Instructions: This assignment consists of five SDS charts. These are typical sam
ID: 3515353 • Letter: I
Question
Instructions:
This assignment consists of five SDS charts. These are typical same day surgery visits which are to be coded from the facility side.
Assign the ICD-10-CM diagnosis code including external cause codes (as needed) and any appropriate Surgical CPT codes with any appropriate modifiers for each for the following cases:
PAGE 1:
Global Care Medical Center
100 Main St
Alfred NY 14802
(607) 555-1234
Ambulatory Surgery
Face Sheet
PATIENT INFORMATION:
NAME: SNOWFLAKE, Suzie
PATIENT NUMBER: ASUCase005
ADDRESS: 5439 Jones Parkway
DATE OF BIRTH: 06-04-YYYY
CITY: Sparrowville
AGE: 39
STATE: WV GENDER: Female
ZIP CODE: 45685
ORGAN DONOR: N
TELEPHONE: 555-555-0009
DATE OF ADMISSION: 07-23-YYYY
ADMITTING INFORMATION:
SURGEON: Frank Bowser, M.D.
SERVICE: Gynecology
PRIMARY CARE
PROVIDER:
Joanne Oaks, M.D.
FINANCIAL CLASS: Blue Cross (BC)
CODES
ADMITTING DIAGNOSIS: Sterilization
FIRST-LISTED DIAGNOSIS: Desires surgical sterilization
SECONDARY DIAGNOSES:
FIRST-LISTED PROCEDURE: Bilateral tubal ligation with
SECONDARY PROCEDURES: fallopian tube rings
SURGEON’S SIGNATURE Reviewed and Approved: Frank Bowser MD ATP-B-S:02:1001261385: Frank
Bowser MD (Signed: 7/23/YYYY 2:20:44 PM EST)
PAGE 2:
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Ambulatory Surgery
Operative Report
PATIENT INFORMATION:
NAME: SNOWFLAKE, Suzie
PATIENT NUMBER: ASUCase005
DATE OF SURGERY: 07-23-YYYY
SURGEON: Frank Bowser, M.D.
ASSISTANT SURGEON: Georgia Peach, MD
PREOPERATIVE DIAGNOSIS: Desires surgical sterilization.
POSTOPERATIVE DIAGNOSIS: Desires surgical sterilization.
PROCEDURES: Bilateral tubal ligation with fallopian tube rings.
INDICATIONS AND FINDINGS:
Indications: The patient is a 39-year-old female on lithium who is unable to discontinue this medication and does not
desire to become pregnant while on the medication. The patient therefore desires surgical sterilization.
Findings: Examination under anesthesia reveals a normal size uterus, anteverted, palpated. A small myoma was
palpated on the right side. No other unusual masses were noted. On laparoscopy, normal tubes and ovaries were noted.
A pedunculated myoma of approximately 2 to 3 cm in diameter was noted on the right posterior wall of the uterus and a
myoma was noted on the left posterior wall.
DESCRIPTION OF PROCEDURE:
The patient is brought into the operating room and placed in the dorsal lithotomy position. After good anesthesia was
achieved, the bladder was emptied using a straight catheter and examination under anesthesia was performed which
revealed the previously mentioned results of an anteverted uterus of normal size with a myoma noted on the right side. No
adnexal masses or other abnormalities were noted. The vaginal vault was prepped with Betadine scrub and solution and
rinsed. A pack was placed on the anterior lip of the cervix and a Rubin cannula was introduced into the cervical os. The
abdomen was then prepped and draped in the usual sterile manner. A 1.5 cm incision was made subumbilically and the
Veress needle was introduced into the incision. CO2 gas was insufflated into the abdomen. High-flow and low pressure
were noted. Once adequate pneumoperitoneum was achieved, the Veress needle was removed and a 10 mm trocar was
introduced into the incision. The laparoscopic camera was placed in the trocar sheath confirming intra-abdominal position.
A second incision was made in the midline approximately 3 fingerbreadths above the pubic symphysis. An 8 mm trocar
was introduced through the incision under direct visualization. The fallopian tube ring applicator was introduced through
the trocar sheath. Inspection of the abdomen revealed a normal size uterus with pedunculated myoma on the right
posterior wall of the uterus and a second myoma was noted on the left posterior side. Normal tubes and ovaries were
noted. The fallopian tube rings were placed on the proximal tubes bilaterally without problem. Good blanching of the
knuckles was noted. The abdominal instruments were then removed and the incisions were closed with 4-0 Vicryl. The
vaginal instruments were removed. Good hemostasis of the cervix was noted when the tenaculum was removed.
Anesthesia was reversed, and the patient was transferred to the PACU in satisfactory condition. Estimated blood loss was
10 cc.
SURGEON’S SIGNATURE Reviewed and Approved: Frank Bowser MD ATP-B-S:02:1001261385:
Frank Bowser MD (Signed: 7/23/YYYY 2:20:44 PM EST)
SDS Case #1
First listed diagnosis
List all appropriate secondary codes
External Cause codes
CPT surgical code – modifier (as appropriate)
Explanation / Answer
SDS case #1:
First listed diagnosis: is surgical sterilization code- Z30.2
Secondary codes: code blue for emergency life saving procedure .
External cause code: inducing lithium N05AN01(WHO)
CPT surgical code: Bilateral laparoscopic fallopian tube rings code is 58671