Simulated Medical Coding InternshipModule 2:ANESTHESIA1BuckFinal Exam 2-1:The anesthesia service was provided by a CRNA with the anesthesiologist medically directing 2...

Simulated Medical Coding Internship

Module 2:

ANESTHESIA

1

Buck

Final Exam 2-1:

The anesthesia service was provided by a CRNA with the anesthesiologist medically directing 2 concurrent cases.

The patient’s physical status was -P1.

2-1 OPERATIVE REPORT, DILATATION AND CURETTAGE

LOCATION

: Outpatient, Hospital

PATIENT

: Jackie Reller

PHYSICIAN

: Andy Martinez, M.D.

ANESTHESIOLOGIST

: Janice E. Larson, M.D.

PREOPERATIVE DIAGNOSIS

: Incomplete abortion with hemorrhage.

POSTOPERATIVE DIAGNOSIS

: Same.

PROCEDURE PERFORMED

: Suction dilatation and curettage.

ANESTHESIA

: General endotracheal.

ESTIMATED BLOOD LOSS

: 150 ml.

URINE OUTPUT

: 50.

FLUIDS

: 1000

COMPLICATIONS

: None.

INDICATIONS

: Patient presented with history of positive pregnancy test 4 weeks ago. Had bleeding and

cramping overnight and presented to the ER today for evaluation. HCG levels are low and pelvic and transvaginal

ultrasound show no viable fetus. Discussed with patient and partner risks and benefits of surgical management

of retained products of conception. Questions answered and consent obtained.

FINDINGS

: Cervical os is open to a size 10 dilator with tissue present at the os.

PROCEDURE

: The patient was prepped and draped in the lithotomy position under general endotracheal

anesthesia and the bladder was straight cathed. A weighted speculum was placed in the vagina. The anterior lip

of the cervix was grasped with a ring forceps. The size 10 curved suction curette was used to evacuate the

intrauterine contents. The sharp curette was then used to gently palpate the uterine walls with no return of

tissue and the suction curette is used again with negative return of tissue. The ring forceps is removed from the

anterior lip of the cervix and the weighted speculum from the vagina. All sponges and needles were accounted

for at the completion of the procedure. The patient left the operating room in apparent good condition having

tolerated the procedure well.

Pathology Report Later Indicated

: Products of conception, no viability

ABSTRACT/ASSIGN/ARRANGE THE CODES:

Professional Service (Anesthesia code):

Anesthesiologist

: _____

CRNA

: ____

ICD-10-CM codes

: ____

Mar 30, 2023

SOLUTION.PDF

Simulated Medical Coding InternshipModule 2:ANESTHESIA1BuckFinal Exam 2-1:The anesthesia service was provided by a CRNA with the anesthesiologist medically directing 2...

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