AAPC - Chapter 12 Practical Applications with
expert interventions (Guaranteed Success)
CASE 1
Preoperative diagnosis: Transitional cell carcinoma in the bladder.
Postoperative diagnosis: Transitional cell carcinoma in the bladder. (This is the diagnosis to
report, since the pre and post-operative diagnoses are the same. The operative note is
consistent with a tumor on the posterior bladder wall. Pathology is not back yet, but the stated
diagnosis is transitional cell carcinoma in the bladder. In the US, 90% of all bladder cancers are
transitional cell in origin. This is sometimes referred to as urothelial carcinoma.)
Procedure: Cystoscopy; Excision bladder tumor -1 cm.
Bilateral retrograde pyelogram.
Cytology of bladder.
Anesthesia: General. (Anesthesia, local or general, is usually not reported by the physician
performing the procedure. This information is for documentation quality purposes only.)
Estimated Blood Loss: 10 cc.
Complications: None.
Counts: Correct.
, Indications: The patient i - answer 52234
74420-26
C67.4
CASE 2
Preoperative diagnosis: Gross hematuria.
Postoperative diagnosis: Bladder/Prostate tumor. (This is the diagnosis if no other positive
findings are found in the operative note. In this case, the post-operative diagnosis is different
from the pre-operative and has incorporated findings from the operative session and ultimately
the pathology report.)
Operation: Transurethral resection bladder tumor (TURBT) large (5.3 cm).
Anesthesia: General.
Findings: The patient had extensive involvement of the bladder with solid and edematous-
appearing hemorrhagic tumor completely replacing the trigone and extending into the bladder
neck and prostatic tissue. The ureteral orifices were not identifiable.
Digital rectal examination revealed nodular, firm mass per rectum.
Procedure description: The patient was placed on the operating room table in the supine
position, and general anesthesia was induced. He was then placed - answer 52240
C67.0
C67.5
C61
expert interventions (Guaranteed Success)
CASE 1
Preoperative diagnosis: Transitional cell carcinoma in the bladder.
Postoperative diagnosis: Transitional cell carcinoma in the bladder. (This is the diagnosis to
report, since the pre and post-operative diagnoses are the same. The operative note is
consistent with a tumor on the posterior bladder wall. Pathology is not back yet, but the stated
diagnosis is transitional cell carcinoma in the bladder. In the US, 90% of all bladder cancers are
transitional cell in origin. This is sometimes referred to as urothelial carcinoma.)
Procedure: Cystoscopy; Excision bladder tumor -1 cm.
Bilateral retrograde pyelogram.
Cytology of bladder.
Anesthesia: General. (Anesthesia, local or general, is usually not reported by the physician
performing the procedure. This information is for documentation quality purposes only.)
Estimated Blood Loss: 10 cc.
Complications: None.
Counts: Correct.
, Indications: The patient i - answer 52234
74420-26
C67.4
CASE 2
Preoperative diagnosis: Gross hematuria.
Postoperative diagnosis: Bladder/Prostate tumor. (This is the diagnosis if no other positive
findings are found in the operative note. In this case, the post-operative diagnosis is different
from the pre-operative and has incorporated findings from the operative session and ultimately
the pathology report.)
Operation: Transurethral resection bladder tumor (TURBT) large (5.3 cm).
Anesthesia: General.
Findings: The patient had extensive involvement of the bladder with solid and edematous-
appearing hemorrhagic tumor completely replacing the trigone and extending into the bladder
neck and prostatic tissue. The ureteral orifices were not identifiable.
Digital rectal examination revealed nodular, firm mass per rectum.
Procedure description: The patient was placed on the operating room table in the supine
position, and general anesthesia was induced. He was then placed - answer 52240
C67.0
C67.5
C61
