Get Answer: Grading There Operative Question Guide

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Original Question

Grading: There are two operative reports that have been coded. You will be auditing the ICD 10 PCS codes for each of the two operative reports. Each audit is worth a potential of 10 points. Points in parentheses are for each step of the audit. A total of 20 points are available for the full assignment. Instructions for Operative Report #1 Audit the following ICD-10-PCS codes that were assigned by the coder for operative report #1: 0DBC8ZX, ODJD8ZZ Read each operative report and review the codes reported. Then place your answers in the space provided after the report. Accurate spelling and grammar will be considered in grading. Coding guidelines should be directly applicable to the case study. Avoid submitting generalized coding guidelines that can be applicable to any or all coding scenarios e.g., A11. Step 1-After reviewing the Operative Report #1, review the two codes to be audited and determine if each code is correct or not. Or indicate if the code should be deleted. If not, give the correct code. Do this for both codes. Place answer in the space provided after the Operative Report. (5 points) Step 2- In your own words, explain your rationale for the auditing decisions you made in Step 1. In your rationale you should be specific as to why you changed the code and indicate coding guidelines, PCS definitions, and concepts to support your decisions when they apply. Place answer in the space provided after the Operative Report. (5 points) Operative report #1 Procedure: Colonoscopy with possible polyp removal. Indication for Procedure: Evaluation (diagnostic) of a patient with a history of colon polyps. Preoperative Diagnosis: Patient with a history of colon polyps Postoperative Diagnosis:A small polyp was noted at the ileocecal valve. No other abnormalities of note on examination of the colon. History of colon polyps. Procedure Notes: After informed consent was obtained from the patient, the risks and benefits of the procedure were explained to the patient. The patient was placed in a left lateral decubitus position. The colonoscope (endoscope used for the colon) was passed to the cecum with adequate visualization. The cecum appeared normal. A .5 cm polyp was noted at the ileocecal valve. The polyp was small and benign in appearance and therefore was not removed at this time.The remainder of the ascending colon appeared to be normal as were the transverse, descending, and sigmoid colon. The rectum has internal hemorrhoids, not inflamed at this time. The colonoscope was withdrawn. The patient tolerated the procedure with no complications. The patient will follow up in the clinic and with a plan for future colonoscopy in 3 years unless symptoms present. PROVIDE THE ANSWER TO STEP 1 AND STEP 2

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