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May 15, 2015
Test your coding knowledge with this scenario about coding bilateral upper eyelid with ICD-9, ICD-10... Learn More

April 24, 2015
Test your coding knowledge with this scenario about coding prostate cancer with ICD-9-CM, CPT, and H... Learn More

April 10, 2015
Test your coding knowledge with this scenario about coding right colon mass with ICD-9-CM, ICD-10-CM... Learn More

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2011 Code This Scenarios
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December 07, 2011 -

PRE-OP DIAGNOSIS: Aortic valve stenosis
OPERATION: Transcatheter aortic valve replacement (TAVR)
POST-OP DIAGNOSIS: Aortic valve stenosis

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November 21, 2011 -

Outpatient Hospital Setting – Chemotherapy
Severe rheumatoid arthritis involving MCP and PIP joints of fingers of both hands, nodules are present

Brief History:
The patient is a 35 year old female diagnosed with RA two years ago. Due to the extent of the patient’s disease she is disabled. Patient had a Hickman catheter inserted 7/1/11.

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November 14, 2011 -

Hospital Catheterization Lab – Subject to OPPS

The patient is a 44-year-old cigarette smoker with a markedly positive family history of coronary artery disease who has an electrocardiogram showing an old anterior septal myocardial infarction. Nuclear study showed a fixed anterior defect. He has had episodes of chest pain and coronary angiography has been recommended.

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October 27, 2011 -

CHIEF COMPLAINT: Visual disturbances

A 52-year old male presents to the ophthalmology clinic as a new patient. He has experienced a recent onset of decreased visual acuity and visual disturbances.

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October 04, 2011 - DIAGNOSIS: Recalcitrant exogenous obesity

OPERATION: Laparoscopic vertical sleeve gastrectomy

INDICATION FOR PROCEDURE: A 38-year-old female with a BMI of 38 presents for laparoscopic vertical sleeve gastrectomy as treatment for exogenous obesity, recalcitrant to diet and exercise.

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September 26, 2011 - Outpatient Surgery setting

Op report: Shunt tap
Adjustment of Medtronic Strata Valve

Diagnosis: Suspected ventriculoperitoneal shunt malfunction

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September 07, 2011 - Operative Report: Laparoscopic repair of hiatal hernia

Laparoscopic fundoplication

Laparoscopic-assisted gastrostomy tube

Diagnosis: Gastroesophageal reflux

Hiatal hernia

History of aspiration

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August 29, 2011 - Case Study of a Left Heart Failure

The patient is a 72-year-old male who presents to an OPPS hospital for outpatient placement of a cardiac resynchronization therapy device.

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August 18, 2011 - Preoperative/postoperative diagnoses:
  1. Right chronic mastoiditis
  2. Right cholesteatoma
  3. Right chronic otorrhea

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July 15, 2011 -

Preoperative Diagnosis: Secondary varicose veins, venous insufficiency, leg pain

Postoperative Diagnosis: Varicose veins with reflux in secondary varices

Procedures Performed:

  1. Ultrasound-guided sclerotherapy (chemical ablation)
  2. Diagnostic ultrasound and pre-procedure vein mapping

Anesthesia: None

Complications: None

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June 29, 2011 -

Preoperative diagnosis: Left breast extra-abdominal desmoid tumor

Postoperative diagnosis: Left breast extra-abdominal desmoid tumor with acquired absence of the breast

Surgeons: Dr. A, Dr. B

Anesthesia: General with local

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June 07, 2011 -

Case Study: Correction of amblyopia

Preoperative Diagnosis: Strabismus

Postoperative Diagnosis: Same

Procedure: Resection of medial and lateral rectus muscle for correction of amblyopia

Anesthesia: General

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May 18, 2011 -

Case Study: Excision of spermatocele

Preoperative Diagnosis: Left inguinal hernia, possible left spermatocele

Postoperative Diagnosis: No left inguinal hernia, left spermatocele


  1. Exploration of left groin
  2. Spermatocelectomy

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May 06, 2011 -

Case Study: Excision of a pilonidal cyst

Preoperative Diagnosis: Pilonidal cyst

Postoperative Diagnosis: Pilonidal cyst

Operation: Excision of pilonidal cyst with primary closure.

Anesthesia: General endotracheal

Complications: None

Blood Loss: 150 cc

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April 13, 2011 -

Case Study: Seroma of the back

Preoperative Diagnosis: Postoperative seroma of the back

Postoperative Diagnosis: Postoperative seroma of the back

Operation: Puncture aspiration of postoperative seroma of the back

Anesthesia: 5 cc 1 % lidocaine with epinephrine

Complications: None

Blood Loss: None

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April 01, 2011 - The patient is a 59-year-old female with a two-year history of pain and swelling in her feet bilaterally that has gradually inhibited her ability to walk and to exercise. She has tried conservative measures including wrapping of the toes, injections, anti-inflammatory medications, and ice to no avail over the past eight months.
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March 18, 2011 -

The patient is a 44-year-old woman who presents with a 2 cm x 2 cm atypical nevus on the central mid back and another 0.5 cm x 0.5 cm atypical nevus on the upper central back. Based on the nature of these lesions, anatomic location, and availability for adjacent normal skin, the various therapeutic and reconstructive options along with the alternatives and risks of each procedure were discussed with the patient.

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March 02, 2011 -

History: Patient is a 13-month-old boy who was referred due to impalpable left testicle. The right testicle is normally descended and located within the right hemiscrotum.

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February 04, 2011 -

A patient presents to her dermatologist’s office with cellulitis of her foot caused by an unknown source, potentially a wood sliver. The dermatologist performs a 4 sq cm debridement of the skin of the foot using a scalpel, going only to the level of the dermis. The wound is appropriately dressed, and the patient will follow up with the physician in one week to check the progress of the wound.

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