How to Answer Location Outpatient Hospital Questions (Complete Guide)

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Original Question

LOCATION: Outpatient, Hospital PATIENT: Jerry Fulcrum ATTENDING PHYSICIAN: Ira Avila, MD SURGEON: Ira Avila, MD PREOPERATIVE DIAGNOSIS: Hypospadias with chordee and right hydrocele. POSTOPERATIVE DIAGNOSIS: Hypospadias with congenital chordee and right hydrocele. PROCEDURE PERFORMED: Right hydrocele repair and one-stage repair of hypospadias with preputialonlay flap. ANESTHESIA: General. CLINICAL NOTE: This 12-month-old male has a midshaft hypospadias with a very mild degree of chordee. He also has a persistent right hydrocele. PROCEDURE: The patient was given a caudal block as well as a general mask anesthetic. He was prepped and draped in the supine position. A right inguinal incision was made. The testicular cord was identified at the level of the external ring and delivered. The gubernacular fibers were divided with electrocautery. The hydrocele sac was opened, and the partial end of it was resected and then bottled behind the testicle using 5-0 chromic. There was no evidence of communication of the hernia. The testis was then returned to the scrotum. The subcutaneous tissue was closed with 5-0 chromic and the skin with 5-0 subcuticular plain. Steri-Strip was applied. The hypospadias was then addressed. The patient was catheterized using a #8 French feeding tube. The first step following this was to mobilize the hooded foreskin. This was isolated on its own pedicle. Then the urethral meatus was circumscribed using the Beaver blade. Once the penile shaft skin had been mobilized, there was very minimal chordee. I did not believe it was necessary to remove the dorsal urethral plate from the region of the coronal sulcus. Saline erection was performed that showed a good straight penis without evidence of significant chordee. The glans was incised and mobilized. The flap was then prepared and sutured to the dorsal urethra with 6-0 PDS. A mucosa-running stitch was used, and an interrupted second layer also was utilized. The glans was then further mobilized, rotated around behind and over the urethra, and secured with 5-0 Vicryl sutures. The prepuce was reanastomosed to the penile skin and the midline defect in the shaft skin closed with Vicryl suture. I had a good cosmetic appearance at the end of the procedure. The #8 French catheter was not tight on the anastomosis. It could be introduced without difficulty. A Prolene stitch was placed through the glans, and the #8 French feeding tube was cut and secured as a stent. Vaseline and Coban dressing were applied to the penis. The patient tolerated the procedure well and was transferred to the recovery room in good condition. CPT Code(s):_________________________ ICD-10-CM Code(s): ____________________ Abstracting Questions: 1. Does the stage of the repair affect the code assignment? 2. Does the type of flap repair affect the code assignment? 3. Was the hydrocele excised or repaired? 4. Are any of the diagnosis codes affected by the gender of the patient? 5. Is the chordee diagnosis code for an acquired or congenital condition?

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