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MEDICAL RECORD CODING CASE
DUE 01/20/10


Note: 20 Points for each correct code on the attached answer sheet
Code the procedure(s) performed at the ambulatory surgery center for the
gastroenterologist only.
AMBULATORY SURGERY CENTER CHART
Admit Date/Time: 3/14 10:00 am Discharge Date/Time: 3/14 12:45 pm
Sex: M Age: 59 Disposition: Home Height: 5’6” Weight: 160
Admitting Diagnosis:
1. Abdominal Pain
2. R/O Ulcer
Discharge Diagnosis:
1.

Procedures:
1.
F:\MEDICAL CODING\To Copy/Exam Case Study1 GASTROENTEROLOGY NOTE

Date: 3/14
Height: 5’6”
Vital Signs: T 99, P 80, R 20, BP 122/74, stable
Mental Status: Alert and oriented
Allergies: NKA
NPO: Yes, since midnight
Current Meds: Stomach pills, Tagamet
History and Physical

Date: 3/10 (performed in office)
History of Present Illness: 59-year-old male with abdominal pain,
unresponsive to H2 blockers
Past Medical History: Periodic high blood-pressure readings
Medications: Tagamet, Dicyclomine
Allergies: NKA
Examination:
General: Well-developed, well-nourished male in minor distress.
HEENT:
No gross lesions noted. Pupils round and equal. No icterus. Neck supple, trachea
midline. Negative soft tissue swelling. Oropharynx negative. Soft tissues within
normal limits.
Heart: Regular rate and rhythm. EKG showed normal sinus rhythm
Lungs: Clear to auscultation
Abdomen: Soft, tender to touch
Extremities: No clubbing, cyanosis, or edema
F:\MEDICAL CODING\To Copy/Exam Case Study1
Rectal: Deferred
Impression: Abdominal pain, possible ulcer
Pre-procedure Diagnosis: Abdominal pain, rule out ulcer

Orders:
1. Set up EGD and possible flexible sigmoidoscopy at ambulatory surgery

2. NPO after midnight day of procedure

OPERATIVE REPORT

Date of Procedure: 3/14
Procedure: Esophagogastroduodenoscopy and flexible sigmoidoscopy
Preoperative Medication: Preop Demerol 50 mg, Vistaril 50 mg, Atropine .4 mg,
Versed 4 mg given by the anesthesiologist
Preoperative Diagnosis:
Abdominal pain, possible peptic ulcer disease. Patient has upper abdominal pain,
unresponsive to H2 blockers.
Postoperative Diagnosis:
F:\MEDICAL CODING\To Copy/Exam Case Study1 Findings:
Endoscopy was performed with the Olympus video panendoscope, which was
easily introduced into the esophagus. This was normal to the proximal midportion
of the esophagus, but at the GE junction, there was evidence of a moderate
degree of reflux esophagitis with several small superficial erosions at the location
and also isolated erosions several centimeters above. The endoscope was
advanced into the stomach and turned in a retrograde direction. The cardiac and
fundic areas were examined and found to be otherwise normal. The antrum
showed normal peristalsis and mucosa. In the immediate prepyloric area, there
was a small defect that was thought to represent scarring from previous ulcer,
which was still healing. Biopsies were obtained. The duodenum, including the
second portion, was normal. Subsequently, the endoscope was withdrawn. The
patient turned on his left side. Flexible sigmoidoscopy was then carried out to the
lower descending colon. A biopsy of the sigmoid was obtained. Patient tolerated
the procedure well.
ENDOSCOPY ORDERS

3/14:
Admit to ambulatory surgery, endoscopy area
Obtain consent for procedure, sign, and witness
Start IV of 55 cc D5W or NS TO KVO or heparin lock.
Preoperative Medications: Vistaril 50 mg IM, Demerol 50 mg IM, atropine .4 mg
IM
3/14:
To Recovery
Give soft diet
Discharge at 12:30 p.m.
F:\MEDICAL CODING\To Copy/Exam Case Study1 EXAMINATION ANSWER SHEET

DIAGNOSES ICD-9-CM CODES
DX1


PROCEDURES CPT CODES
F:\MEDICAL CODING\To Copy/Exam Case Study1

Source: http://www.mlcoleman.com/web/procedural_coding/session10_ops_report/weeklychallenge.pdf