1
Week 3
In the week 3 Coding Roundtable, you will dissect and code the
following 16 operative reports:
Chapter 7: Pages 164-168 (operative reports 2, 4, 6, 8)
Chapter 8: Pages 187-191 (operative reports 2, 4, 6, 8)
Chapter 9: Pages 208-213 (operative reports 2, 4, 6, 8)
Chapter 10: Pages 230-234 (operative reports 2, 4, 6, 8)
Posting RequirementsNo later than Thursday, in one single post,
provide your code(s) for each operative report, total of 16 reports,
worth 5 points per report. Credit is given for your efforts, not for
the correct answer. The goal is for you to learn the process! Note:
it is strongly recommended that you use the dissecting
operative report (figure 2.6) to code each report. Your instructor
will post the answers on Friday morning, late posts are not
accepted and do not earn credit in the coding roundtable.
Operative Report in the Textbook
Chapter 7: Pages 164-168 (operative reports 2, 4, 6, 8)
2. Operative Report
PREOPERATIVE DIAGNOSIS: Osteomyelitis, 5th metatarsal,
left
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Amputation of toe
The patient was brought to the operating room and placed in
a supine position. After adequate general anesthesia was
obtained, the left foot was scrubbed, prepped, and draped in
the usual manner. No tourniquet was utilized. A skin incision
was made along the entire lateral border of the 5th
metatarsal and carried down to the subcutaneous tissue in
line with the skin incision. Bleeders were clamped and
electrocoagulated. Dissection was carried down to the base
, 1
of the 5th metatarsal where a capsulotomy was made at the
base. The bone was then delivered from the wound and sent
to the pathology department. There was erosion of the head
of the 5th metatarsal consistent with osteomyelitis. The
entire toe and metatarsal were amputated down to the tarsal
space, and all of the specimen was sent to the pathology
department. All of the tissues were debrided. The wound was
irrigated and hemostasis ensured. The subcutaneous tissue
was very loosely reapproximated utilizing 4-0 Vicryl suture.
The skin was not closed and was allowed to drain. A sterile
dressing was applied to the wound. The patient was then
transferred to the recovery room in satisfactory condition.
Answer Key
2. ICD-10-PCS code: 0Y6N0Z8Rationale: The amputation of the toe
through the 5th metatarsal is coded to the root operation Detachment in
the Anatomical Regions, Lower Extremities body system. The body
part value of N is assigned for a ray of the left foot. The qualifier value
of 8, complete 5th ray, is appropriate because the amputation involves
the entire toe and metatarsal.
4. Operative Report
PREOPERATIVE DIAGNOSIS: Abscess, left buttock
POSTOPERATIVE DIAGNOSIS: Abscess, left buttock
OPERATIONS: Incision, drainage, and anoscopy
FINDINGS: The patient presented with an abscess overlying
his left buttock. The patient was prepped and draped in the
jackknife position under general endotracheal anesthesia.
Rectal exam revealed no perirectal induration. A bivalve
anoscope was placed, and there was no apparent fistula. An
18-gauge needle was placed in the area of induration on the
buttock. Purulent material was obtained. An elliptical
incision was made, excising a segment of skin; the abscess
cavity was bluntly opened, drained, and digitally explored to
break
, 1
up loculations. It was then irrigated and packed with
Iodoform gauze. The patient tolerated the procedure
satisfactorily and returned to the recovery room in good
improvement and good condition. Estimated blood loss was
less than 5 mL.
Answer Key
4. ICD-10-PCS code: 0Y910ZZ, 0DJD8ZZRationale: The root operation
Drainage is used to describe the incision and drainage procedure. The
left buttock is identified with body part value 1 in the Anatomical
Regions, Lower Extremities body system. The root operation
Inspection is coded to the lower intestinal tract. The inspection is
performed with an anoscope, which is an endoscopic instrument.
6. Operative Report
PREOPERATIVE DIAGNOSIS: Right index, middle, and
ring fingertip necrosis
POSTOPERATIVE DIAGNOSIS: Right index, middle, and
ring fingertip necrosis
OPERATION: Right index, middle, and ring fingertip of partial
amputations
ANESTHESIA: General
TECHNIQUE: The patient was taken to the operating room
and placed on the operating table in a supine position; care
was taken to pad all bony prominences. Anesthesia was used
by the anesthesiologist, and the patient’s right upper
extremity was prepped and draped in the normal standard
manner. Next, attention was turned to the patient’s right-
hand index finger, where the necrotic portion of the index
finger was incised circumferentially. The edge of the skin did
not have very good bleeding, and it was decided to
progressively incise the skin more proximally until good
bleeding could be found. At this point the incision was
carried around circumferentially, and the bone was cut of f
at
Week 3
In the week 3 Coding Roundtable, you will dissect and code the
following 16 operative reports:
Chapter 7: Pages 164-168 (operative reports 2, 4, 6, 8)
Chapter 8: Pages 187-191 (operative reports 2, 4, 6, 8)
Chapter 9: Pages 208-213 (operative reports 2, 4, 6, 8)
Chapter 10: Pages 230-234 (operative reports 2, 4, 6, 8)
Posting RequirementsNo later than Thursday, in one single post,
provide your code(s) for each operative report, total of 16 reports,
worth 5 points per report. Credit is given for your efforts, not for
the correct answer. The goal is for you to learn the process! Note:
it is strongly recommended that you use the dissecting
operative report (figure 2.6) to code each report. Your instructor
will post the answers on Friday morning, late posts are not
accepted and do not earn credit in the coding roundtable.
Operative Report in the Textbook
Chapter 7: Pages 164-168 (operative reports 2, 4, 6, 8)
2. Operative Report
PREOPERATIVE DIAGNOSIS: Osteomyelitis, 5th metatarsal,
left
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE: Amputation of toe
The patient was brought to the operating room and placed in
a supine position. After adequate general anesthesia was
obtained, the left foot was scrubbed, prepped, and draped in
the usual manner. No tourniquet was utilized. A skin incision
was made along the entire lateral border of the 5th
metatarsal and carried down to the subcutaneous tissue in
line with the skin incision. Bleeders were clamped and
electrocoagulated. Dissection was carried down to the base
, 1
of the 5th metatarsal where a capsulotomy was made at the
base. The bone was then delivered from the wound and sent
to the pathology department. There was erosion of the head
of the 5th metatarsal consistent with osteomyelitis. The
entire toe and metatarsal were amputated down to the tarsal
space, and all of the specimen was sent to the pathology
department. All of the tissues were debrided. The wound was
irrigated and hemostasis ensured. The subcutaneous tissue
was very loosely reapproximated utilizing 4-0 Vicryl suture.
The skin was not closed and was allowed to drain. A sterile
dressing was applied to the wound. The patient was then
transferred to the recovery room in satisfactory condition.
Answer Key
2. ICD-10-PCS code: 0Y6N0Z8Rationale: The amputation of the toe
through the 5th metatarsal is coded to the root operation Detachment in
the Anatomical Regions, Lower Extremities body system. The body
part value of N is assigned for a ray of the left foot. The qualifier value
of 8, complete 5th ray, is appropriate because the amputation involves
the entire toe and metatarsal.
4. Operative Report
PREOPERATIVE DIAGNOSIS: Abscess, left buttock
POSTOPERATIVE DIAGNOSIS: Abscess, left buttock
OPERATIONS: Incision, drainage, and anoscopy
FINDINGS: The patient presented with an abscess overlying
his left buttock. The patient was prepped and draped in the
jackknife position under general endotracheal anesthesia.
Rectal exam revealed no perirectal induration. A bivalve
anoscope was placed, and there was no apparent fistula. An
18-gauge needle was placed in the area of induration on the
buttock. Purulent material was obtained. An elliptical
incision was made, excising a segment of skin; the abscess
cavity was bluntly opened, drained, and digitally explored to
break
, 1
up loculations. It was then irrigated and packed with
Iodoform gauze. The patient tolerated the procedure
satisfactorily and returned to the recovery room in good
improvement and good condition. Estimated blood loss was
less than 5 mL.
Answer Key
4. ICD-10-PCS code: 0Y910ZZ, 0DJD8ZZRationale: The root operation
Drainage is used to describe the incision and drainage procedure. The
left buttock is identified with body part value 1 in the Anatomical
Regions, Lower Extremities body system. The root operation
Inspection is coded to the lower intestinal tract. The inspection is
performed with an anoscope, which is an endoscopic instrument.
6. Operative Report
PREOPERATIVE DIAGNOSIS: Right index, middle, and
ring fingertip necrosis
POSTOPERATIVE DIAGNOSIS: Right index, middle, and
ring fingertip necrosis
OPERATION: Right index, middle, and ring fingertip of partial
amputations
ANESTHESIA: General
TECHNIQUE: The patient was taken to the operating room
and placed on the operating table in a supine position; care
was taken to pad all bony prominences. Anesthesia was used
by the anesthesiologist, and the patient’s right upper
extremity was prepped and draped in the normal standard
manner. Next, attention was turned to the patient’s right-
hand index finger, where the necrotic portion of the index
finger was incised circumferentially. The edge of the skin did
not have very good bleeding, and it was decided to
progressively incise the skin more proximally until good
bleeding could be found. At this point the incision was
carried around circumferentially, and the bone was cut of f
at
