AAPC Chapter 13 - Reproductive Systems,
Female Genital System, and Maternity -
Practical Application Cases 1-10
DIAGNOSES: Stage III cystocele, stage II uterine prolapse. (Do not code the cystocele
separately as it is included in the diagnosis code for the uterine prolapse.)
PROCEDURE: Pessary fitting.
INDICATIONS: A 75-year-old, gravida 4, para 4,(This information indicates that the
patient has had four pregnancies with four term births and the last two babies were
quite large.) female with pelvic organ prolapse. She is back for a pessary fitting today.
FINDINGS: She has a third-degree cystocele, and after examination we've determined
she actually has a third-degree uterine prolapse.(The diagnosis is cystocele with uterine
prolapse. Stage III uterine prolapse is considered a complete prolapsed.) Her vaginal
tissues are improved, but much less thin than prior appointment.
DESCRIPTION OF PROCEDURE: After her exam, I started with a #4 ring pessary with
support. This was clearly not large enough and the cystocele was coming aroun -
ANS-Correct Answer
57160
N81.3
Indications: 21-year-old, G3, P1-0-2-1,(Patient has been pregnant three times, has
given birth to a term infant one time, has had two abortions/miscarriages and has one
living child.) found to have an abnormal cervical Pap test (Abnormal cervical Pap smear
is the diagnosis.) with possible LGSIL.(Low-Grade Squamous Intraepithelial Lesion
(LGSIL) is documented as possible so it is not coded.) She presents for follow-up pap
and colposcopy.
EXAM: Pubic hair is shaved. Negative inguinal adenopathy. The urethra, the introitus,
and anus are grossly normal. Vagina is long, and an extra-long Pederson speculum is
needed. Cervix is posterior, parous. Uterus anteverted, normal size. Some tenderness
of the adnexa to deep palpation. No cervical motion tenderness. Normal discharge. Pap
test was performed.(Pap test is performed.)
COLPOSCOPIC PROCEDURE: Speculum was inserted for the colposcopy. An
extra-long, narrow Pederson speculum - ANS-Correct Answer
57460
R87.619
ANESTHESIA: General with LMA.
, PREOPERATIVE DIAGNOSIS: Patient requesting sterilization.
POSTOPERATIVE DIAGNOSIS: Sterilization.(Select a code from the postoperative
diagnosis.)
PROCEDURE PERFORMED: Tubal ligation with bilateral Falope-ring
application.(Indicates the tubal ligation by Falope ring. This method of sterilization uses
a small silastic ring shaped band placed around a loop of each fallopian tube.)
COUNTS: Needle, sponge and instrument counts were correct.
INTRAOPERATIVE MEDICATIONS: 0.25% Marcaine with epinephrine.
OPERATIVE FINDINGS: The left ovary was mildly adhered to the side of the uterus.
The right ovary appeared normal. Both tubes appeared normal. The upper abdomen
appeared normal. There was a small subserosal fibroid approximately 1 to 1.5-cm on
the left upper aspect of the uterus.
DESCRIPTION OF PROCEDURE: After informed consent, Ms. Mathews was taken to
operating suite #4 and a general anesthetic - ANS-Correct Answer
58671
Z30.2
PREOPERATIVE DIAGNOSIS: Severe cervical dysplasia.
POSTOPERATIVE DIAGNOSIS: Severe cervical dysplasia.
PROCEDURE PERFORMED: Cold knife conization.(A cold knife conization is a biopsy
performed to sample abnormal tissue from the cervix.)
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 25 cc.
FLUIDS: 500 cc crystalloid.
DRAINS: Straight catheter x 1.
INDICATIONS: All risks, benefits and alternatives of this procedure were discussed with
the patient and informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where
general anesthesia was obtained without difficulty. She was prepped and draped in the
normal sterile fashion after being placed in the dorsal lithotomy position.
Attention was turned to the patient's pelvis where a weighted speculum was placed
inside the patient's vagina.(A vaginal approach is performed.) The anterior lip of the
cervix was grasped w - ANS-Correct Answer
57520
D06.9
DIAGNOSIS: Intrauterine pregnancy at 18 weeks with multiple fetal anomalies.
PROCEDURE: D&E(Dilation and evacuation.)
ANESTHESIA: Moderate sedation.
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