HIM1257 Ambulatory Coding
Module 05 Written Assignment - Coding Audit
Instructions: Each operative report audit is worth a potential 10 points. Points in parentheses are for
each operative report. This assignment is worth a total of 30 points.
Read each operative report and review the assigned codes.
Identify the error in code assignment (3 points)
Identify the coding guideline or instructional note that applies and explain why the code(s)
should or should not be reported as listed (3 points)
Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about
reimbursement, compliance, coder performance, reporting, and any other processes that are affected
by coding. (4 points)
Operative report #1
PREOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
POSTOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
Procedures:
1. Cystoscopy.
2. Urethral dilation and hydrodilation.
Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is
normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is
normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with
interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL.
Module 05 Written Assignment - Coding Audit
Instructions: Each operative report audit is worth a potential 10 points. Points in parentheses are for
each operative report. This assignment is worth a total of 30 points.
Read each operative report and review the assigned codes.
Identify the error in code assignment (3 points)
Identify the coding guideline or instructional note that applies and explain why the code(s)
should or should not be reported as listed (3 points)
Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about
reimbursement, compliance, coder performance, reporting, and any other processes that are affected
by coding. (4 points)
Operative report #1
PREOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
POSTOPERATIVE DIAGNOSES:
1. Interstitial cystitis.
2. Urethral stenosis.
Procedures:
1. Cystoscopy.
2. Urethral dilation and hydrodilation.
Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is
normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is
normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with
interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL.
