This type of coding is based on the services recorded in the anesthesia record. The record...
This type of coding is based on the services recorded in the anesthesia record. The record contains preoperative notes, intraoperative notes, and postanesthesia care unit documentation. Preoperative notes cover the patient's medical and surgical history, history of anesthetic complications, current medications, and respiratory condition, and the chosen anesthesia. Postanesthesia care unit (PACU) documentation record the monitoring of the patient for immediate postoperative complications. Intraoperative notes reflect the monitoring of the patient during the procedure.
In addition to the anesthesiologist's document in the anesthesia record, what other document or documents do you feel that the coder can review to allow the coder to sequence the highest paying procedure first on the claim?
Homework Answers
I think respiratory condition of the patient should be prioritized for reviwing the coder to sequence the highest paying procedure.
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This type of coding is based on the services recorded in the
anesthesia record. The record...
CRITICAL THINKING ACTIVITIES 1. Prioritize the following list of preopera Deinritize the following list of preoperative...
CRITICAL THINKING ACTIVITIES 1. Prioritize the following list of preopera Deinritize the following list of preoperative activities for the morning of surgery. (737-739) Check the surgeon's orders. Check for a signed surgical consent form. Check that lab work is complete and in the medical record. Have the patient empty the bladder. Check to see that preoperative medications ordered are available on the unit. Complete the preoperative checklist. Have the patient shower. Prepare the unit for the postoperative return of the...
year old women in the PACU. The woman me but is confused, restless and agitated en...
year old women in the PACU. The woman me but is confused, restless and agitated en l angs to her ation of an oxygen problem or possibly t mation are normal postoperative findings and ve confusion is common in the end in the elderly, but it could also indicate a tation indicate inadequate pain management, will diminish in time Postoperative confusio Significant blood loss Contin and and analgesics will help 425. You admit a patient to the pos 130/90 and...
Mr. Ellis returns from the Post Anesthesia Care Unit (PACU) after his surgical procedure. He has an Ⅳof LR infusing...
Mr. Ellis returns from the Post Anesthesia Care Unit (PACU) after his surgical procedure. He has an Ⅳof LR infusing at 125 mL hr O2 at 2 L/min per nasal cannula, and an indwelling 1. catheter attached to a drainage bag. Four hours later, the nurse documents Mr. Elis ntake/output. The LR solution has been running for 4 hours, and the nurse administers and IV antibiotic that runs in 150 mL of normal saline. Mr. Ellis is still NPO after...
surgical case54 i need help coding this cpt code and hcpcs if necassary i didnt know...
surgical case54 i need help coding this cpt code and hcpcs if
necassary
i
didnt know which catergory to place it in
Surgical Case #54 Operative Report Preoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Postoperative Diagnosis: Same Procedure: Anesthetic: Brief Clinical History: The patient had a biopsy-proven squamous cell carcinoma of Excision of the same with layered primary closure Local After explanation of the risks, benefits, and alternatives, she agreed to re-excision and closure. She understood...
The following documentation is from the health record of a patient who received outpatient surgical services....
The following documentation is from the health record of a patient who received outpatient surgical services. Operative Report Preoperative Diagnosis: Melanoma of the skin of the forehead Postoperative Diagnosis: Same Procedure: Excision of forehead melanoma with split-thickness skin graft The patient was given a local IV sedation and taken to the operating room suite. The face and left thigh were prepped with pHisoHex soap. The cancer was outlined for excision. The cancer measured approximately 2.5 cm in diameter. The forehead...
41 the Su Care of Admiss Ambu (ou tp//ewlve.vcom /Coper/ioundationsadult Sam ac Inpa Objectives 10. Explain...
41 the Su Care of Admiss Ambu (ou tp//ewlve.vcom /Coper/ioundationsadult Sam ac Inpa Objectives 10. Explain conscious sedation. 11. Describe the roles of the circulating nurse and the s 1. ldentity the purposes of surgery 2. Distinguish among elective, urgent, and emergency surgery 3. Explain the concept of perioperative nursing. 4. Discuss the factors that influence an individual's ability to tolerate surgery 5. Discuss considerations for the older adult surgical patient. 6. Describe the preoperative checklist. 7. Explain the importance...
PLEASE ANSWER ALL THE QUESTIONS: 1) In textbook“Conquer Medical Coding - A Critical Thinking Approach with...
PLEASE ANSWER ALL THE QUESTIONS: 1) In textbook“Conquer Medical Coding - A Critical Thinking Approach with Coding Simulations” 2017, Chapter 7, page 231 there are specific directives regarding "Pressure Ulcers." Specifically, there is a yellow dot box, which means that the coder should "proceed with caution." That the notes explain how to move ahead carefully in the particular coding situation. In this case, when coding "Pressure Ulcers." According to the Inpatient Prospective Payment System (IPPS), Stage III and Stage IV...
UNIT THREE CODING AND MEDICAL BILLINO 14 Basics of Diagnostic Coding vider's VOCABILARY REVIEW eerination of...
UNIT THREE CODING AND MEDICAL BILLINO 14 Basics of Diagnostic Coding vider's VOCABILARY REVIEW eerination of the nature of a disease, injury, or congenital defect is a is any contact hetween a patient and a provider of vervice is an indication of the presence of an illness lists diagnostic torms and related codes in alghabetical onder 4. The 5._ are broad sections of the ICD-10-0'M coding manual grouped by disease 6 Converting oral or wrilten descriptions into alphanumeric designations is...
assign the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Left tibial tubercle avulsion fracture....
assign the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Left tibial tubercle avulsion fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left distal end of the tibia PROCEDURE: Open reduction and internal fixation of left tibia. ANESTHESIA: General. The patient received 10 ml of 0.5% Marcaine local anesthetic. TOURNIQUET TIME: 80 minutes. ESTIMATED BLOOD LOSS: Minimal. DRAINS: One JP drain was placed. COMPLICATIONS: No intraoperative complications or specimens. Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw...
Q: Need help with my assignment to code diagnoses(ICD-10-CM) and CPT for the following cases with...
Q: Need help with my assignment to code diagnoses(ICD-10-CM) and CPT for the following cases with explanation. Case-1 Patient Name: DOB: Age: 2Y Date of Surgery: 04/04/2014 Primary Care Physician: Cecil H Lashlee, M.D. Referring Physician(s): John F Bealer, M.D. PCP Operative Report Surgeon: John F Bealer, M.D. Assistant(s): None. Preoperative Diagnosis: Umbilical hernia. Postoperative Diagnosis: Umbilical hernia. Procedure: Umbilical herniorrhaphy. Anesthesia: General endotracheal anesthesia. Estimated Blood Loss: Less than 5 mL. Complications: There were no intraoperative complications. Counts: Correct....
CRITICAL THINKING ACTIVITIES 1. Prioritize the following list of preopera Deinritize the following list of preoperative activities for the morning of surgery. (737-739) Check the surgeon's orders. Check for a signed surgical consent form. Check that lab work is complete and in the medical record. Have the patient empty the bladder. Check to see that preoperative medications ordered are available on the unit. Complete the preoperative checklist. Have the patient shower. Prepare the unit for the postoperative return of the...
year old women in the PACU. The woman me but is confused, restless and agitated en l angs to her ation of an oxygen problem or possibly t mation are normal postoperative findings and ve confusion is common in the end in the elderly, but it could also indicate a tation indicate inadequate pain management, will diminish in time Postoperative confusio Significant blood loss Contin and and analgesics will help 425. You admit a patient to the pos 130/90 and...
Mr. Ellis returns from the Post Anesthesia Care Unit (PACU) after his surgical procedure. He has an Ⅳof LR infusing at 125 mL hr O2 at 2 L/min per nasal cannula, and an indwelling 1. catheter attached to a drainage bag. Four hours later, the nurse documents Mr. Elis ntake/output. The LR solution has been running for 4 hours, and the nurse administers and IV antibiotic that runs in 150 mL of normal saline. Mr. Ellis is still NPO after...
surgical case54 i need help coding this cpt code and hcpcs if
necassary
i
didnt know which catergory to place it in
Surgical Case #54 Operative Report Preoperative Diagnosis: Squamous cell carcinoma of the left forearm, 8 mm Postoperative Diagnosis: Same Procedure: Anesthetic: Brief Clinical History: The patient had a biopsy-proven squamous cell carcinoma of Excision of the same with layered primary closure Local After explanation of the risks, benefits, and alternatives, she agreed to re-excision and closure. She understood...
41 the Su Care of Admiss Ambu (ou tp//ewlve.vcom /Coper/ioundationsadult Sam ac Inpa Objectives 10. Explain conscious sedation. 11. Describe the roles of the circulating nurse and the s 1. ldentity the purposes of surgery 2. Distinguish among elective, urgent, and emergency surgery 3. Explain the concept of perioperative nursing. 4. Discuss the factors that influence an individual's ability to tolerate surgery 5. Discuss considerations for the older adult surgical patient. 6. Describe the preoperative checklist. 7. Explain the importance...
UNIT THREE CODING AND MEDICAL BILLINO 14 Basics of Diagnostic Coding vider's VOCABILARY REVIEW eerination of the nature of a disease, injury, or congenital defect is a is any contact hetween a patient and a provider of vervice is an indication of the presence of an illness lists diagnostic torms and related codes in alghabetical onder 4. The 5._ are broad sections of the ICD-10-0'M coding manual grouped by disease 6 Converting oral or wrilten descriptions into alphanumeric designations is...
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