A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 5.docx

A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 5: INTERMEDIATE INPATIENT HOSPITAL CODING MATCHING Directions: Identify the portion of the medical record in which the following statements would MOST likely be found. QUESTIONS ANSWERS 2HR GLUC H 131 Ref 64-112. D Left ventriculography is performed in the RAO projection and is recorded on 35-mm film. G Perineum normal. B On day 3, blood cultures were drawn and antibiotics were switched to Ancef. F Length of stay 6 days. J Unremarkable except for father with Parkinson’s disease. A Estimated blood loss: Less than 25cc. E Postpartum tubal ligation. Pomerov type. I Showed no cyanosis, clubbing, or edema C Portable AP supine view of the chest demonstrates a Swan-Ganz catheter directed out the right pulmonary outflow tract. H CHOICES: Family history Pelvic exam Extremities exam Laboratory report Operative report description Discharge summary Cardiac catheterization laboratory report Radiology report Operative report procedure performed Face sheet MULTIPLE CHOICE Directions: Select the word or phrase that best completes each sentence or best answers the question. QUESTION ANSWER UHDDS defines _____ as performed for definitive treatment rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication. Principal diagnosis Principal procedure Postoperative diagnosis Significant procedure B As of October 1, 2015, inpatient hospitals will report procedures using which code set? CPT ICD-10-PCS ICD-10-CM ICD-9-CM, Volume 3 B What is the main basis for determination of payment to acute care inpatient hospitals under the prospective payment system? POA indicator Complications Principal diagnosis Principal procedure C UHDDS defines _____ as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. principal diagnosis present on admission indicator comorbidity principal procedure A UHDDS defines a _____ as an additional diagnosis describing a condition that arises after the beginning of hospital observation and treatment that modifies the course of the patient’s illness or the medical care required. principal diagnosis secondary diagnosis comorbidity complication D What is the principal diagnosis for the following inpatient encounter? “Patient was admitted with right lower abdominal pain and an elevated white cell count. The physician documents acute appendicitis with an open appendectomy.” Lower abdominal pain Elevated white blood cell count Acute appendicitis Open appendectomy C UHDDS defines ______ as all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or the length of stay in the hospital/facility. POA indicators complications principal diagnoses secondary diagnoses D UHDDS defines ____ as pre-existing conditions present at time of admission that, because of their presence, increase the patient’s length of stay or resources required to treat the patient. comorbidities complications POA indicators principal diagnoses A What are the correct diagnosis codes and sequencing for the following scenario? “A patient with hypertension (HTN) was admitted to the hospital for breast cancer of the upper-inner quadrant of the right breast. She was taken to the OR for a modified radical mastectomy. The day after surgery, she developed a urinary tract infection (UTI) and was given IV antibiotics before she was discharged home the following day.” C50.211, T81.4XXA, N39.0, I10 I10, N39.0, C50.211 C50.211, N39.0, I10 9T81.4XXA, N39.0, C50.211, I10 A The FIRST piece of documentation an inpatient should read is the _____. discharge summary history and physical operative report physician progress notes A What is the principal diagnosis for the following inpatient encounter? “Patient was admitted for dehydration and IV saline was ordered. The physician also ordered Lasix and a nebulizer treatment. Upon review of the history and physical you see that the patient has CHF and asthma.” CHF Asthma Dehydration Edema C What is the FIRST step in coding inpatient hospital encounters? Read the documentation and determine the principal diagnosis. Assign principal and significant procedure codes. Review the chart to ensure that all required documentation is present. Check the assigned MS-DRG. C The _____ was developed by the U.S. Department of Health, Education and Welfare in 1974 to ensure that all hospitals report a minimum set of data for all patient admissions and use uniform definitions when reporting that data. POA UHDDS MS-DRG ICD-10-CM B The final piece of documentation a coder should review is the: discharge summary. history and physical. operative report. physician progress notes. A What is the POA indicator for the following condition? “The day after surgery, the patient developed a urinary tract infection (UTI) and was given IV antibiotics before she was discharged home the following day.” Y N U W B Which guidelines does an inpatient coder NOT follow? ICD-10-CM OGCR CPT guidelines UHDDS guidelines Facility-specific guidelines B The UHDDS defines _______ as one which is surgical in nature, carries a procedural risk, carries an anesthetic risk, and/or impacts MS-DRG assignment. significant procedure principal procedure POA indicator principal diagnosis A UHDDS stands for: Universal Healthcare Diagnosis and Discharge Statistics. Uniform Hospital Discharge Diagnosis System. Uniform Hospital Data Discharge Set. Universal Healthcare Documentation Data Set. C The _____ on inpatient claims identifies whether a diagnosis code was present or not present at the time an order for an inpatient admission occurred. comorbidity POA indicator principal diagnosis secondary diagnosis B A facility policy may require coding of ____ _ for data reporting, even if they are hard coded in the chargemaster. wound debridement procedures deliveries IV insertions MRI scans D CASES Directions: Code the following cases for inpatient facility purposes using ICD-10-CM and PCS codes. Calculate the MS-DRG. Identify the principal vs. secondary diagnoses and procedures. Use external cause codes when appropriate. Do NOT code procedures that are captured by the facility chargemaster. Secondary diagnoses and procedures do not need to be sequenced in any particular order. Enter “None” when no code is required. 1. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 75-50-77 Age: 25 Gender: Female Length of Stay: 3 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Abdominal Adhesive Disease Laparoscopic Lysis of Adhesion with Biopsy DISCHARGE SUMMARY PATIENT: MARY INPATIENT RECORD NUMBER: 75-50-77 ADMITTED: 11-04-XX DISCHARGED: 11-06-XX PHYSICIAN: DR. ALEX, M.D. ADMITTING DIAGNOSIS: Persistent pelvic pain. DISCHARGE DIAGNOSIS: Abdominal adhesive disease, probable right salpingitis versus chronic interval appendicitis. HOSPITAL COURSE: The patient is a 25-year-old white female with persistent right lower quadrant pain. She underwent IV antibiotic therapy approximately 2½ weeks ago with incomplete resolution and subsequent return of her pain. She underwent laparoscopy, at which time adhesions of the right lower quadrant involving the cecum, appendix, small bowel, right ovary, fallopian tube, and omentum were encountered. Adhesiolysis was performed, appendectomy performed, right ovarian biopsy. She was maintained on IV antibiotics for 24 hours and subsequently discharged to home. The patient was discharged to home with instructions to follow up. She will be discharged with saline lock and maintenance to follow up in the emergency room tomorrow for an additional dose of Rocephin and have the saline lock discontinued at that time. She will continue of Vibramycin, 100 mg b.i.d., and follow up with me in the clinic in 1 week. Instructions were given on activities, bowel care and precautions. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 11-07-xx , 3343 HISTORY AND PHYSICAL PATIENT: MARY INPATIENT RECORD NUMBER: 75-50-77 ADMITTED: 11-04-XX DISCHARGED: 11-06-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Abdominal adhesive disease, probable right salpingitis versus chronic interval appendicitis. HISTORY OF PRESENT ILLNESS: This is a 25-year-old white female with a history of right pelvic pain. She had initial flare approximately three weeks ago and was given 5 days of IV antibiotic followed by a week of po antibiotic and had near but not complete resolution of her pain. It was associated with some GI complaints, though not notable. Ultrasound was performed which showed a generous sized right ovary consistent with oophoritis or normal variant. The patient is quite large. Appendix was not visualized. She is not status post-operative laparoscopy with lysis of adhesions, appendectomy, ovarian biopsy, and tubal dye perfusion. She tolerated it well but because of previous infection and likelihood of involved infection, she is kept for further antibiotic therapy. ALLERGIES: No Known Allergies MEDICATIONS: Proventil inhaler prn, Voltaren, 50 mg, one to two q. 6 hours, Lortab and Vibramycin. PAST HISTORY: She has chronic hypertension and obesity. She had a cesarean section in January of 1995. FAMILY HISTORY: Significant for malignancy of her father, specifics unknown, as well as some hypertension. SOCIAL HISTORY: She smokes greater than one pack per day, denies significant use of alcohol or recreational drugs. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/90. She is afebrile. GENERAL: Alert and appropriate. Skin is clear. HEENT/NECK: Unremarkable. LUNGS: Clear to auscultation with decreased pulmonary excursion secondary to habitus. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft. Bowel sounds are normal. Incisions are dry. EXTREMITIES: Unremarkable. GENITORECTAL: Unremarkable. IMPRESSION: Persistent right pelvic pain. RECOMMENDATIONS: Proceed with a laparoscopic evaluation. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 11-04-xx , 3343 OPERATIVE REPORT PATIENT: MARY INPATIENT RECORD NUMBER: 75-50-77 DATE OF SURGERY: 11-04-XX SURGEON: DR. ALEX, M.D PREOPERATIVE DIAGNOSIS: Persistent right pelvic pain. POSTOPERATIVE DIAGNOSIS: Abdominal pelvic adhesive disease. Chronic interval appendicitis versus chronic P.I.D. versus endometriosis. OPERATIVE PROCEDURE: Laparoscopy with lysis of adhesions. Right ovarian biopsy. Tubal dye perfusion. Appendectomy. INTRAOPERATIVE FINDINGS: The right ovary was large and boggy, approximately 6 cm. in greatest dimension. It was swollen, lacking superficial convolutions. The appendix was involved with fat wrapping and adhesions to the pelvic brim, which also included distal right fimbria, large and small bowel, as well as omentum. The left ovary was normal size, consistency, normal convolutions, stigma of ovulation. Left fallopian tube was normal as was the uterus, vesicouterine plicae, and peritoneum of the pelvis including the ovarian fossa bilaterally. Upper abdominal sweep was unremarkable. DESCRIPTION: With patient under general anesthetic and in dorsal lithotomy position, suitably prepped and draped with bladder drained with straight catheter, a Kroner uterine manipulator was placed. A pneumoperitoneum was created and trocar placed. Additional trocars in the suprapubic bilateral space were placed under direct visualization. The upper abdominal sweep showed findings as listed at the right pelvic brim. The patient was placed in gentle Trendelenburg and left tilt. Adhesiolysis was carried out until the base of the appendix was freed. The right fallopian tube was also freed, as was the right ovary. A right ovarian wedge biopsy was carried out and specimen submitted. An Endo-GIA was used to perform an appendectomy with sharp and blunted adhesiolysis to the appendiceal stump and a single white endostaple placed across the appendiceal stump. Hemostasis was immediate. Copious irrigation was undertaken. Additional adhesiolysis was performed involving the large and small bowel. The left ovary and remainder of pelvis was visualized and peritoneum again was noted to be normal. No alterations or distortions of the superficial vasculature. No scarring throughout the cul-de-sac, anterior vesicouterine plicae. Tubal dye perfusion was then performed and easy spill noted bilaterally. Irrigation was again carried out. Inferior trocars were removed and remained hemostatic. Abdominal trocar was removed. Pneumoperitoneum was allowed to escape. Sutures were placed in the fascia on the 10 or greater trocar sites and subcuticular stitches of 4–0 un-dyed Vicryl used to approximate the skin. Instrumentation was removed from the vagina. Dressings were applied. Patient was taken to the recovery room in stable condition. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 11-04-xx, 3343 PATHOLOGY REPORT PATIENT: MARY INPATIENT RECORD NUMBER: 75-50-77 ADMITTED: 11-04-XX PHYSICIAN: DR. ALEX, M.D OPERATION: Laparoscopy with lysis of adhesions, right ovarian biopsy, tubal dye perfusion, and appendectomy. GROSS DESCRIPTION: The tortuous appendix is 11 cm in length, 5 mm in width and blends with abundant mesoappendix. The serosal surface of the appendix is smooth; the wall is firm; the lumen contains firm brown fecal material. The specimen labeled ovarian biopsy consists of two irregular portions of light grey or dark red hemorrhagic tissue, the larger 25 x 10 x 5 mm. MICROSCOPIC DESCRIPTION: The entire appendix was examined microscopically and there is no evidence of an acute, sub-acute appendicitis. There is also no evidence of a periappendicitis such as one might expect to find in pelvic inflammatory disease. The ovarian biopsy simply reveals normal ovarian stroma containing a few primordial follicles. DIAGNOSIS: 1. Appendix normal. 2. Segment, ovary, normal, right side. DR. PAT, M.D. Electronically authenticated by Dr. Pat, 11-05-xx, 4432 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: K66.0 SDx: K36, N73.6, N70.91, N73.1, N80.9, I10, E66.9, Z72.0 ICD-10-PCS procedure code(s): PPx: 0DNE4ZZ SPx: 0UN74ZZ, 0DTJ4ZZ, 0UB04ZX MS-DRG: 337 2. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 78-50-77 Age: 66 Gender: Female Length of Stay: 8 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Chest Pain Congestive Heart Failure DISCHARGE SUMMARY PATIENT: MARGARET INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-26-XX DISCHARGED: 12-03-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSES Chest pain, uncertain etiology, myocardial infarction was excluded (based on normal ECG, and normal LDH isoezymes obtained that were 2 days prior to admission). Consider gallbladder abnormality. Elevated liver function tests, which gradually fell through the hospitalization. Dyspnea with organic heart disease as noted above on the echocardiogram. I suspect that much of her dyspnea and congestive heart failure is due to diastolic noncompliance of the left ventricle, and feel that she should be on a calcium blocker to help this. Slow atrial fibrillation: I do not believe that she requires a pacemaker at this time. However, she is not a candidate for any kind of rate slowing drugs. (Procardia is utilized.) She did not receive any diuretics at all through this hospitalization, and maintained stable weight and good urine output. Renal insufficiency: Her renal function improved quite a bit during the admission. It was felt that her renal insufficiency is probably due to a combination of diuretics, Captopril and Voltaren. All of these were discontinued and she did well. Abnormal gallbladder with elevated liver function tests: This requires further follow up as an outpatient. DISCHARGE MEDICATION: Enteric aspirin 5 grains 1 q. day. Procardia XL, 30 mg 1 q. day. Pepcid 20 mg, 1 q. day. She is not to take any Bumex, Capoten, Cytotec, or Voltaren. She is to have a double dose oral cholecystogram 1 week from today. HISTORY: The patient is a 66-year-old female received here in transfer from critical access hospital following chest pain with subsequent renal insufficiency. LABORATORY DATA: The labs were obtained the day of admission at Harms Memorial Hospital. BUN 70, creatinine 1.6, glucose 136, uric acid 9.2, total bilirubin 0.4, alkaline phosphatase 214, SGPT 108, SGOT 28, LDH 158, GGTP 292, sodium 144, potassium 4.7, cholesterol 300, triglycerides 403. Daily CMP’s were obtained. On second day of hospitalization, lab pertinent values showed BUN 60, Creatinine 1.3, Alk. Phos. 187, SGPT 83, GGTP 256. Third day of hospitalization labs were BUN 57, creatinine 1.2, alk. phos. 191, SGPT 75, GGTP 252, and on fourth hospitalization day, Glucose 134, Bun 47, creatinine 1.1, uric acid 75, alk. phos 180, SGPT 62, SGOT 25, LDH 139, GGTP 236, albumin 3.7, sodium 144, potassium 4.4, cholesterol 295, triglycerides 285. ELECTROCARDIOGRAM: Slow atrial fibrillation. Otherwise, this is unchanged. RADIOLOGIC STUDIES: Gallbladder ultrasound that showed echodensity within the gallbladder consistent with a polyp, slow flowing sludge, or even an adenoma or carcinoma. The wall thickness was normal and there was no dilatation of the intrahepatic biliary tree. The common duct is a little enlarged at 6.5 mm. There appeared to be no stones. An oral cholecystogram is recommended in follow up. A double dose oral cholecystogram was performed and was non-visualizing. Chest x-ray showed cardiomegaly with a globular configuration and pulmonary venous distention consistent with congestive heart failure. Ventilation perfusion lung scan was normal. Echocardiogram showed a small vigorous left ventricle with concentric left ventricular hypertrophy. There is moderate bi-atrial enlargement and probable atrial septal defect. The right ventricle is of normal size and systolic performance. There is mild aortic valve sclerosis with no stenosis or insufficiency. There is no pericardial effusion. HOSPITAL COURSE: The patient is admitted to the hospital and multiple tests are obtained. She is initially treated only with oxygen, Pepcid, and aspirin. Procardia XL 30 mg daily was initiated on day one of hospitalization. As noted above, her renal function continued to improve on a daily basis. Her blood sugars were also followed and remained between 115 and 157 throughout the hospitalization on Accu-Cheks. Her blood pressure during the first part of the hospitalization ranged around 100 to 135/70. Toward the latter part of the hospitalization it slowly rose. On the day of discharge, it was 150/80 with a pulse of 50 and respiration of 18, afebrile. Her cardiac telemetry showed slow atrial fibrillation with rate in the high 40s and low 50s for the most part. During the night she does slow somewhat and has pauses, but these are only when she is asleep, and are asymptomatic. They are not excessive. The patient had no chest pain or dyspnea, and felt well. DISPOSITION: She is to have a double dose oral cholecystogram after discharge from the hospital. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, on 12-05-xx, 4434 HISTORY AND PHYSICAL PATIENT: MARGARET INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-26-XX DISCHARGED: 12-03-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female received in transfer today from a critical care hospital for evaluation of recent episode of chest pain with subsequently no insufficiency. The patient has a long history of suspected heart disease. She reports having had MI’s 24 years ago and 12 years ago. These are nondocumented. She has a 20-some year history of substernal dull chest pain, relieved in part with nitroglycerin or isordil. It also comes on with exertion, at rest, and occasionally at night. This was increasing quite a bit about 5 years ago. She was tried on calcium blockers and seemed to have some benefit accrued from those. Echocardiogram showed bi-atrial enlargement with concentric LVH, good LV function, and possible ASD. Because of these findings, she had a right and left heart catheterization done five months ago. Oximetry series in the right heart was grossly normal. The green dye curve showed no evidence for a left to right shunt. Pulmonary artery pressure 50/20, mean 32. Right atrial pressure 11, pulmonary wedge pressure is 22 with a 16–18 mm V-wave. The left ventricular and diastolic pressure is 18. Left ventriculogram is normal. There are no aortic or mitral valve gradients. Selective coronary artery angiography is essentially normal with a few minimal irregularities, less than 25%. These are seen in the right coronary artery. The patient since then has really done fairly well until 2 days ago while driving, she had the abrupt onset of dyspnea, flushing a hot feeling, marked diaphoresis, and near syncope. This was associated with moderately severe left sub mammary, hard chest pain that was somewhat pleuritic. She says it is the first time she has ever had a pain like this. Altogether, it lasted about 60 minutes. She has not had any since then. Up until then, she has been feeling fairly well recently. She has not been having much chest pain or dyspnea. She, however, on 11–18 had to increase her pillows at night on her bed from one to two pillows because of orthopnea. She has had no edema, paroxysmal nocturnal dyspnea, or change in her exertional dyspnea. She has no palpitations, light-headed spells, near syncope, or syncope. DRUG ALLERGIES: She is allergic to Penicillin, Sulfa, Methylate, and Tylenol. MEDICATIONS: Bumex 0.5 mg, two tablets q. day, Capoten 12.5 mg ½ tablet tid, Quinine one tablet prn for leg cramps, Darvon prn, Voltaren 75 mg bid (sometimes she takes it tid), Cytotec one tablet bid-. Previously she had been on Pepcid, but has not been taking any recently at home. She denies having remembered taking Prilosec. FAMILY HISTORY: Her mother died of an MI in her 60s. REVIEW OF SYSTEMS: The patient’s past review of systems is remarkable for a long history of atrial fibrillation. She has not smoked in many, many years. She has a 20-year history of hypertension. She has a long history of hyperlipidemia. She has been massively obese in the past and has weighted as much as 300 lbs. The patient has been a diabetic for a number of years, and has been on insulin off and on since the early 1980s. She has had distant deep venous thrombosis. She has had a venous stripping in her legs in the past. She had a history of gout, manifested as podagra. She has had DJD in the right knee. She has a peripheral sensory neuropathy, but no other complications of her diabetes particularly. She has a history of reactive depression. She has a history of episodic cutaneous candidiasis, and varicose veins and previous history of cystitis. She has nocturnal leg cramps for which she takes Quinine. The patient was in the hospital 4 months ago with fever, back pain, and Staphylococcal septicemia and septic knee. At that time, she had marked renal insufficiency of acute onset. This seemed to resolve following cutting back on her Capoten and Lasix, as well as with treatment of her septicemia. Her sodium at that time fell to a low of 117. Her BUN rose to a high of 101. Her creatinine rose to 2.4. Her potassium rose to a high of 7.4. PHYSICAL EXAMINATION: Blood pressure 115/65, pulse 61, respirations 16, afebrile. No jugular venous distention with few bi-basilar rales. Skin is warm and dry. Heart: S1, S2, within normal limits, with a Grade 1/6 systolic ejection murmur at the left upper sternal border. She has minimal, if any, change in a mildly split S2 with respiration. Abdomen is remarkable for mild epigastric tenderness. She is quite obese. There is no peripheral edema. DIAGNOSTIC STUDIES: ECG is stable, showing slow atrial fibrillation with a rate from about 42 to about 60. PA and lateral chest x-ray shows pulmonary venous distention with Kerley B lines, and cardiomegaly. The configuration is globular. Ventilation-perfusion lung scan done here is basically normal. LABORATORY DATA: Admission bilirubin 2.5, alk phosphatase 203, amylase 29, SGOT 295, LDH 376. Urinalysis shows 4–6 white cells and 2–4 red cells. Glucose 139, BUN 4.5, creatinine 1.4, chloride 101, CPK 111, LDH 271, sodium 149, potassium 4.6. Subsequent CKs are normal. Blood gas on admission on room air pH 7.42, PC 2 35, PO2 63, bicar 26, saturation 92%. Strep screen is normal. Protime 12.6. Repeat SGOT is 594 with CPK of 75, LDH 727. White count on admission 6,900, Hgb. 12.7, MCV 85, platelets 139,000. Repeat labs: Glucose 146, BUN 60, creatinine 2.0, total bilirubin 0.7, SGOT 53, LDH 163, CPK 45, cholesterol 281, triglycerides 313, sodium 144, and potassium 5.3. Repeat labs: Glucose 135, BUN 80, creatinine 2.8, sodium 142, and potassium 6.1. That was at 7:15 a.m. Repeat labs later on in the day: Sodium 141, potassium 5.5, BUN 78, creatinine 2.2, glucose 167, white count 8,500, Hgb. 12.6, platelets 147,000. LD isoezymes are received. The patient’s first three LDHs were 271, 727 and 376. In each case, the ratio of LD1 to LD2 is 0.6. Percent of LD5 rose from 28% on the first, 61% on the second and then fell to 50% on the third. These are all felt to be not reflective of myocardial ischemia, but do show an elevation predominantly due to LD 5. IMPRESSION: 1. Recent episode of chest pain, dyspnea, and diaphoresis: Myocardial infarction is excluded with normal LD, CKs and serial ECGs. There was a clear rise in LDH predominantly from LD5 isoenzyme, as well as a transient marked rise in SGOT. Admission blood gas is normal and current ventilation-perfusion lung scan is normal. I suspect pulmonary embolism is not particularly likely. Etiology remains unclear. 2. Renal insufficiency: the patient’s BUN and creatinine clearly went up (with treatment with Captopril, Bumex and Voltaren) and appeared to be a little better this morning. Will follow patient on this process. 3. Chronic diabetes. 4. Severe hyperlipidemia. 5. Possible ASD on previous echocardiogram, but not substantiated on previous heart catheterization. 6. Elevated filling pressures felt due to diastolic stiffness of the left ventricle, with normal left ventricular systolic performance. 7. Normal coronary arteries in 1986 with borderline elevation of right heart pressures, felt secondary to the elevated wedge. RECOMMENDATIONS: Admit for careful observation and treatment as needed. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, on 12-03-xx, 4434 RADIOLOGY REPORT PATIENT: MARGARET INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-26-XX DISCHARGED: 12-03-XX PHYSICIAN: DR. ALEX, M.D. CHEST X-RAY HISTORY: Acute renal failure with shortness of breath. CHEST: The heart is enlarged. It appears quite globular in its configuration. Pulmonary venous distension is present with peribronchial thickening and diffuse thickening of the interstitium with Kerley B lines. These findings are all consistent with congestive heart failure. The heart configuration is somewhat globular and may suggest pericardial effusion. IMPRESSION: 1. Congestive heart failure. RADIOLOGY REPORT PATIENT: MARGARET INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-26-XX DISCHARGED: 12-03-XX PHYSICIAN: DR. ALEX, M.D VENTILATION/PERFUSION LUNG SCAN HISTORY: Congestive heart failure. V/P LUNG SCAN: The patient was administered 11.8 mCi of Xenon-133 gas by inhalation. Single breath, equilibrium and washout images were obtained. The patient was then injected with 3.94 mCi of 99mTc MAA. Orthoganal and both posterior oblique images of the lungs were obtained. The ventilation study shows a diffuse homogeneous distribution of radiopharmaceutical without ventilation defects. No significant air trapping is noted. The perfusion study shows diffuse homogeneous distribution of the radiopharmaceutical throughout all lung fields without segmental or subsegmental defects. There are several areas of increased radiopharmaceutical deposition and these probably represent small clumps of the radiopharmaceutical, which is usually related to MAA preparation and may range from increased amount of aluminum to a poor mixing of the albumin. IMPRESSION: Basically normal ventilation/perfusion lung scan. DR. RAY, M.D. Electronically authenticated by Dr. Ray, 11-28-xx, 34455 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: R07.9 SDx: K82.9, R79.89, I50.1, I50.30, I48.91, N28.9, I10, E78.5, E11.40, G47.62, Z88.0, Z88.2, Z88.6, Z88.8, Z82.49 ICD-10-PCS procedure code(s): PPx: None SPx: None MS-DRG: 313 3. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 78-50-77 Age: 59 Gender: Male Length of Stay: 4 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Cholelithiasis Cholecystitis Total Cholecystectomy DISCHARGE SUMMARY PATIENT: PETER INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-15-XX DISCHARGED: 11-19-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Cholelithiasis. Acute and chronic cholecystitis. Gallbladder adhesions. Allergic reaction to anesthesia. PROCEDURE: Total cholecystectomy/ Failed attempt laparoscopic cholecystectomy. REASON FOR ADMISSION: The patient is a 59-year-old Caucasian male who was admitted for cholecystectomy for cholelithiasis and cholecystitis. The patient had no admitting lab or x-ray; it had all been done as an outpatient and was all normal. HOSPITAL COURSE: The patient was taken to surgery where an attempt was made at laparoscopic cholecystectomy. This could not be accomplished because of severe adhesions and an inability to distinguish anatomy in the area. The patient, therefore, underwent an open cholecystectomy. His postoperative course was complicated by an allergic reaction to the anesthesia. The patient had shortness of breath and urticaria all over his body. The patient was treated immediately for the allergic reaction and responded well. By the next morning, the urticaria and shortness of breath had resolved. He is being discharged to be seen in follow up in my office in one week DISCHARGE INSTRUCTIONS: Discharge diet is regular. He may participate in activity as tolerated except for heavy lifting or straining. The patient is sent home with same medications as previously taken. He may bath or shower and pat his incision dry. The patient is to report any nausea, vomiting, diarrhea, fever, or chills, redness or swelling of his incision. He is not to drive if he takes pain pills. The patient is being discharged in the care of his wife who is capable of taking care of him. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D. 11-21-xx 467 HISTORY AND PHYSICAL PATIENT: PETER INPATIENT RECORD NUMBER: 78-50-77 ADMITTED: 11-15-XX DISCHARGED: 11-19-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old Caucasian male who has had known gallbladder disease for the last 8 years with multiple episodes of severe right upper quadrant pain with penetration through to the back accompanied by diarrhea and belching. He has also had intolerance of fatty foods. Symptoms have been getting progressively worse and he is now being admitted for a cholecystectomy. PAST MEDICAL HISTORY: Usual childhood diseases. Medical diseases: He had an MI approximately 14 years ago. No other medical diseases. Previous surgery was an appendectomy and a coronary artery bypass. He has had multiple small bone fractures. He denies any allergies. He has had no transfusions. DRUG ALLERGIES: None known. MEDICATIONS: He takes Lopressor, Pepcid and aspirin. FAMILY HISTORY: Mother is alive with diabetes and three MI’s. His father died of pulmonary embolism. No other history of familial diseases. SOCIAL HISTORY: The patient is disabled because of back problems. He is married. Does not drink or smoke. REVIEW OF SYSTEMS: Negative and noncontributory. PHYSICAL EXAMINATION VITAL SIGNS: GENERAL: Demonstrates a well-nourished, well-developed 59-year-old Caucasian male. HEENT: Normal. NECK: Supple. Trachea midline. Thyroid is normal. There are no nodes, masses or bruits in the neck. The supraclavicular and infraclavicular regions are clear. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Heart regular rhythm without murmur. S1, S2 are normal. No S3, S4. ABDOMEN: Soft. Bowel sounds are normal. No megaly, masses, hernias, bruits. SPINE: Straight. No CVA tenderness. RECTAL: Demonstrates a normal sphincter and no masses. EXTREMITIES, NEUROLOGICAL /VASCULAR EXAMINATIONS: Normal. IMPRESSION: Cholelithiasis and cholecystitis. RECOMMENDATIONS: Laparoscopic cholecystectomy. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D. 11-21-xx 467 OPERATIVE REPORT PATIENT: PETER INPATIENT RECORD NUMBER: 78-50-77 DATE OF PROCEDURE: 11-15-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Cholelithiasis with acute and chronic cholecystitis. POSTOPERATIVE DIAGNOSIS: Cholelithiasis and acute and chronic cholecystitis. OPERATIVE PROCEDURE: 1. Cholecystectomy with intra-operative cholangiography. 2. Lysis of adhesions. 3. Failed laparoscopic cholecystectomy. ANESTHESIA: General. DESCRIPTION: After adequate sedation, the patient was brought to the operating room and placed in the supine position on the operating table. Anesthesia was induced with intravenous Pentothal, endotracheal tube was passed and the patient was maintained on endotracheal anesthesia. After obtaining proper anesthesia, the patient was prepped and draped in the usual fashion. An infraumbilical incision was made, the Verres needle introduced, and satisfactory pneuma-peritoneum obtained. The 10 mm trochar was then placed through the infraumbilical incision and the camera introduced after which a second 10 mm and two 5 mm ports were placed. Laparoscopy was performed in the usual fashion and except for a large amount of adhesions to the gallbladder, no pathology was identified. Using sharp and blunt dissection an attempt was made to free the adhesions from the gallbladder. The patient’s colon was stuck in this area and in spite of an extensive attempt; it was felt unsafe to proceed any further trying to separate the colon from the gallbladder. It was therefore elected to do the procedure open. A standard subhepatic incision was accomplished, carried down through subcutaneous tissue. The anterior rectus fascia was divided with a knife, the rectus muscle with a Bovie. The posterior sheath and peritoneum were divided with a knife and the peritoneal cavity entered. Exploration of the peritoneal cavity was normal. The adhesions to the gallbladder were all carefully taken down after which cystic duct was identified. A clip was placed on its junction with the gallbladder and operative cholangiography performed in the usual fashion and read by the radiologist and myself as being normal. The gallbladder was then taken down in retrograde fashion. Hemostasis was obtained with a Bovie. The cystic artery was clipped twice proximally and once distally and then divided. The gallbladder was then excised. A 10 mm Jackson-Pratt drain was placed. The wound was irrigated with antibiotic solution. Hemostasis was checked and found to be satisfactory, after which the posterior sheath and peritoneum were approximated with continuous #1 Vicryl. The anterior sheath was approximated with continuous #1 Vicryl. The wound was irrigated with antibiotics, injected with Marcaine after which the skin was approximated with staples. Sterile dressings were applied. The patient experienced an allergic reaction to the anesthesia while in the recovery room. Approximately 5 minutes after arriving in recovery, the patient began to experience shortness of breath and allergic urticaria presented all over his body. This allergic reaction was immediately treated with immediate resolution of the respiratory issue. The urticaria had resolved by 9:00 a.m. the following morning. PATHOLOGY returned with diagnosis of cholelithiasis with acute and chronic cholecystitis. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D. 11-21-xx 467 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: K80.66 SDx: K82.8, T41.0X5A, L50.0, R06.02, Y92.234 ICD-10-PCS procedure code(s): PPx: 0FT40ZZ SPx: 0FN40ZZ, 0FJ44ZZ MS-DRG: 416 4. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 74-50-77 Age: 39 Gender: Male Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Chronic Sinusitis Left Caldwell-Luc Procedure DISCHARGE SUMMARY PATIENT: TIMOTHY INPATIENT RECORD NUMBER: 74-50-77 ADMITTED: 03-16-XX DISCHARGED: 03-!8-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Chronic left maxillary sinusitis. PROCEDURE: Left Caldwell-Luc procedure. HISTORY OF THE PRESENT ILLNESS: This 39-year-old has a long history of chronic pressure pain symptoms involving the left side of the face. He also has chronic cough and generalized malaise. He has been found to have a totally opacified left maxillary sinus, which has not resolved with prolonged and adequate medical treatment. He has misshapen sinuses bilaterally secondary to a congenital mid-face deformity. He is presently admitted for a left Caldwell-Luc procedure. HOSPITAL COURSE: The patient underwent Caldwell-Luc procedure for chronic sinusitis. Operative session was uneventful and the patient recovered rapidly and was ready for discharge on day two of hospitalization. There were no complications. DISCHARGE PLANS: Patient is sent home with prescription for pain control and follow up visit to the office in 2 weeks. Patient is to notify my office if complications arise and seek medical help immediately. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 8567 HISTORY AND PHYSICAL PATIENT: TIMOTHY INPATIENT RECORD NUMBER: 74-50-77 ADMITTED: 03-16-XX DISCHARGED: 03-!8-XX PHYSICIAN: DR. ALEX, M.D. HISTORY OF PRESENT ILLNESS: This 39-year-old has a long history of chronic pressure pain symptoms involving the left side of the face. He also has chronic cough and generalized malaise. He has been found to have a totally opacified left maxillary sinus, which has not resolved with prolonged and adequate medical treatment. He has misshapen sinuses bilaterally secondary to a congenital mid-face deformity. He is presently admitted for a left Caldwell-Luc procedure. PAST MEDICAL HISTORY: Otherwise reasonable benign. Patient takes Centrax occasionally for anxiety and is currently on Ceftin as an antibiotic. DRUG ALLERGIES: He denies any allergies. MEDICATIONS: Patient takes Centrax occasionally. Patient is currently taking Ceftin. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: GENERAL: Well-developed male in no acute distress. HEENT: Eyes are clear. Ear canals and drums are within normal limits. The nose reveals a nasal septal deviation with a spur deformity to the left, which is not obstructive to the nasal airway but may very well obstruct the middle meatus. Oral cavity is clear. NECK: Negative. LUNGS: Clear to percussion and auscultation. CARDIOVASCULAR: Regular rate and rhythm without murmurs or gallops. ABDOMEN: Benign. EXTREMITIES: Within normal limits. GENITORECTAL: Waived as clinically not necessary. IMPRESSION: Chronic left maxillary sinusitis. RECOMMENDATIONS: Caldwell-Luc procedure. The patient wishes not to proceed with nasal surgery for the septal spur. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 03-16-xx 54 OPERATIVE REPORT PATIENT: TIMOTHY INPATIENT RECORD NUMBER: 74-50-77 DATE OF SURGERY: 03-16-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Chronic left maxillary sinusitis. POSTOPERATIVE DIAGNOSIS: Chronic left maxillary sinusitis. OPERATIVE PROCEDURE: Left Caldwell-Luc. DESCRIPTION: The patient was brought to the operating room and induced into general oral tracheal anesthesia. He was positioned, prepped, and draped in the standard fashion. 1% Xylocaine with 1:2100, 000 epinephrine was infiltrated locally into the left sublabial canine fossa. 5% cocaine on cottonoids was placed in the nostrils bilaterally. A sublabial incision was made and carried down to bone. The antrum was entered with a gouge and mallet and the enterotomy was enlarged with a Kerrison rongeur. Sinus was full of extremely thick inspissated mucous, which required a pituitary forceps to remove, as it was much too thick to be suctioned. A culture was obtained. Interestingly, aside from a few very small sessile polyps along the left lateral wall, the sinus mucosa appeared reasonably healthy. A large nasal antral window was then created by egg shelling the bone over the medial wall of the sinus and creating an inferiorly based flap of nasal mucosa, which was turned into the sinus. Hemostasis was achieved with electrocoagulation. No packing was necessary. The sublabial wound was closed with interrupted 4–0 chromic. The patient tolerated the procedure well. His throat was thoroughly suctioned and he was awakened, extubated, and taken to the recovery room in satisfactory condition. There were no complications. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 03-16-xx 54 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: J32.0 SDx: J34.2 ICD-10-PCS procedure code(s): PPx: 09CR0ZZ SPx: None MS-DRG: 136 5. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 71-50-77 Age: 44 Gender: Female Length of Stay: 3 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Uterine fibroids. Total abdominal hysterectomy. Bilateral salpingo-oophorectomy. DISCHARGE SUMMARY PATIENT: MELISSA INPATIENT ADMITTED: 06-15-XX DISCHARGED: 06-17-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Uterine fibroids. PROCEDURE: 1. Total abdominal hysterectomy. 2. Bilateral salpingo-oophorectomy. HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old Gravida 1, Para 1, female who was noted to have an enlarged and irregular uterus on examination. The patient had an ultrasound, which confirmed that she had enlarged irregular fibroids. Alternatives for treatment have been discussed with the patient including continuing to watch this or a hysterectomy. The patient has noted that she has had pelvic discomfort for some time, which has gradually gotten worse and intensified in her back and seems to be cyclic and related to her menstrual periods. She had a hysteroscopy and dilatation and curettage 2 years ago for irregular bleeding and is scheduled now for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient understands that removing the ovaries will require estrogen replacement therapy. HOSPITAL COURSE: The patient underwent a total abdominal hysterectomy and bilateral salpingo-ooporectomy without complications. The patient’s hematocrit was slightly down after surgery but was not enough to warrant a blood transfusion. The patient’s hematocrit was watched over the next several days and was stable. The patient was able to be discharged on postoperative day two. DISCHARGE PLANS: The patient was provided discharge education and instructions regarding care after a total abdominal hysterectomy. The patient and family voiced understanding of instructions and discharge prescriptions. Patient is to return to my office for follow up visit six weeks post op or immediately if she experiences a fever or any other complications. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 856 HISTORY AND PHYSICAL PATIENT: MELISSA INPATIENT ADMITTED: 06-15-XX DISCHARGED: PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Patient presents with enlarged irregular uterus on examination. HISTORY OF PRESENT ILLNESS: This is a 34-year-old Gravida 1, Para 1, female who was noted to have an enlarged and irregular uterus on examination. The patient had an ultrasound, which confirmed that she had enlarged irregular fibroids. Alternatives for treatment have been discussed with the patient including continuing to watch this or a hysterectomy. The patient has noted that she has had pelvic discomfort for some time, which has gradually gotten worse and intensified in her back and seems to be cyclic and related to her menstrual periods. She had a hysteroscopy and dilatation and curettage 2 years ago for irregular bleeding and is scheduled now for a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient understands that removing the ovaries will require estrogen replacement therapy and she understands this. PAST MEDICAL HISTORY: No prior serious illnesses. She had a sinus surgery in the remote past and a hysteroscopy dilatation and curettage 2 years ago. She was diagnosed with thoracic outlet syndrome 2 years ago. When the patient underwent her sinus surgery, she did have a reaction to anesthesia and wound up going into pulmonary edema and was in the intensive care unit for several days. DRUG ALLERGIES: Sulfa and the reaction she had to general anesthesia in the past. MEDICATIONS: Effexor 75mg two daily and KCL tid, Moduretic and Ortho-Novum 1/50. FAMILY HISTORY: The patient’s mother died at age 79 with heart disease and her father died at age 54 from an aortic aneurysm. Mother also had colon cancer. Father also had hypertension. SOCIAL HISTORY: Rare alcohol and no tobacco or drugs. There is no history of domestic abuse. She works full time as an accountant. REVIEW OF SYSTEMS: Unremarkable. PHYSICIAL EXAMINATION: HEENT: Unremarkable. NECK: No thyromegaly or lymphadenopathy. CHEST: Clear bilaterally. CARDIOVASCULAR: Regular rate and rhythm with no murmurs. S1, S2, sounds are normal. BREASTS: No palpable masses. ABDOMEN: No palpable organomegaly or masses noted. GENITORECTAL: Pelvic exam shows the external genitalia, vagina, and cervix is normal. The uterus is retroflexed and very irregular at 12 - 14 weeks size. It is very prominent on the left and tender to palpation. Adnexal examination is unremarkable. Rectal exam is negative for guaiac. EXTREMITIES: Unremarkable. NEUROLOGIC: Unremarkable. DIAGNOSIS: Uterine fibroids. PLAN: Total abdominal hysterectomy and bilateral salpingo-oophorectomy. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21-xx 856 OPERATIVE REPORT PATIENT: MELISSA INPATIENT DATE: 06-15-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Uterine fibroids. POSTOPERATIVE DIAGNOSIS: Uterine fibroids. OPERATIVE PROCEDURE: 1. Total abdominal hysterectomy. 2. Bilateral salpingo-oophorectomy. ANESTHESIA: Spinal anesthesia. DESCRIPTION: Under adequate spinal anesthesia, a lower abdominal transverse incision was made with a knife to the level of the fascia and then continued with the scissors. Some hemostasis was obtained with cautery due to excessive subcutaneous bleeders. The fascia was divided and the muscles divided in the midline and peritoneum easily entered. An O’Connor-O’Sullivan retractor was inserted and the lower abdomen was explored. The upper abdomen was not explored as the patient only had spinal anesthesia. The lower abdomen appeared normal and the appendix was also normal. The uterus was retroflexed and there were multiple uterine fibroids. The adnexa bilaterally appeared essentially normal. The round ligaments were ligated on either side and divided and the bladder flap developed anteriorly. Pelvic ligament was isolated and clamped with curved Heaney clamp, divided, and doubly tied with 0-Vicryl suture. Uterine vessels were then clamped with curved Heaney clamp, divided, and tied with 0-Vicryl suture. Straight Heaney was then placed in each of the cardinal ligaments. These were then divided with a knife and tied with 0-Vicryl suture. Curved Heaney was then placed in each of the uterosacral ligaments and these were then divided with scissors and tied with 0-Vicryl sutures. A TA-55 stapler was then placed across the vaginal cuff below the cervix. The staple was applied and the cuff divided from the cervix with a knife. There was good excision of the cervix and good closure of the vaginal cuff. The pelvis was then re-peritonealized after typing the cardinal ligaments to the cuff in the midline. No bleeding was noted from any of the operative sites. The ureters appeared normal in peristalsis and caliber. The moist laps and retractor were removed and the parietal peritoneum then closed with 0-Vicryl running suture and the muscle was closed with interrupted 0-Vicryl suture and the fascia with 0-Monocril running suture. Subcutaneous tissue with 2–0 Vicryl running suture and the skin was closed with 2–0 Prolene running subcuticular stitch. Sponge count, needle count, and instrument count were correct. Blood loss was 200 cc. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21-xx 856 PATHOLOGY REPORT PATIENT: MELISSA INPATIENT DATE: 06-15-XX SURGEON: DR. ALEX, M.D. OPERATION: Total abdominal hysterectomy with bilateral salpingo-oophorectomy. GROSS DESCRIPTION: The specimen is received in formalin in one container labeled “uterus and ovaries” and consists of a 120.0 x 7.1 x 6.4 cm, 230 grams, uterus with contiguous cervix, as well as separate ovaries, each with its corresponding fallopian tube. The uterine serosa and ectocervical mucosa are pink-tan, smooth and reflective. The uterine fundus is misshaped by numerous subserosal and intramural tumors. The uterus is dissected into anterior and posterior halves revealing a patent endocervical canal and an endometrial cavity lined by a thin pink-tan mucosa. The cut surfaces of the cervix show few, small, submucosal cysts, up to 0.2 cm in diameter. The cut surfaces of the uterus show many, firm, off-white, circumscribed, submucosal, intramural, and subserosal tumors ranging from 0.2–3.2 cm. One ovary is 3.1 x 2.1 x 1.0 cm and its corresponding fallopian tube, 4.2 cm long and 0.5 cm in diameter. The other ovary is 2.5 x 1.9 x 0.9 cm and its corresponding fallopian tube, 4.6 cm long and 0.5 cm in diameter. The cortical surface of each ovary is firm, white-tan and somewhat convoluted. The tubal serosa of each tube is pink-tan, smooth and reflective. The fimbrias are intact. The cut surfaces of the larger ovary show a 1.3 cm cyst. The cut surfaces of the other ovary are unremarkable. The cut surfaces of each fallopian tube are unremarkable. Representative sections are submitted. Summary of sections: A- Anterior uterus. B- Posterior uterus. C- Anterior cervix. D- Posterior cervix. E- Largest leiomyoma. F/G- Ovaries and fallopian tubes. MICROSCOPIC DESCRIPTION: Microscopic examination is performed. DIAGNOSIS: 1. Uterus, cervix, right and left ovaries and fallopian tubes, hysterectomy with bilateral salpingo-oophorectomy. 2. Weakly proliferative endometrium. 3. Multiple benign leiomyomata, up to 3.2 cm in greatest dimension. 4. Atrophic ovaries, bilateral, one with corpus luteum cyst. 5. Histologically, unremarkable fallopian tubes, bilateral. Dr. PATH Electronically authenticated by Dr. Path, 06-22-xx 556 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: D25.9 SDx: Z88.2, Z88.9 ICD-10-PCS procedure code(s): PPx: 0UT90ZZ SPx: 0UTC0ZZ, 0UT20ZZ, 0UT70ZZ MS-DRG: 743