Cystoscopy urethral dilation and hydrodilation

HIM1126c Module 04 Coding Assignment This worksheet has a total of 30 possible points. 10 points are possible in the coding section using brief documentation and 20 points possible in the case studies section. Follow the instructions for each section of the worksheet. Build the correct ICD 10 PCS code based on the documentation in the Operative Report documentation given under each Case Study. 1. Case# 1 PREOPERATIVE DIAGNOSES: 1. Interstitial cystitis. 2. Urethral stenosis. POSTOPERATIVE DIAGNOSES: 1. Interstitial cystitis. 2. Urethral stenosis. Procedures: 1. Cystoscopy. 2. Urethral dilation and hydrodilation. Description of Procedure: Urethra was tight at 26-French and dilated with 32-French. Bladder neck is normal. Ureteral orifice is normal size, shape and position, effluxing clear bilaterally. Bladder mucosa is normal. Bladder capacity is 700 mL under anesthesia. There is moderate glomerulation consistent with interstitial cystitis at the end of hydrodilation. Residual urine was 150 mL. The patient was brought to the cystoscopy suite and placed on the table in lithotomy position. The patient was prepped and draped in the usual sterile fashion. A 21 Olympus cystoscope was inserted and the bladder, viewed with 12- and 70-degree lenses. Bladder was filled by gravity to capacity, emptied and again cystoscopy was performed with findings as above. Urethra was then calibrated with 32French. The patient was taken to the recovery room in stable condition. ICD-10-PCS Code: Click here to enter text. 2. Case #2 PREOPERATIVE DIAGNOSIS: 1. Atrophic left testis. 2. Right spermatocele. POSTOPERATIVE DIAGNOSIS: 1. Atrophic left testis. 2. Right spermatocele. PROCEDURE PERFORMED: 1. Right scrotal exploration, and right spermatocelectomy. 2. Left scrotal exploration and left orchiectomy. INDICATIONS: This 55-year-old gentleman was admitted to this Hospital approximately 4 months ago with bilateral testicular pain and swelling and enlargement. Ultrasound revealed a cystic mass of the right scrotum consistent with right hydrocele. On the left side, the patient had severe left epididymitis/orchitis that turned to an abscess with spontaneous drainage. Subsequent ultrasounds revealed essentially no vascular flow to the left testis and the testes gradually became smaller, but it was painful to the patient. The patient requested surgery because of pain in the left side and because of enlargement of the right side, which he states interfered with his sexual activity. The patient was advised that following that spermatocelectomy on the right side, the patient could have recurrence of the spermatocele/bleeding/infection and pain. DESCRIPTION OF PROCEDURE: After satisfactory general anesthesia, the patient was prepped and draped in a supine position. An incision was made in the midline of the scrotum vertically. The right testis was exposed and delivered from the incision. This was done within the sac of the spermatocele. Spermatocele was identified, being adherent to the right epididymis. There was significant adherence and numerous small blood vessels present and adherence of the spermatocele sac to both the testis and the epididymis. Dissection was done sharply. The sac was excised, sent to histology. Care was taken to preserve the blood supply to the right testis. The small bleeding points were cauterized or suture ligated. Hemostasis was also directed towards the scrotal wall.