Week 2 Essays

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Question 1 Needs Grading LOCATION: Outpatient, Hospital PATIENT: Glory Ann Borden SURGEON: Mohomad Almaz, MD DIAGNOSIS:Right carpal tunnel syndrome PROCEDURE PERFORMED:Right carpal tunnel release PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal…show more content…
The head was shaved. The halo apparatus was applied with screws and four-points. Then the vest was applied. The patient was then discharged to the recovery room to have films taken in the recovery room. Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Josh Blake: ICD-9-CM: __________ ICD-9-CM: __________ ICD-9-CM: __________ (hint: this one is an E-Code!) Answer Selected Answer: 805.01 805.02 E819.0 Correct Answer: 805.01 (Fracture, vertebrae/vertebral, cervical, first [atlas] 805.02 (Fracture, vertebra/vertebral, cervical, second E819.0 (Accident, motor vehicle, driver) RATIONALE: Each fracture site would be coded separately. The C1 fracture would be coded with 805.01, and the C2 fracture with 805.02. As reported in the Indication section, this was an MVC of an unspecified nature, and the patient was the driver. E819 is the code for MVC of unspecified nature with the 4th digit of 0 to show the patient was driving. Question 4 Needs Grading LOCATION: Outpatient, Hospital PATIENT: Josh Blake SURGEON: Mohamad Almaz, MD PREOPERATIVE DIAGNOSIS: Fracture of CI, C2 POSTOPERATIVE DIAGNOSIS: Fracture of CI. C2 PROCEDURE PERFORMED: Placement of a halo INDICATION: Fracture occurred when the patient was involved in an unspecified motor vehicle collision. It is known that Mr. Blake was the driver of the vehicle.

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