Applied Sciences

CHAPIER 23 r DiSestive System

PRACTICAT

Using the CPT and ICD-10-CM/ICD-9-CM manuals, code the following:

19. Rigid esophagoscopy with removal of a foreigntody.

CPT Code:

Ligation of an intraoral salivary duct.

CPT Code:

21,. Transection of esophagus with repair of esophageal varices.

CPT Code:

,/22. Enterotomy of the small intestine for removal of a foreign body.

CPT Code:

23. Complicated revision of a colostomy.

CPT Code:

,t. Pr”notomy, labial.

CPT Code:

25. Excision of a

CPT Code:

palate lesion without closure.

29.

n{u. *”^oval of a foreign body from the pharynx.

CPT Code:

27. Amy is an l8-year-old with severe snoring. She is having an adenoidectomy in order to treat her snoring.

,/CW Code: ./

/Zg. partial colectomy with cotostomy.

CPT Code:

Open repair of an incarcerated recurrent inguinal hernia.

CPT Code:

0. Surgical laparoscopic placement of a gastric band.

CPT Code:

Odd-numbered answers are located ln Appendix B, while the full answer key is only avallable in the TEACE rnstfuctor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.

CHAPTER !l r Digestive System

31. Fuli-thickness repair of the vermilion of the lip’

i CPT Code: \’4, ,,,,,0,.,.,

CPT Code:

33. Bilateral Pa

CPT Code:

epair of 1.6-cm laceration of floor of mouth’

rotid duct diversion.

,i. s,ugicar laparoscopic repair of a paraesophageal hernia with fundoplasty

with imPlantation of mesh’

CPT Code:

Biopsy of the stomach by laparotomy’

*d6. Nontune open ileostomY’

CPT Code:

37. Coiorrhaphy for multiple perforations of large

-‘ auto accihent. No colostomy was required’

rzls. tncision and drainage of perirectal abscess’

CPT Code:

39. Diagnostic abdominal laParoscoPY’

fo. r*urRocEDURE DIAGNoSIS: Screening coionoscopy’

POSTPROCEDURE DIAGNOSIS: Colon polyps’

PREMEDICATIONS: Fentanyl 100 mcg and Versed 4 mg’

PROCEDURE: A colonoscopy was perform:q to th.:,:”cum’ The scope

was advanced to the cecum urd.r’dir..t vision without any difflculty’

FINDINGS:Thececum,ascending’transverse’,desc11ding’andsigmoid colon *r, t’o’-ui’ r” trt” d””””8i”g colott’ there was a Z-mm

polyp

that was biopsied and submitted for histoiogy’

ASSESSMENT Diminutive colon polyps’

odd-numbered answers are located rn Appendrx B, while the futl a’swer key is only avallable in

the TEACTT

Instructor Resources on Evolve’

35.

intestine sustained in

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc’ A11 rights reserved

CHAPTER 23 r Digestive System

REPORTS

In Appendix A of this workbook you will find a section titled Reports, which ,onfiins original reports. Read the reports indicated below and supply the appropriate cPT and ICD-L0-CMfiCD-9-CM codes on the following lines:

v42. Report 22

& rcp-ro-cM code(s):

.1& tco-l-cM code(s):

d+. xeport zz

& cvr code(s):

& Ico-ro-cM code(s):

(& tcp-g-cM code(s):

43. Report 31

& cpr code(s):

& cpr code(s):

& lco-ro-cM code(s):

(& ICD-g-cM code(s):

45. Report 33

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

&

&

(e

d. v”port z+ CPT Code(s):

ICD-1O-CM Code(s):

ICD-9-CM Code(s):

& Ur”r to declde number of codes necessary to correctly answer the question. Odd-numbered answers are located ln Appendix B, while the full arlswer key is only available in the TEACfl Instructor Resources on Evolve.

Coppight O 2015 by Saunders, an imprint of Elsevier Inc. AII rights reserved.

CHAPTER 23 r Digestive System

47. Report 35

& crrr code(s):

& Icp-ro-cM code(s):

I& ICD-g-cM code(s):

\46. Report 39

& cpr code(s):

& rco-ro-cM code(s):

(& ICD-g-cM code(s):

& u”ur to decide number of codes necessary to correctly answer the questlon. Odd-numbered answers are located ln Appendix B, whlle the ftrll answer key is only avallable ln the TEACE Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A r Reports

and cltobrush was then used to obtain cervical curetting. The endocervical os was unable to be demonstrated by the Pipelle curette or the uterine sound. The cytobrush was then used to locate the central endometrial canal, and the Pipelle curette was then used to obtain endometrial curetting. Bimanual examination shows the uteruS to measure 4to 6 weeks, antevefted, smooth, mobile. Adnexa negative. Rectal declined. BUS within normal limits.

IMPRESSION: Clear cell carcinoma of unknown origin.

PLAN: Refer the patient to the University of Minnesota for diagnostic workup and treatment. The patient and University of Minnesota will be advised of the results of the biopsies when they become available.

PATHOLOGY REPORT LATER INDICATED: See Report 54.

PREOPERATM DIAGNOSIS: Atelectasis of the right lower lobe, suspecting either a mucous plug or obstructing cancer.

posToPERATM DIAGNOSIS: Mildly inflamed airways with some thick secretions. No definite mucous plug was seen, and certainly no cancer was noted.

PROCEDURE PERFORMED: Bronchoalveolar lavage, bronchial brushings, and bronchial washings.

For a detail of drugs used and amounts of drugs used, please refer to the bronchoscopy report sheet.

The patient was in the ICU on the ventilator, intubated, and so we simply used ICU sedation. We put the bronchoscope down the endotracheal tube. We could see the trachea, which appeared okay. The carina appeared normal. In the right and left lungs, all segments were patent and entered, and in the right lower lobe and middle lower lobe, there were increased, thick, tenacious secretions. No definite mucous plug. It did take a little suctioning to dislodge all of the mucus; however, it was not as bad as I thought it would be looking at the x-ray. The area was brushed, washed, and then, to be more specific, because of evidence on chest x-ray of something going on in the periphery/ a bronchoalveolar lavage of the right lower lobe is performed. The patient tolerated the procedure well. Specimens were performed. Specimens were sent for appropriate cytological, pathological, and bacteriological studies, and we hope to be able to follow up on that tomorrow.

PATHOLOGY REPORT LATER INDICATED: See Report 66.

PREOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

POSTOPERATM DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis.

PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy.

OPERATM NOTE: The patient is a 1S-year-old woman who was seen in the offlce and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure.

She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved.

APPENDIX A I RCPOTTS

intravenous injection. She was then intubated endotracheally’ The Jennings

gug *r, inserted into the mouth and expanded; this was secured to a Mayo stand. TWo red rubUer catheters were pliced through the nose and

brought

outthroughthemouth;theseweresecuredwithsnaps’Thiswasdoneto etevate th[ palate. A lar,rgeal mirror was placed in the nasopharynx’ The

adenoid tissue was visuiliied. Using suction cautery, the adenoid tissue was

removed in systemic fashion. oncJthis was completed, the- red rubbers were

i”f”ur.a and |rought out through the nose. fhe iight tonsilwas grasped – with an Allis forceps and retracied mediatly using a harmonic scalpel, and

thecapsulewasenteredbilaterally.Thetonsilwasremovedfromitsfossain an inferior fashion, and one ,-uil ut”u was cauterized. The left tonsil was lfr”., grurp”d with u.r atnt forceps and retracted medially. Again, the capsule

was identifled laterally, and the.harmonic scalpel was used to remove the

tonsil from its fossa in an inferior to superior fashion’ Once this was

.o*praraa, the bed was inspected, and -two

small areas wele cauterized here’

Three tonsillar sponges weie soaked in 1o/o Marcaine with epinephrine; one

was placed in the ,rulropt ury.r, and one in each tonsil bed. These were left

in p6sition for 5 minuier, u.td at the end of this interval they were remcved’

The beds were inspected. No further bleeding was noted. The gag was then

removedfromthemouth.TheTMJjointwaschecked.Thepatientwas allowed to recover from a general anesthetic and taken to the post

anesthesia care unit in stadle condition. There were no complications during this Procedure’

PATIIOLOGY RBPORT LATER INDICATED: Benign tonsil and adenoid

tissue.

PRE0PERATIVE DIAGN0SIS: Pleural fluid, unknown cause.

PoSToPE,RATIVEDIAGNOSIS:Loculatedpleuraleffusionwithremoval of 40 cc of bloodY Pleural fluid.

PROCEDURE PERFORMED: Diagnostic thoracentesis’- -o, ultrasound, the areas were lolulated by that method as well as by

attempting to draw out fluid. I had to do four different sticks to get 40 cc

of fluid and that was about the extent of each pocket’ T,here were four

&i;;;;fi;.tJr r entered just in the one general area that was marked by ,iirurorrrrO. This, of courr., *u, done after marking it with ultrasound’ i.rU5i.tg the area with swabs to sterilize the area, and then using 20 cc of

1olo

ilOo.iii” for loca1 anesthesia. With a one-pass maneuver, we were able to get into some fluid. At flrst actually, we did not get anf f-igi{‘ We moved

overaboutlinch,andthen*”*t'”abletogetlOccoffluidbeforethe po.i.”ipu*”red oui. The next one we got 5 cc, and I had to go to a different ‘nocket io set that. Then in the fourth pocket we were able to get two

;rr;;;.fufit *irt 10 cc to get at least-4b cc of fluid’ As this was such a tl*J”r area, I did not put”a chest tube in to drain it because I did not think we would get ffining that would amount to anything with the r*ili.t.tt tube”I had at -y-.o-*und’ I think we might need tfroir.oi.opy to break up adhesions and drain it right’ Of course’ the

differentiaiof Utooay pleural fluid includes tuberculosis, ttauma, cancer,

“”Jp”f*”nary embol-us. A ViQ scan would probably be pointless in this

pu*i.”fur effoit. I think I would wait to see *hat the cultures are before

i*.rt oo*n the pulmonary embolus tree. I wili have to get a hold of Dr. Marrot about CT surgerY’

PATH0LoGYRE,PoRTLATERINDICATED:SeeReport67.

Copyright O 2015 by Saunders, an imprint of Eisevier Inc’ A1l rights reserved’

APPEND1X A r Reports

rNDrcATroN: This is a 46-year-old white male with rourette,s and some MR who has had some hematochezia. There are no risk factors with no other symptoms.

PREoPERlrrrvE MEDTGATTONS: Fentanyl 100 mcg I[ versed 4 mg IV. FTNDTNGS: The Pentax video colonoscope was inserted without difficulty to the cecum. The ileocecal valve was identified. The appendiceal orifice was seen. I could not enter the cecum. Just above the valve, there was a small 2- to 3-cm polyp. This was hot biopsied off. There was a sessile 3-mm polyp in the proximal ascending colon, hot biopsied off. Inspection of the remainder of the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and sigmoid colon, revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The rectum showed a small Z-mm polyp that was hot biopsied off. The patient tolerated the procedure well.

TMPRESSTON: Three small polyps, two in the cecum ascending colon area and one on the rectum, hot biopsied off.

PLAN: If these polyps are adenomatous/ the patient should return again in 5 years for surveillance.

PATHOLOGY REPORT LATER INDICATED: See Report 56.

PREOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. POSTOPERATM DIAGNOSIS: Nonhealing duodenal ulcer. PROCEDURES PERFORMED:

1. Exploratory laparotomy. 2. P artial gastrectomy (antrectomy). 3. Truncal vagotomy. 4. Gastrojejunostomy. 5. Cholecystectomy with intraoperative cholangiogram. rNDrcATroN: The patient is a 60-year-old female who presented with a nonhealing gastric ulcer. She has had symptoms for about a year. She complains of epigastric pain. Medical therapy with prilosec failed, as did therapy for H. pylori. Biopsy of the ulcer has been done, and it was benign. The patient had a negative workup for gastrinoma. calcium level was also normal. The patient now presents for exploratory laparotomy and partial gastrectomy. The risks and benefits were discussed with the patient in detail. She understood and agreed to proceed.

PROCEDURE: The patient was brought to the operating room. Her abdomen was prepped and draped in a sterile fashion. A midline umbilical incision was made. The peritoneal cavity was entered. Initial inspection of the peritoneal cavity showed normal liver, spleen, colon, and small bowe1. There was an ulcer along the first portion of the duodenum just beyond the pylorus with some scarring. There was also an ulcer in the posterior part of the duodenal bulb, which was penetrating to the pancreas. we started dissection along the greater curvature of the stomach. vessels were ligated wrth 2-0 silk ties. There was an enlarged lymph node along the greater curvature of the stomach, which was sent for frozen section. It proved to be a benign lymph node. This was the only enlarged node found during dissection. we then proceeded with truncal vagotomy. The anterior r,agus

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

APPENDIX A .r Reports

and posterior vagus were identifled. They were clipped proximally and

distaily, and a segment of each nerve was excised and sent for frozen

section, and a segment of both vagus nerves was excised and confirmed by

frozensection. An incision was made around the gastrohepatic ligament’

The mesentery along the lesser culvatule of the stomach was dissected.

The vessels were ligited with 2-0 silk ties along the lesser-curvatule of the

stomach. A Kocheimaneuvel was performed to aid mobilization. The

pancreas was completely normal. No masses were found in the pancfeas.

tfr”r. was penetraiion of the ulcer in the superior part of the head of the pancreas. iissection was continued posterior to the stomach. The adhesions

iosterior to the stomach were taken down. The ulcer was in the posterior

i”grrr.rrt of the duodenal bulb iust beyond the pylorus and it had pJnetrated the pancreas. All the posterior layer of the ulcer that was left

idherent to the pancreas was shaved off. The stomach was divided with

ift” Cn stapler * tttut the complete antrum would be in the specimen. The duodenum was divided betweert clamps. The stomach pylorus and

f,rst part of the duodenum were sent to pathology for-examination’ Then

the duodenal stump was closed with running suture. Using 3-0 Lembert

sutures, the posterior wall of the ulcer was incorporated for duodenal

closure. The^base of the duodenum was rolled over the ulcer, and it was all-incorporating to the duodenal closure. Our next step was to proceed

with cholecysteitomy. The galibladder was separated from-the liver,

reflected, and taken do*r, ind the gallbladder was divided from the liver with blunt dissection and cautery. The cystic altely was doubly ligated

with silk. The cystic duct was identified. The cystic duct and gallbladder junction and gittbtadder ducts were identified. Intraoperative thoiangiogram was performed showing free flow of bile into the

intrahJpatlc duct ur’d i.rto the duodenum. No leaks were seen. The cystic

duct wis doubly ligated, and the gallbladder was sent to pathology. The

staple line in the pioximal stomaih was oversewn with 3-0 silk Lembert ,rtirr.r. A retrocoiic isoperistaltic Hofmeister-t)?e gastrojejunostomy was performed on the remaining stomach and loop of ieiunum. This was an

isoperistaltic end-to-side two-layer anastomosis with 3-0 chromic and 3-0 silk. The stomach was secured to the transverse mesocolon with several interrupted silk sutures to prevent any herniation along the retrocolic space. The anastomosis had a good lumen and good blood supply. There was no twist along the anastomosis. Before the anastomosis was finished, a nasogastric tube was placed along the afferent limb of the jejunum to decompress the duodenum and prevent blow out of the duodenal stump. Extra holes were made in the NG tube to provide adequate drainage. The anastomosis was marked with two clips on each side, and a Jackson-Pratt drain was placed over the duodenal stump. The peritoneal cavity was irrigated until clear. Hemostasis was adequate. The fascia was then closed with interrupted 0 Ethibond sutures. Skin edges were approximated with staples. Subcutaneous tissues were irrigated before closure. Estimated blood loss throughout the procedure was 200 ml. IV fluids: 3400 mI. Urine output: 840 ml.

FINDINGS: 1. Nonhealing benign ulcer in the posterior duodenal bulb penetrating into

the head of the pancreas. 2. Pafiial gastrectomy (antrectomy performed) and excision of the pylorus,

flrst portion of the duodenum along with ulcer. 3. Hofmeister-type retrocolic isoperistaltic gastrojejunostomy. 4. Posterior wall of the ulcer that was penetrating into the pancreas

incorporated into closure of the duodenal stump.

Copyright @ 2015 by Saunders, an imprint of Eisevier Inc. AII rights reserved,

APPENDIX A r Reports

6.

5.

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