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Case 1

The document provides coding answers and rationales for various medical conditions, including sickle-cell anemia (D57.1), ruptured spleen (D73.5), cellulitis of the arm (L03.119), and chest mass (R22.2). It also details an operative report for a patient with splenic abscess and multiple intra-abdominal abscesses, including the procedures performed such as exploratory laparotomy and splenectomy. The report emphasizes the importance of verifying code accuracy and includes specific coding instructions for each diagnosis.

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26 views2 pages

Case 1

The document provides coding answers and rationales for various medical conditions, including sickle-cell anemia (D57.1), ruptured spleen (D73.5), cellulitis of the arm (L03.119), and chest mass (R22.2). It also details an operative report for a patient with splenic abscess and multiple intra-abdominal abscesses, including the procedures performed such as exploratory laparotomy and splenectomy. The report emphasizes the importance of verifying code accuracy and includes specific coding instructions for each diagnosis.

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2. Sickle-cell anemia Answer: D57.1 Rationale: The main term is anemia.

From the Index to Diseases and


Injuries look for Anemia/sickle-cell – see Disease/ sickle-cell. Diseases/sickle cell directs you to D57.1.
Review the code in the Tabular List to verify code accuracy. Note there is a category note under D57 to
use an additional code for associated fever. This is coded if known. 13. Ruptured spleen (not due to an
injury) Answer: D73.5 Rationale: The main term is ruptured. From the Index to Diseases and Injuries,
look for Rupture, ruptured/spleen/nontraumatic. You are referred to D73.5. Review the code in the
Tabular List to verify code accuracy. The diagnosis documents that the rupture of the spleen was not
due an injury, nontraumatic. 14. Cellulitis of the arm Answer: L03.119 Rationale: The main term is
cellulitis. From the Index to Diseases and Injuries, look for Cellulitis/arm – see Cellulitis, upper limb. Look
for Cellulitis/upper limb you are referred to L03.11-. The dash indicates another character is required for
a complete code. Review the code in the Tabular List to report the sixth character and verify code
accuracy. The diagnosis does not specify if the cellulitis is in the left or right arm report L03.119. 15.
Chest mass Answer: R22.2 Rationale: The main term is Mass. From the Index to Diseases and Injuries,
look for Mass/chest. You are referred to R22.2. Review the code in the Tabular List to verify code
accuracy. 16. Novel H1N1 flu Answer: J10.1 Rationale: The main term is Flu. From the Index to Diseases
and Injuries, look for Flu, there are no subentries for Novel or H1N1. It does instruct you to see also
Influenza. Look for Influenza/novel (2009) H1N1 influenza. You are referred to J10.1. Review the code in
the Tabular List to verify code accuracy. Note the code also notes if applicable. 17. Uncontrolled
diabetes with diabetic cataracts Answer: E13.36 Rationale: The main term is diabetes. From the Index to
Diseases and Injuries, look for Diabetes, diabetic/with/cataract. You are referred to E13.36. Review the
code in the Tabular List to verify code accuracy. 18. Left outer cheek abrasion, initial encounter Answer:
S00.81XA Rationale: The main term is abrasion. From the Index to Diseases and Injuries, look for
Abrasion/cheek. You are referred to S00.81. Review the code in the Tabular List to assign the seventh
character and to verify code accuracy. Because this code needs seven characters the letter X is used as a
placehold

Acute cholecystitis with chronic cholecystitis Answer: K81.2 Rationale: The main term is Cholecystitis.
From the Index to Diseases and Injuries, look for Cholecystitis/acute/with/ chronic cholecystitis. You are
referred to K81.2. Review the code in the Tabular List to verify code accuracy. Two codes are not
reported for the acute and chronic cholecystitis, because there is a combination code that fully identifies
all the elements documented in the diagnosis. 20. Right eyebrow laceration, subsequent encounter
Answer: S01.111D Rationale: The main term is laceration. From the Index to Diseases and Injuries, look
for Laceration/eyebrow – see Laceration, eyelid. Look for Laceration/eyelid you are referred to S01.11-.
Review the code in the Tabular List to report sixth and seventh characters and to verify code accuracy.
S01.111D is the correct code to report because the laceration is the on the right side. The seventh
character D is reported to indicate subsequent encounter

Case 1 Operative Report Preoperative Diagnoses: Splenic abscess and multiple intra-abdominal abscess,
related to HIV, AIDS, and hepatitis C. Postoperative Diagnoses: Splenic abscess and multiple intra-
abdominal abscess, related to HIV, AIDS, and hepatitis C. |1| Operative Procedure: 1. Exploratory
laparotomy with drainage of multiple intra-abdominal abscesses. 2. Splenectomy. 3. Vac Pak closure.
Findings: This is a 42-year-old man who was recently admitted to the Medical Service with a splenic
defect and found to have a splenic vein thrombosis. He was treated with antibiotics and anticoagulation.
He returned and was admitted with a CT scan showing mass of left upper quadrant abscess surrounding
both sides of the spleen, |2| as well as multiple other intra-abdominal abscesses below the left lobe of
the liver in both lower quadrants and in the pelvis. The patient has a psychiatric illness and was difficult
to consent and had been anticoagulated with an INR of 3. Once those issues were resolved by psychiatry
consult and phone consent from the patient’s father, he was brought to the operating room. Operative
Procedure: The patient was brought to operating room, and a time-out procedure was performed. He
was already receiving parenteral antibiotics. He was placed in the supine position and then under
general endotracheal anesthetic. Anesthesia started multiple IVs and an arterial line. A Foley catheter
was sterilely inserted with some difficulty requiring a Coude catheter. After the abdomen was prepped
and draped in the sterile fashion, a long midline incision was made through the skin. This was carried
through the subcutaneous tissues and down through the midline fascia using the Bovie. The fascia was
opened in the midline. The entire left upper quadrant was replaced with an abscess peel separate from
the free peritoneal cavity, this was opened, and at least 3 to 4 L of foul smelling crankcase colored fluid
was removed. Once the abscess cavity was completely opened, it was evident that the spleen was
floating within this pus |3| as had been predicted by the CT. This was irrigated copiously and the left
lower quadrant subhepatic and pelvic abscesses |4| were likewise discovered containing the same foul
smelling dark bloody fluid. All of these areas were sucked out, irrigated, and the procedure repeated
multiple times. At this point, we thought it reasonable to go ahead with the splenectomy. The anatomic
planes were obviously terribly distorted. There was no clear margin between stomach spleen, colon
spleen, etc, but most of the dense attachments were to the abscess cavity peel. Using this as a guide,
the spleen was eventually rotated up and out to the point where the upper attachments presumably
where the short gastrics used to reside were taken via Harmonic scalpel. The single fire of a 45 mm
stapler with vascular load was taken across the lower pole followed by 2 firings of the echelon stapler
across the hilum. This controlled most of the ongoing bleeding. Single bleeding site below the splenic
artery was controlled with 2 stitches, one of 3-0 Prolene and the other of 4-0 Prolene. Because of diffuse
ooze in the area and the fact that the patient would be scheduled for a return visit to the operating
room tomorrow to reinspect the abscess cavities, it was elected to leave two laparotomy pads in the left
upper quadrant and Vac Pak the abdomen. The Vac Pak was created using blue towels and Ioban
dressings in the usual fashion with 10 mm fully perforated flat Jackson-Pratt drains brought out at the
appropriate level. The patient was critical throughout the procedure and will be taken directly to the
Intensive Care Unit, intubated, with a plan for re-exploration and removal of the packs tomorrow. The
patient received 4 units of packed cells during the procedure, as well as, albumin and a large volume of
crystalloid. There were no intraoperative complications noted and the specimen sent included the
spleen. Cultures from the abscess cavity were also taken

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