Surgery Case-014 week 5 Surgery for Outpatient assign CPT and ICD-10-CM codes Global OB Care PREOPERATIVE...

Surgery Case-014

week 5 Surgery for Outpatient

assign CPT and ICD-10-CM codes

Global OB Care PREOPERATIVE DIAGNOSES: 1. Intrauterine pregnancy at 36 weeks gestation. 2. Breech presentation. 3. Oligohydramnios. 4. Decreased biophysical profile. 5. Probable placental insufficiency. POSTOPERATIVE DIAGNOSES: 1. Intrauterine pregnancy at 36 weeks gestation 2. Breech presentation. 3. Oligohydramnios. 4. Decreased biophysical profile. 5. Probable placental insufficiency. 6. Meconium. 7. Fibrous areas on the placenta. PROCEDURE: Primary low transverse cesarean section. FINDINGS: 1. Viable female infant with Apgar of 4 and 9 at one and five minutes respectively. 2. Meconium noted during procedure. 3. Placenta had areas of fibrous tissue throughout. There was a large area which was quite white and dense. 4. Left parafallopian cyst. 5. Normal tubes, ovaries, and uterus. PREAMBLE: The patient is a 33-year-old gravida 1, para 0 at 36-3/7 weeks' gestation who has been admitted to the hospital for oligohydramnios. The patient's ultrasound this morning revealed an AFI of 2.5. Biophysical profile was 4/8. It was elected to discuss with the patient the risks and complications of primary low transverse cesarean section including bleeding and its inherent risk of 1 | P a g e Surgery Case-014 possible blood transfusion with its risks. We also discussed the risks of infection and damage to underlying structures including but not limited to bowel, bladder, ureters, urethra, bladder, tubes, ovaries, uterus, cervix, vagina, and infant. The patient voiced understanding of all of these risks and did wish to proceed. Consent was signed and we took her back to the operating room. PROCEDURE: The patient was brought back to the operating room where spinal anesthetic was administered. She was prepped and draped in the usual manner in supine position with left lateral tilt. A Pfannenstiel incision was made 2 fingerbreadths above the pubic symphysis and carried down to the fascia. The fascia was identified, entered sharply, and extended laterally. The fascia was then tented up and the rectus muscles were separated. This was carried down to the pubic symphysis. Rectus muscles in the midline had to be sharply dissected superiorly. The peritoneum was then entered bluntly and extended with gentle traction. Bladder blade was inserted. The lower uterine segment was identified. Vesicoureteral peritoneum was identified, entered sharply, and extended laterally, and bladder flap created. The bladder blade was repositioned. The lower uterine segment was entered sharply. I did have to use a Kelly clamp to lift up on the uterus because the infant was quite close to the placental wall. The lower uterine incision was then extended with blunt traction bilaterally. The amniotic bag was still intact and at that point a Kelly clamp was used to enter the amniotic sac and meconium fluid returned. The infant's feet were identified and removed from the placenta. The infant was attempted to be rotated belly down with her back up. Arms were then delivered with sweeping motions. The infant's neck was then flexed and the infant's head was delivered via fundal pressure. The infant was bulb suctioned in the nose and mouth. Cord was cut and clamped and a segment was cut and clamped for blood gases which did not require being sent. The infant was then immediately taken to the awaiting pediatric team. The placenta was then delivered with gentle traction and concomitant uterine massage. The cord did separate from the placenta and once the placenta was starting to bulge out, I removed it with my hand at that point. The uterus was then exteriorized and placed on a wet lap sponge. It was cleared of clot and debris with a dry lap sponge. Bladder blade was reinserted for protection and the lower uterine segment incision was closed using a running locking suture of O Vicryl. A second imbricating layer was placed. We did have to use figure-of-eight sutures to 2 | P a g e Surgery Case-014 control some areas of hemostasis. Once hemostasis was obtained, the posterior cul-de-sac was then cleared of clot and debris with a wet lap sponge. It was quite clean in posterior area. The uterus was inspected. There were normal ovaries, tubes, and uterus. The uterus was quite small though normal in appearance. There was a left parafallopian cyst which we used electrocautery to remove. The uterus was then returned to the abdominal cavity. The left and right gutters were irrigated with warm saline. The lower uterine incision was inspected again for hemostasis and confirmed. Fascia was closed using running 0 Vicryl suture. Subcutaneous tissue was reapproximated using 2-0 Vicryl suture. Skin edge was reapproximated using a 4-0 Vicryl subcuticular stitch. Pressure bandage was applied. The patient was transferred to the postoperative anesthesia care unit in stable condition. Pathology Report Later Indicated: Umbilical cord demonstrates three vessels. Placenta, no pathologic diagnosis.

Homework Answers

Answer #1

Ans) CPT -current procedure terminology.

ICD-10-CM- International classification of diseases,tenth revision,clinical modification.

CPT and ICD -10-CM codes are:

Delivery and postpartum care. - CPT procedure codes 59410 ,59515 ,59614 ,or59622.

Hospital inpatient services. - 99221 ,99239.

Therapeutic or diagnostic injections - 90782 ,90799.

Breech presentation - 032.1XX0 (.ICD - 10- CM codes).

Oligohydramnios -041.00X0.

36 weeks gestation of pregnancy - Z3A.36.

Decreased biophysical profile - 0.36.8120.

Placental insufficiency - 036.5110.

Meconium staining - P96.83.

Fibrous areas on the placenta - 043.893.

Cesarean section - 2018 ICD -10- CM diagnosis code- 075.82.

Spinal anaesthesia - 074.5.

Pfannenstiel incision -T81.31XA.

Sutures - T 81.31.

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