Submit an Encounter to “Can You Code It?”
Submit an Encounter to “Can You Code It?”
Fill in the following form to submit a sample medical procedure or encounter to be added to the “Can You Code It?” section of this website.
If your submission contains all the necessary information to provide our visitors with enough to properly code the encounter, our team will add it to the archive for everyone to respond, code it and comment.
Submit an Encounter to “Can You Code It?”
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Documented Diagnosis: Acute Appendicitis.
Documented Procedure: Laparoscopic Appendectomy
Your Encounter Documentation:
“A 33 year old man visits the emergency department complaining of pain in his right lower abdomen. I spoke with the patient preoperatively regarding the goals, benefits, and risks of surgery. All of his questions were answered.
He then received preoperative antibiotics, heparin, and bilateral lower extremity SCDs prior to induction with general anesthesia. Once the patient was asleep, his left arm was tucked to the side. Care was taken to appropriately pad the ulnar nerve. The abdomen was prepped and draped in standard fashion. Time out was performed verifying the correct patient for the procedure.
The procedure was begun by making a 10mm incision just below the umbilicus. Dissection was carried down to the anterior sheath fascia which was elevated with Kochers and divided with electrocautery.
Posterior sheath was elevated with tonsils and divided with Metzenbaum scissors and then 0 Vicryl sutures were placed in the fascia. Hasson trocar was introduced into the abdomen and the abdomen insufflated easily. Two 5 11 ports were placed, 1 in the left lower quadrant and 1 in the suprapubic position, both under direct vision.
Upon entering the scope into the abdomen, the patient appeared to have previous inflammation above the liver and tenting up the gallbladder and previous inflammation at the midpoint of the colon. These bands looked suspicious for perhaps prior episode of Fitz-Hugh-Curtis syndrome and the bands were left in place. I identified the appendix and it was obviously inflamed. I dissected out the mesoappendix away from the base of the appendix. An Endo-GIA purple load was fired across the base of the appendix and a gold load was fired across the mesoappendix.
The appendix was then bagged and removed. There was no evidence of perforation of the appendix. I then inspected the staple lines. There was some minor oozing from them and 10mm clips were applied to the points of oozing and the oozing stopped. I laid some surgicel over the top of the staple lines. The 5 11 ports were then removed under direct vision. There was no evidence of bleeding. The 10 mm port was then removed. The abdomen was desufflated and the fascia repaired with 0 Vicryl sutures. Skin was numbed with 0.25% Marcaine with epinephrine.
The skin was then reapproximated with 4-0 Monocryl sutures. Steri-strips and sterile dressings were applied. The patient was awoken and transported to recovery in stable condition.”
The above sample contains enough information to be properly coded by visitors, please make sure you provide enough information for us to add your encounter to the archives.
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