Two Case Studies for someone familiar with 3MEncoder and (ICD-10-CM)
This assignment is for someone familiar with 3MEncoder and (ICD-10-CM).
Answer the questions in bold for both case studies. There are 14
questions in all.
Case Study 1
LOCATION: Outpatient, Hospital
PATIENT: Harold White
ATTENDING PHYSICIAN: Jeff King, MD
SURGEON: Jeff King, MD
PREOPERATIVE DIAGNOSES
1. Left true vocal cord mass.
2. Hoarseness.
3. Asthma.
4. Gastroesophageal reflux disease.
POSTOPERATIVE DIAGNOSIS: Same as Preoperative.
OPERATIVE PERFORMED: Direct laryngoscopy with use of operating microscope for
excision of a left anterior true vocal cord mass.
ANESTHESIA: Endotracheal.
INDICATIONS: A 65-year-old male with chronic hoarseness. He has a long-term history
of tobacco use but finally was able to quit 2 years ago. Examination reveals a mass
involving the anterior portion of the left true vocal cord. The patient also has a history of
asthma and reflux disease.
PROCEDURE: After consent was obtained, the patient was taken to the operating room
and placed on the operating room table in the supine position. After an adequate level
of general endotracheal anesthesia was obtained, the patient was positioned for direct
laryngoscopy. The laryngoscope was placed in position. There were no lesions in the
oropharynx or hypopharynx. This was placed into the suspension. The microscope was
then brought in. An exophytic mass was noted involving the anterior third of the left true
vocal cord extending to the area of the anterior commissure. Utilizing the forceps and
the micro scissors, the mass was excised. Hemostasis was achieved with pledgets
soaked with 1:100,000 units of epinephrine. The laryngoscope was then removed and
the patient turned over to anesthesia. The patient tolerated the procedure well, and
there was no break in technique. The patient was extubated and taken to the
postanesthetic care unit in good condition.
Pathology Report Later Indicated: Adenocarcinoma, poorly diffused, primary.
FLUIDS ADMINISTERED: 1000 cc of RL
ESTIMATED BLOOD LOSS: Less than 5 cc.
PREOPERATIVE MEDICATIONS: 12 mg of Decadron and 20 mg of Pepcid IV.
Abstracting & Coding Questions:
1. Was the laryngoscopy direct or indirect?
2. Does the use of the operating microscope affect code assignment?
3. What other factor affected code assignment?
4. The primary diagnosis was identified based on what report?
5. Do the diagnosis codes differentiate between true and false vocal cords?
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: Inpatient, Hospital
PATIENT: A. G. Vanyo
ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD
SURGEON: James Noonar, MD
PREOPERATIVE DIAGNOSIS: Atherosclerotic heart disease.
POSTOPERATIVE DIAGNOSIS: Atherosclerotic heart disease.
PROCEDURE: Coronary artery bypass graft times two of the left internal mammary
artery to the left anterior descending bypass and a single saphenous vein bypass from
the aorta to the obtuse marginal branch of the left circumflex.
ANESTHESIA: General.
INDICATION: This 76-year-old male patient with accelerating angina was noted on
cardiac catheterization to have high-grade ostial left main coronary disease. He also
had a 70% obtuse marginal branch lesion. The left ventricular function was normal.
FINDINGS AT SURGERY: The left anterior descending artery was diffusely diseased
throughout and measured 1.5 mm in diameter where it was grafted and was of poor
quality. The internal mammary artery was a 2-mm vessel of good quality with excellent
flow. The vein was a 6-mm diameter vessel of poor quality, somewhat varicosed, and
was used in a reversed fashion. It was not harvested with the endoscopic technique
because of the patient’s unstable presentation. The obtuse marginal branch was a 2-
mm diameter vessel and was of good quality.
PROCEDURE: On May 8 of this year the patient was brought to the operating room and
placed in the supine position, and under general intubation anesthesia, the anterior
chest, abdomen, and legs were prepped and draped in the usual manner. A segment of
greater saphenous vein was harvested from the left thigh and prepared for grafting. The
sternum was opened in the usual fashion, and the left internal mammary artery taken
down and prepared for grafting. The pericardium was incised sharply, and pericardial
well created. The patient was systemically heparinized and placed on single right atrial
to aortic cardiopulmonary bypass with a sump in the main pulmonary artery for cardiac
decompression. The patient was cooled to 26°C, and on fibrillation, the aortic
crossclamp was applied to potassium-rich cold crystalline cardioplegic solution
administered through the aortic root with satisfactory cardiac arrest. Subsequent doses
were given via the coronary sinus in retrograde fashion and down the vein graft as the
anastomosis was completed. The end of the greater saphenous vein was then
anastomosed to the proximal portion of the obtuse marginal branch with 7–0 Prolene.
The left internal mammary artery was then brought down to the junction of the middle
and distal one third of the left anterior descending and anastomosed thereto with 8–0
continuous Prolene. Please note that all grafts were pro patent prior to closure. The
aortic crossclamp was removed after 47.6 minutes with spontaneous cardioversion to a
normal sinus rhythm. The patient was then warmed to 37°C esophageal temperature
and weaned from cardiopulmonary bypass without difficulty after 72 minutes. No
inotropes were used. The patient was decannulated, protamine given, and hemostasis
achieved. Temporary pacer wires were placed in the right atrium and right ventricle. The
chest was drained with two chest tubes and closed in layers in the usual fashion. The
leg was closed similarly. Sterile compression dressings were applied, and the patient
returned to surgical intensive care unit in satisfactory condition. Sponge count and
needle count correct times two.
Abstracting & Coding Questions:
1. Was the grafting done with arterial grafts, venous grafts, or both?
2. What code range is referenced for assignment of the venous grafting code?
3. Was the arterial grafting a single graft or multiple grafts?
4. Is the harvesting of the vein graft reported separately?
5. Is the cardiopulmonary bypass and cooling reported by the cardiologist?
6. What CPT code(s) would be reported for this case?
7. What ICD-10-CM code(s) would be reported for this case?
