vaginal support and I do feel that if any further surgery needs to be done to control bleeding, it will have to be done

transabdominally. The patient was brought to the operating room and placed in the lithotomy position. The patient was prepped and draped in the usual fashion. Cervix was grasped with a single tooth tenaculum and dilated to a #10. It was sounded. Polyp forceps were introduced followed by sharp curettage. The patient did have a small laceration of the anterior lip of the cervix from the tenaculum. This was oversewn with sutures of 2-0 chromic. This controlled the bleeding at that site. The bleeding was well controlled in the cervix. The procedure was terminated.

vesicular uterine peritoneum was reapproximated using 2-0 Vicryl in a running nonlocking fashion. The parietal peritoneum was reapproximated using 2-0 Vicryl in a running nonlocking fashion. The rectus muscles were reapproximated in the midline loosely using 1 Vicryl. The rectus fascia was then reapproximated using 1 Vicryl in a running nonlocking fashion. The skin was then reapproximated in a subcuticular fashion using 4-0 Vicryl. The patient tolerated the procedure well. All counts were correct. The infant delivered was a female infant demonstrated spontaneous respirations. Currently mother and baby remained in the PACU.

Questions for Scenario Four Answers

  1. Demonstrate the correct coding path used to establish the correct codes. (3 points)
  2. Record the correct code(s). (2 points) Scenario Five - PROCEDURE: Extracapsular lens extraction with peripheral iridectomy and implantation of 23. Diopter, posterior chamber, intraocular lens, O.S. PRIMARY DIAGNOSIS: Bilateral Cataracts. PROCEDURE: The patient was given a retrobulbar injection of 2.5 to 3.0 cc of a mixture of equal parts of 2 percent lidocaine with epinephrine and 0.75 percent Marcaine with Wydase. The area about the left eye was infiltrated with an additional 6 to 7 cc of this mixture in a modified Van Lint technique. A self- maintaining pressure device was applied to the eye, a short time later, the patient was taken to the OR. The patient was properly positioned on the operating table and the area around the left eye was prepped and draped in the usual fashion. A self-retaining eyelid speculum was positioned, and a 4-0 silk suture was passed through the tendon of the superior rectus muscle, thereby deviating the eye inferiorly. A 160- degree fornix-based conjunctival flap was created, followed by a 150-degree corneoscleral groove with a #64 beaver blade. Hemostasis was maintained throughout with gentle cautery. A 6-0 silk suture was introduced to cross this groove at the 12 o’clock position and looped out of the operative field. The anterior chamber was then entered superiorly temporally, after injecting Occucoat, and anterior capsulotomy was performed without difficulty. The nucleus was easily brought forward into the anterior chamber. The corneoscleral section was opened with scissors to the left and the nucleus delivered with irrigation and gentle lens loop manipulation. Interrupted 10-0 nylon sutures were placed at both the nasal and lateral extent of the incision. A manual irrigating-aspirating setup was then used to remove remaining cortical material from both the anterior and posterior chambers. At this point, a modified C-loop chamber lens was removed from its package and irrigated and inspected. It then was positioned into the inferior capsular bag without difficulty, and the superior haptic was placed behind the iris at the 12 o’clock location. The lens was rotated to a horizontal orientation in an attempt to better enhance capsular fixation. Miochol was used to constrict the pupil, and a peripheral iridectomy was performed in the superior nasal quadrant. In addition, three or four interrupted 10-0 nylon sutures were used to closed the corneal scleral section. The silk sutures were removed, and the conjunctiva was advanced back into its normal

OPERATION: Da Vinci assisted total laparoscopic hysterectomy with bilateral salpingectomy and right oophorectomy FINDINGS: Enlarged uterus with multiple fibroids SPECIMEN: Uterus, bilateral fallopian tubes and right ovary weighing 250 g immediately post-op PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without any difficulty. The patient was then prepped and draped in the normal sterile fashion in the dorsal lithotomy position. A Foley catheter was placed via their urethra into the bladder and a Fornicee intrauterine manipulator was introduced via the cervical canal into the uterus in the normal manner. An 8 mm supraumbilical skin incision was then made approximately 10 cm above the level of the uterine fundus a Veress needle was introduced through this incision at a 45-degree angle and intra- abdominal placement was confirmed with a positive water drop test. Pneumoperitoneum was obtained with 3L of CO2 gas. The Veress needle was then removed, and an 8 mm trocar and obturator introduced through the same incision at a 45-degree angle under direct visualization. 2 right and 2 left lateral incisions were then made. The more medial of the lateral incisions was made approximately 10 cm lateral to the more medial incisions approximately 3 cm below their level. 8 mm trocars with obturators were introduced through each of these incisions under direct visualization. There was never any contact between the entering trocars and the surrounding viscera. The patient was then placed in steep Trendelenburg with reflex. The da Vinci device was then docked in the normal manner. The round ligaments bilaterally were grasped, ligated, and incised using the vessel sealer device. The anterior leafs of the broad ligament were then incised using the Endoshears and the bladder was bluntly dissected away from the lower uterine segment using the blunt end of the ProGrasp. The right infundibulopelvis ligament was grasped, ligated, and incised using the vessel sealer device. The right broad ligament was grasped, ligated, and incised in multiple steps using the vessel sealer device. The right uterine artery was grasped, ligated, and incised using the vessel sealer device. The left utero- ovarian ligament was grasped, ligated, and incised using the vessel sealer device. The left broad ligament was grasped, ligated, and incised in multiple steps using the vessel sealer device. The left uterine artery was grasped, ligated, and incised using the vessel sealer device. Anterior and posterior colpotomy incisions were then made using the EndoShears.bilateral^ fallopian The^ tubes cardinal^ and ligamentsright^ ovary andwere uterosacral^ then^ delivered^ via^ the^ vaginal^ incision^ without^ difficulty. The vaginal cuff with then reapproximated using the V lock suture in a running nonlocking fashion. The abdomen was then copiously irrigated and cleared of all clots and debris. Hemostasis from all pedicles was noted. FloSeal was then placed on the surgical bed. The da Vinci was then undocked, the patient was flattened out and her pneumoperitoneum was allowed to escape. All trocars were then removed, and the skin of each incision was reapproximated using 4-0 Vicryl in an interrupted fashion. Each incision was infiltrated with 5 mL’s of 5% Marcaine without epinephrine at the procedure’s initiation and another 5 mL’s of 5% Marcaine without epinephrine at the procedure’s conclusion. The vagina was packed with a

Betadine and 2% Lidocaine jelly-soaked Kerlix gauze. The patient tolerated the procedure well and all counts were correct. Questions for Scenario Six Answers

  1. Demonstrate the correct coding path used to establish the correct codes. (3 points)
  2. Record the correct code(s). (2 points)