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April 10, 2015
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Code This!

Current Scenario Week of April 10, 2015:
View Answer From Last Scenario

Assign the correct ICD-9-CM and ICD-10-CM diagnosis and PCS procedure codes for the following inpatient coding scenario.

HISTORY AND PHYSICAL: 75-year-old female presented with progressive fatigue, 10-pound weight loss over three months’ time. She denied changes in bowel habits, melena, or blood per rectum. Her only current medication is aspirin prn for low back discomfort. She had not seen a physician for several years except for a respiratory tract infection when she saw me for the first time three weeks ago.

The patient was found to be anemic and underwent colonoscopy with biopsy of a large polypoid lesion at the hepatic flexure, which was found on pathologic examination to be adenocarcinoma.

SOCIAL HISTORY: Non-smoker, negative ETOH

FAMILY HISTORY: Significant for family history of father with heart attack, mother with CHF


PREOPERATIVE DIAGNOSIS: Right colon (hepatic flexure) mass, biopsy proven moderately differentiated adenocarcinoma;
Iron deficiency anemia secondary to chronic gastrointestinal blood loss


OPERATION: Right hemicolectomy

FINDINGS: 4-5cm mass in the right colon hepatic flexure, no metastases noted. The remainder of the exploration was unrevealing.

PROCEDURE: With the patient in the supine position and under satisfactory general anesthesia, the abdomen was prepped and draped in the usual fashion. The abdomen was entered through a midline incision. Exploration was carried out. The right colon was mobilized by incising the lateral peritoneal attachments and rotating the colon medially. The right half of the gastric colonic omentum was clamped, divided, and tied. Distal ileum was immobilized. Just to the right of the mid colonic artery, the mesentery was incised toward the base and then toward the distal ileum.

Blood supply to the right colon distal ileum was clamped, divided, and tied, thus completing division. At approximately 5 cm proximal to the ileocecal valve, the mid transverse colon was cleared and held together with clamps. Small incisions were then made in each. A GIA stapler was inserted and fired along the antimesenteric border. Anastomosis was completed via transverse application of TAs, specimen excised. The anchoring sutures proximally and distally were placed and the mesenteric defect was closed. Anastomosis was widely patent. Irrigation was carried out. Peritoneum was closed with running Vicryl, fascia with running Vicryl, skin with clips. Sterile dressings applied. Blood loss was minimal. All surgical counts were correct. There were no complications.

Code this scenario with ICD-9-CM, ICD-10-CM and PCS codes.


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