As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case StudynnPreoperative Diagnosis:nRecurrent colorectal cancer at the anastomotic site.nnPostoperative Diagnosis:nRecurrent colorectal cancer at the anastomotic site.nnProcedures:n
- Partial colectomy with end colostomy.
- Small bowel resection with primary anastomosis.
- Flexible sigmoidoscopy.
nIndications: The patient is a 54-year-old gentleman who presented with colorectal cancer over a year ago. He had a resection and was just finishing chemotherapy and had some GI problems that necessitated a colonoscopy. He was found to have a stricture at the anastomosis, which was biopsied and found to have recurrent colorectal cancer. Risks and benefits were discussed with the patient who understood and agreed with the treatment plan.n