Question

Chapter 2 18 HISTORY: The patient is a 62-year-old female who was admitted to the hospital for scheduled surgery to treat her recently diagnosed carcinoma of the rectosigmoid colon. She had noticed a change in her bowel habits about 6 to 7 months ago but did not seek medi- cal care until two weeks ago when she went to her primary care physician. The patient was immediately scheduled for an outpatient colonoscopy, and a 10-cm tumor was found and biopsied, with carcinoma diagnosed. She has a long history of angina and had a percutaneous transluminal coronary angioplasty (PTCA) twice in the past 4 years, with two non-drug-eluting stents in the right coronary artery. She also has a history of tobacco use, but she is no longer smoking. She was cleared for surgery by her cardiologist with the diagnoses of coronary artery disease with stable angina and hypercholesterolemia that continued to be managed with her usual medications while she was in the hospital. The patient was discharged home with home health services following an uneventful postoperative recovery. She has an appointment with her oncologist in 2 weeks to discuss the next treatment options. OPERATIVE FINDINGS: During an anterior resection of the rectosigmoid colon. the patient was found to have a tumor that extended into the muscular wall but not through the muscular wall of the rectosigmoid colon. No tumor was found outside the rectosigmoid intestine. The pathologist identified the tumor as a primary infiltrating papillary adenocarcinoma of the colon, rectosigmoid junction that extended focally into the outer muscular wall with no evidence of metastasis to pericolonic lymph nodes. The tumor staging was T2 NO MO. The colon specimen was a sessile round lesion about 12 cm in length with the tumor measuring 3 cm x 2.5 cm. The tumor was elevated about 0.8 cm above the surrounding mucosal surface. DESCRIPTION OF PROCEDURE: The patient consented to an anterior resection of the sigmoid colon. Under endotracheal anesthesia, the abdomen was prepped and draped in the usual surgical manner. It was opened through a lower abdominal midline incision extending to the left of the umbilicus using a hot knife. Exploration of the abdominal cavity revealed a normal-feeling-and- appearing stomach, liver, gallbladder, and large and small bowels. The aorta and iliac vessels had some atheromatous plaque. Both kidneys appeared and felt normal. The Bookwalter retractor was used. The sigmoid colon was freed from its attachment in the pelvis on the right and left side by sharp dissection. The ureters were both identified and avoided. The blood supply of the rectosigmoid area was serially clamped, divided, and tied with 2-3 Ethibond sutures. The tumor was palpated just below the peritoneal reflection. The colon was freed below the peritoneal reflection Again, the blood supply was serially clamped, divided, and tied with 2-0 Ethibond sutures. Proximally, a portion of the sigmoid colon mesentery was serially clamped, divided, and tied as well. Satinsky clamps were placed proximally and distally, and the colon and specimen were removed. An end-to-end anastomo- sis was performed in a single layer with interrupted 3-0 silks. The wound was inspected for bleeding. and it was dry. A Penrose drain was placed down near the anastomosis from the stab wound in the left lower quadrant. The first sponge and needle count was correct. The peritoneum was closed with continuous 2-0 Vicryl, fascia with interrupted 2-0 Ethibond, subcutaneous with Vicryl, and the skin with skin clips. The drain was sutured in place. All sponge and needle counts were correct The patient tolerated the procedure well and left the operating room in satisfactory condition Principal Diagnosis: Secondary Diagnoses: Principal Procedure: Secondary Procedure(s): sh

please find the ICD-10-CM codes

Answer 1

Based on the history, present illness, operative findings and procedure description:

Principal diagnosis is

• C19 Malignant neoplasm of rectosigmoid junction

Secondary diagnoses are

• Z98.61 Coronary angioplasty status
• I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
• E78.00 Pure hypercholesterolemia, unspecified

Principal procedure is

• 45111 Proctectomy partial resection of rectum transabdominal approach

Secondary procedures are

• 88307 Level V Surgical pathology