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Cpc Icd-9-Cm Coding

By | April 2013
Page 1 of 4
1. A 54-year-old patient is seen by the physician in the outpatient clinic setting for CLL that is currently in remission. The patient's WBC counts, particularly lymphocytes remain within normal limits 2. Susan Oster, 45, is admitted to the hospital with a temperature of 38.5º C, heart rate 102 beats/min, respiration 20/min with septicemia and SIRS. WBC 12,500. Documentation states respiratory and acute hepatic failure are due to septicemia. 3. OPERATIVE REPORT

PATIENT: Mara Bell Lee
PHYSICIAN: Randy Greenfield,
MD PREOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause. POSTOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause. PROCEDURES PERFORMED:
Diagnostic thoracentesis.
Four-quadrant pleural biopsy,
Pleural drainage with small catheter temporary chest tube.
PROCEDURE: With the usual Betadine scrub to the area marked by ultrasound, the area was anesthetized with approximately 15 cc of 1% lidocaine, and then a small-caliber #21-gauge needle was inserted into the space. Fluid was removed for appropriate bacteriological, hematological, and chemical analyses.Once this was accomplished, then a larger tube using a Cope pleural biopsy needle was inserted into the space, and four quadrants were biopsied and sent for appropriate pathological specimens. Once that was accomplished, then using a small-caliber temporary chest tube from the Cope, as well as the pneumothorax set, the space was entered, and 1.5 liters of bloody fluid was removed. A small bandage was attached afterward. There was no pain involved, and the chest x-ray will be taken afterward to assure ourselves that we had a reasonable effect without any ill consequences. PATHOLOGY REPORT PATIENT: MaraBell Lee

PHYSICIAN:Randy Greenfield, MD CLINICAL HISTORY: Pleural effusion.GROSS DESCRIPTION: 1650 ml bloody fluid received in two glass Vacutainers.SPECIMEN RECEIVED: Pleural fluid.SPECIMEN ADEQUACY: Specimen satisfactory for cytologic evaluation.DIAGNOSIS: No cytologic evidence of...
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