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act like a coder Upper Intestinal Endoscopy with Biopsy Patient Name: DOB: Date of Surgery: Surgeon(s): Edwin Liu, M.D. Assistant(s): Shelly Rustagi, MD Preoperative Diagnosis: Eosinophilic esophagitis Postoperative Diagnosis: Same Title of Procedure: Upper Intestinal Endoscopy with Biopsy Anesthesia: General anesthesia with natural airway, nasal cannula, propofol Indications: This is a 4 year old with a history of eosinophilic esophagitis Findings: Mild edema of mid esophagus otherwise visually normal upper endoscopy Description of Procedure: The risks and benefits of the procedure were reviewed with parents of patient and informed consent was obtained. A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. underwent satisfactory anesthesia as described above. The Olympus GIF Q180 endoscope was introduced under direct visualization and advanced into the esophagus. The esophageal mucosa was mildly edematous in mid esophagus, otherwise visually normal. The lower esophageal sphincter was located 26 cm from the mouth. The stomach appeared normal. Retroflexion appeared normal. The duodenum was intubated and appeared normal. Biopsies were taken from the duodenum, antrum , body, distal esophagus and proximal esophagus for histology. Urease testing was not performed. The endoscope was readvanced to the stomach, which was suctioned of all contents, and then withdrawn. The patient was allowed to awaken from anesthesia. ( Printed by [113902] at 8/14/14 10:37 AM Page 4 Operative Notes Op Notes (continued) Op Note by Liu, Edwin at 7:59 AM (continued) Edwin Liu, M.D. was present for and supervised the entire procedure. Estimated Blood Loss: Less than 5 ml Specimens: duodenum, antrum, body, distal esophagus, proximal esophagus Complications: None known Drains: None Shelly Rustagi, MD Fellow of Pediatric Gastroenterology, Hepatology, and Nutrition I was present for and supervised the entire procedure. Edwin Liu, MD Associate Professor of Pediatrics Digestive Health Institute Box B29 What is the first-listed diagnosis? K21.0 K20.8 K20.0 K20.9 Given that you identified the correct first-listed diagnosis in question number 1, assign the correct ICD-10-CM secondary diagnoses and CPT codes with the proper sequencing R60.9, Z91.012, Z910.010, 43238 *Z91.012, Z91.018, 43239 R60.9, Z91.012, Z91.018, 43238 Z91.012, Z91.010, Z91.018, 43239 Which of the following provides macroscopic information about tissue removed during an operative procedure? Laboratory report Anesthesia report Operative report Pathology report

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