1.  Using your ICD-10-CM and CPT code books to, identify which diagnoses, and procedure services, including modifier(s), are to be coded for each case. All codes and answer will be added to the Coding Surgery Scenarios Answer Key for Candidates. 

First Listed Diagnosis 

Secondary Diagnosis or Diagnoses  (if any)

 (if any)E/M Procedure 

OPSX31MayweatherCora

MCCG240 Case Scenario OPSX31 Mayweather, Cora.html[10/21/2021 10:55:48 AM]

Outpatient Surgery

Patient Case Number: OPSX31-Mayweather, Cora

Patient Name: Cora Mayweather DOB: 03-01-66 Sex: F

Date of Service: 08-13-XX Surgeon: Matthew Bordelon, MD

Pre-Operative Diagnosis
Metastatic stage IIIC cancer of
ovary w/ involvement of the
rectosigmoid
colon and ovaries

Post-Operative Diagnosis
Metastatic stage IIIC cancer of ovary w/ involvement of the
rectosigmoid colon and ovaries

Procedure Performed: Insertion of single-lumen infusaport, debridement of necrotic tissue around
stoma, removal of PICC line

Anesthesia: General Complications: None

PREOPERATIVE DIAGNOSES:
1. Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and
the cul-de-sac, status post ovarian cancer debulking.
2. Lack of vascular access.

POSTOPERATIVE DIAGNOSES:
1. Metastatic stage IIIC cancer of the ovary with involvement of the rectosigmoid, both the ovaries and
the cul-de-sac, status post ovarian cancer debulking.
2. Lack of vascular access.

OPERATIVE PROCEDURE CARRIED OUT:
1. Insertion of a single-lumen infusaport.
2. Debridement of necrotic tissue around the stoma.
3. Removal of PICC line.

DESCRIPTION OF PROCEDURE:
After successful induction of general anesthesia, the patient was placed in steep Trendelenburg position.
The neck and the chest wall was prepped and draped in the usual sterile fashion. An infraclavicular
subclavian puncture was then made. Guidewire was inserted into the right atrium. The needle was then
removed. The position of the guidewire was tested radiographically. A dilator introducer kit was inserted
over the guidewire into the right atrium. The right guidewire was removed. The catheter was inserted
into the right atrium under fluoroscopic guidance. A transverse incision was then made on the anterior
chest wall. Subcutaneous tissue was incised along the line of the incision. The catheter was tunneled
subcutaneously to the point on the anterior chest wall. The catheter was connected to the reservoir such
that the tip of the catheter was located in the right atrium. The catheter was then attached to the

OPSX31MayweatherCora

MCCG240 Case Scenario OPSX31 Mayweather, Cora.html[10/21/2021 10:55:48 AM]

reservoir. The reservoir was then flushed. The reservoir was sutured to the anterior chest wall. The
patient tolerated the procedure well. The skin was closed with subcuticular suture. The skin was closed
with subcuticular sutures. The patient tolerated the procedure well. The patient was transferred to the
recovery room under satisfactory conditions. The PICC line was removed by gentle traction. The tip of
the catheter was intact. A sterile dressing was applied on the right arm where the PICC line has been
taken

OPSX29GradyKent

MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]

Outpatient Surgery

Patient Case Number: OPSX29-Grady, Kent

Patient Name: Kent Grady DOB: 07-13-70 Sex: M

Date of Service: 01-22-XX Surgeon: Mary Hollister, MD

Pre-Operative Diagnosis
Acute Pancreatitis

Post-Operative Diagnosis
Esophageal Varices

Procedure Performed: EGD & Endoscopic ultrasound

Anesthesia: Conscious sedation Complications: None

PROCEDURES:
1. EGD
2. Endoscopic ultrasound.

INDICATIONS:
1. Acute pancreatitis.
2. Abnormal CT scan, rule out pancreas head mass.

PROCEDURE #1 EGD:
The Olympus GIF-190 forward-viewing video-endoscope was lubricated and advanced into the
hypopharynx. The scope passed into the esophagus. Examination of the stomach was performed in
straight and retroflexion views. The scope was passed into the second portion of the duodenum.

FINDINGS:
1. Grade 1 esophageal varices x1.
2. Food debris in the proximal stomach, otherwise, normal stomach.
3. Normal duodenum.
4. Acute and chronic pancreatitis

PROCEDURE #2 ENDOSCOPIC ULTRASOUND:
The Olympus linear echoendoscope was lubricated and advanced into the hypopharynx. The scope
passed through the esophagus, stomach, pylorus second portion duodenum. With the water-filling
technique of the balloon and lumen, endoscopic ultrasound examination performed. The pancreas
parenchyma appeared with diffuse inhomogeneity, hypoechoic foci, lobulation, and a few calcifications in
the head of the pancreas. The main pancreatic duct was not dilated, and it had thickened borders. Folds
features are suggestive of chronic pancreatitis. The common bile duct was dilated measuring 9 mm.
There was free fluid around the pancreas body and tail. The splenic vein was distended, consistent with
portal hypertension.

OPSX29GradyKent

MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]

RECOMMENDATIONS:
1. Alcohol abstinence.
2. Repeat EUS in 3 months.

Dictating Clinician: Mary Hollister, MD

Electronical Signed By: Mary Hollister, MD

Copyright © 2020 by The American Health Information Management Association. All Rights Reserved.

  • Local Disk
    • OPSX29GradyKent

OPSX38AndelLucinda

MCCG240 Case Scenario OPSX38 Andel, Lucinda.html[10/21/2021 10:55:47 AM]

Outpatient Surgery

Patient Case Number: OPSX38-Andel, Lucinda

Patient Name: Lucinda Andel DOB: 05-20-62 Sex: F

Date of Service: 11-2-XX Surgeon: Michael Singleton, MD

Pre-Operative Diagnosis
Metastatic primary peritoneal cancer

Post-Operative Diagnosis
Metastatic primary peritoneal cancer

Procedure Performed: Insertion of single-lumen Infusaport

Anesthesia: General Complications: None

Description of Procedure:

After successful induction of general anesthesia, the patient was placed in a steep Trendelenburg
position. The neck and the chest wall was prepped and draped in the usual sterile fashion. An
infraclavicular subclavian puncture was then made to access the subclavian vein. The catheter was
inserted into the right atrium via the subclavian vein. The position of the catheter was checked. The
dilator introducer assembly was inserted over the guidewire into the right atrium. The introducer was
removed. The catheter was inserted into the right atrium. Through the introducer, the introducer set was
peeled away. A transverse incision was then made on the anterior chest wall.
Subcutaneous tissue was incised. The reservoir of the Infusaport was then placed in the subcutaneous
space. This was sutured in place. The catheter was then tunneled subcutaneously to the site of the
reservoir. The catheter was pulled such that the tip of the catheter was located in the right atrium. The
catheter was then connected to the reservoir with the help of a small plastic screw meant for the above
purpose. The reservoir was sutured in place. The patient tolerated the procedure well. A 3-0 Vicryl
sutures were used to approximate the subcutaneous tissues. The skin was approximated with 3-0 Vicryl
subcuticular sutures. The patient tolerated the procedure well and was transferred to the recovery room
under satisfactory condition.

Electronically Signed By: Michael Singleton, MD

Copyright © 2020 by The American Health Information Management Association. All Rights Reserved.

  • Local Disk
    • OPSX38AndelLucinda

OPSX34ClerkSolomon

MCCG240 Case Scenario OPSX34 Clerk, Solomon.html[10/21/2021 10:55:47 AM]

Outpatient Surgery

Patient Case Number: OPSX34-Clerk, Solomon

Patient Name: Solomon Clerk DOB: 08-08-74 Sex: M

Date of Service: 04-17-XX Surgeon: Adrian Michaels, MD

Pre-Operative Diagnosis
R/o torn rotator cuff, right shoulder

Post-Operative Diagnosis
Rotator cuff tear, right shoulder. Impingement syndrome w/
rotator cuff tear. Bursitis, right shoulder.

Procedure Performed: Arthroscopic acromioplasty w/ rotator cuff repair

Anesthesia: General Complications: None

Operative Procedure:

The patient was identified in the preoperative area. Proper surgical site protocol was followed. He was
subsequently taken to the operating suite where a general anesthetic was administered by the department
of anesthesia. The patient was carefully positioned in the beach chair position. All bony prominences
were well padded. The right shoulder and arm were sterilely prepped and draped in the usual manner.

Bony landmarks were identified and arthroscopic portals infiltrated with 1% Xylocaine with epinephrine.
Posterior portal to the glenohumeral joint was established in a standard fashion. An accessory anterior
portal was established under triangulation techniques and a probe and shaver inserted anteriorly. There is
some fraying of the biceps tendon, but the anchor itself was intact. There is an area of erosion in the
glenoid, the anterior labrum is intact. The humeral head appears satisfactory.
Examination of the rotator cuff demonstrates a large area of tearing laterally. The bare spot is quite
evident.

At this point, the arthroscope was reinserted posteriorly into the subacromial space. Moderate bursitis
was present and bursectomy performed through a lateral portal. The rotator cuff tear was identified and
noted to be quite large, easily mobile. I then proceeded with a standard anterior-inferior acromioplasty.
The patient does have an os acromiale and we did not disrupt this area between the anterior process in
the body of the acromion. Following the completion of the acromioplasty, all arthroscopic instruments
removed and I made a lateral incision extending from the lateral aspect of the acromion laterally. The
deltoid fascia was incised and blunt dissection through the deltoid muscle to the subacromial space was
performed. Retractors were inserted.
Excellent exposure of the cuff tear was present. There is a full-thickness non-retracted supra and
infraspinatus tear. The footprint was identified and cleared of all debris and soft tissue. I debrided the
lateral edge of the rotator cuff and utilized 3 medial row Arthrex corkscrews followed by 2 lateral row

OPSX34ClerkSolomon

MCCG240 Case Scenario OPSX34 Clerk, Solomon.html[10/21/2021 10:55:47 AM]

Push locks for double row fixation.

OPSX32SandallOscar

MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]

Outpatient Surgery

Patient Case Number: OPSX32-Sandall, Oscar

Patient Name: Oscar Sandall DOB: 02-19-72 Sex: M

Date of Service: 05-05-XX Surgeon: Sandra Cullman, MD

Pre-Operative Diagnosis

Right knee complex medial
meniscus tear

Post-Operative Diagnosis

Right knee complex medial meniscus tear and medial plica

Procedure Performed: Knee arthroscopy w/ partial medial meniscectomy, chondroplasty of medial
femoral condyle, excision of medial plica

Anesthesia: General Complications: None

Indication for Procedure:

The patient is a 46y/o male who was referred to me with complaints of right knee pain. He has had pain
for several months and failed nonoperative treatment. I recommended a right knee arthroscopy with
partial medial meniscectomy. The risks, benefits and possible complications from the surgery were
discussed in detail and the patient wishes to proceed. The potential risks include: Infection, bleeding,
neurovascular damage, residual pain and dysfunction, recurrence as well as the surgery possibly not
improving the patient’s symptoms. If a meniscectomy is performed the patient understands that there is
an increased chance of developing or accelerating any existing arthritis in that knee. The patient also
understands the risks of anesthesia which include stroke, heart attack, aspiration, blood clot, pulmonary
embolus and death.

Description of Procedure:

After consent was obtained the patient was taken to the operating room and was administered a general
anesthetic and intubated. A well-padded tourniquet was applied to the right upper thigh. The extremity
was then prepped and draped in the usual fashion. An Esmarch was used to exsanguinate the right lower
extremity and the tourniquet inflated to 325 mmHg. a superomedial portal was made for the introduction
of the inflow. An anterolateral portal was made for the introduction of the arthroscope. An anteromedial
portal was made for the introduction of arthroscopic instruments. The findings are as follows:

1. Suprapatellar pouch: Normal
2. Medial plica: Frayed
3. Medial gutter: Normal
4. Lateral gutter: Normal

OPSX32SandallOscar

MCCG240 Case Scenario OPSX32 Sandall, Oscar.html[10/21/2021 10:55:48 AM]

5. Patella: Normal
6. Trochlea: Grade I Chondromalacia – Softening Articular Cartilage
7. Medial Femoral Condyle: Grade IIA Chondromalacia – Fissures/Fragmentation Articular Cartilage

<50% and Grade 118 Chondromalacia -Fissures/Fragmentation Articular Cartilage >50%
8. Medial meniscus: Tear, Complex- Root, Posterior Horn, Body
9. Medial Tibial Plateau: Normal
10. ACL: Normal
11. PCL: Normal
12. Lateral Femoral Condyle: Normal
13. Lateral Meniscus: Normal
14. Lateral Tibial Plateau: N