Two Case Studies for someone familiar with 3MEncoder and (ICD-10-CM)

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This assignment is for someone familiar with 3MEncoder and (ICD-10-CM). Answer the questions in bold for both case studies. There are 13 questions in all.

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Case Study 1

LOCATION: Outpatient, Hospital

PATIENT: Ray Darwin


SURGEON: Gary Sanchez, MD

PREOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.

POSTOPERATIVE DIAGNOSIS: Traumatic amputation of tip of right middle finger.

PROCEDURE PERFORMED: Volar V-Y advancement flap, right middle finger.

ANESTHESIA: 0.5% Marcaine local metacarpal block.

PREOPERATIVE NOTE: The patient sustained an injury yesterday when he partially amputated his dominant right middle fingertip, which was caught between a dock and a boat as a wave rocked the boat at the lake. He was seen at the local emergency room, he was given a tetanus booster, and the wound was dressed. He is scheduled for V-Y advancement flap to the finger today. He is originally from Manytown and will be having follow-up care from his family physician, Dr. Hightower.

After full discussion with the patient, he elects to proceed with this skin flap today.

PROCEDURE: The patient was brought to the operating room, and a metacarpal block was induced with 10 cc of 0.5% Marcaine. The dressings were removed from the right middle finger, and the right upper extremity was prepped with Betadine and draped in a sterile fashion. A digital tourniquet was applied to the finger for approximately 25 minutes. With 4× magnification loupes, we debrided the finger in the area of the amputation, which was at the distal end of the sterile nail matrix. About two thirds of the sterile nail matrix and the entire germinal matrix were still present, but the nail plate was absent. Most of the volar pad was still intact. There was about 3 to 4 mm of distal tuft of the distal phalanx that was absent. However, the wound was extremely clean. We lightly debrided it and removed blood clots. We thoroughly irrigated with sterile saline. We then fabricated a volar V-Y advancement flap back to the distal interphalangeal joint flexor crease. We then moved this flap distalward and advanced it about 5 to 6 mm. We then sutured this directly to the nailbed with interrupted 5–0 Vicryl sutures and closed this up along its margins with interrupted 5–0 nylon sutures. The appearance was excellent. We then placed Xeroform into the nailbed proximally to prevent adhesions. We then removed the digital tourniquet, and excellent circulation returned to the fingertip, including vascular blood in the graft. We then applied Xeroform over the wounds with light gauze dressings, TubeGauz, and light Coban. The patient tolerated the procedure well. He will be dismissed as an outpatient today. He will complete his fishing trip and return to Manytown in 2 or 3 days, and he will follow up with his home physician, Dr. Hightower. (Note that Dr. Sanchez provided only the surgical service.) Patient has been

placed on Keflex 500 mg p.o. q.i.d. for 5 days. We also gave him a prescription for Lorcet, 30 tablets.

Abstracting & Coding Questions:

1. Was the skin repair a free flap or an adjacent tissue transfer?

2. What modifier is required to indicate that only the intraoperative portion of theservice was/will be provided?

3. What other modifier would be appropriate?

4. Which modifier is reported first?

5. How did this injury occur?

6. What CPT code(s) would be reported for this case?

7. What ICD-10-CM code(s) would be reported for this case?

Case Study 2

LOCATION: Outpatient, Hospital

PATIENT: Beth Mahoney


SURGEON: Mohomad Almaz, MD

PREOPERATIVE DIAGNOSES 1. Chondromalacia, left knee. 2. Torn left medial meniscus per MRI scan.

POSTOPERATIVE DIAGNOSIS: Chondromalacia, left knee.

PROCEDURES PERFORMED 1. Examination, left knee, under anesthesia. 2. Arthroscopy, left knee, with debridement of chondromalacia.

ANESTHESIA: General with endotracheal intubation.

FINDINGS: The patient was found to have significant chondromalacia in all three compartments. She had some bare bone on the femoral trochlear and significant fraying of the articular cartilage on the patella, as well as on the medial femoral condyle. The articular cartilage on the lateral femoral condyle was just frayed slightly, but no large flaps of articular cartilage were raised. She did, however, have some flaps of articular cartilage raised on the floor of the lateral compartment. I could not find any specific meniscal tears, but both medial and lateral menisci had fringe tags, which we removed. The anterior cruciate ligament was intact.

PROCEDURE: Under general anesthesia the patient’s left knee was examined. She had no effusion. The collateral ligaments were intact. Lachman test was negative, as was the pivot shift. McMurray test was negative. We then prepped the patient’s left leg with Betadine and draped it in a sterile fashion. An Esmarch bandage was used to exsanguinate the leg, and a tourniquet on the thigh was inflated to 300 mm Hg. The total tourniquet time was about 35 minutes.

Three portals were used for this procedure. The first was placed along the superior anterolateral aspect of the knee, the second was placed along the inferior anterolateral aspect, and the third along the inferior anteromedial aspect of the knee. We distended the knee with lactated Ringer’s solution. We examined the suprapatellar pouch and the medial and lateral gutters. We immediately noted significant chondromalacia involving the patellofemoral joint. There were large flaps of articular cartilage hanging off the articular surface of the patella and actually an area of bare bone on the trochlea, which was close to the lateral femoral condyle. We used the shaver to trim the articular cartilage, which was hanging from the subchondral bone. We trimmed the leading edge of the fat pad slightly as well.

I then examined the medial compartment and probed the medial meniscus. We could not identify a specific tear of the medial meniscus, although there were multiple fringe tags, which were removed with the shaver. She does have, however, significant chondromalacia involving the weight-bearing surface of the medial femoral condyle. There were flaps of articular cartilage that were loose and just laying on the subchondral surface. We used the shaver to trim these loose bits of articular cartilage. We then examined the notch area and probed the anterior cruciate ligament. It was intact. We then examined the lateral compartment and probed the lateral meniscus. The lateral meniscus was intact, although there were several fringe tags, which were removed. She did have some raised flaps of articular cartilage on the lateral tibial plateau, and these were trimmed with the shaver. The articular cartilage in the lateral femoral condyle appeared to be in relatively good condition with only minor fraying. At this point, we thoroughly irrigated the knee and looked for any remaining loose fragments. We then drained the knee and injected 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine. The hardware was removed and the skin incisions were closed using 4– 0 nylon suture. Sterile dressings were applied under a 6-inch Ace wrap. She was then awakened and taken from the operating room in good condition, breathing spontaneously.


MEDICATIONS: She was given IV Kefzol preoperatively, and she will be continued on Keflex for 5 days postoperatively as well. She will also be started on some aspirin postoperatively.

Pathology Report Later Indicated: Chondromalacia.

Abstracting & Coding Questions:

1. Was this a diagnostic or surgical arthroscopy?

2. What is chondromalacia?

3. Debridement of the chondromalacia is also referred to as

4. Was the diagnosis for the meniscal tear reported?

5. What CPT code(s) would be reported for this case?

6. What ICD-10-CM code(s) would be reported for this case?

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