Advance Medical coding and Auditing 2022
Case 10-19 Operative Report, Lymphadenectomy, Prostatectomy, and Plastic Repair
This Prostatectomy includes an additional element of plastic repair of the bladder neck ( cystourethroplasty) which is Included in the Prostatectomy.
Location: Inpatient, Hospital
Patient: Rex Kaat
Surgeon: Ira Avila, MD
PREOPERATIVE DIAGNOSIS: Carcinoma of the prostate
POSTOPERATIVE DIAGNOSIS: Carcinoma of the prostate
Procedure: Bilateral pelvic lymphadenectomy with frozen section, radical retropubic, and plastic repair of bladder neck.
CLINICAL NOTE: This man was found to have poorly differentiated diffuse adenocarcinoma of the prostate after presenting with a PSA ( Prostate- specific antigen) of 7.8 and an abnormal digital rectal examination.
Procedure Note: the patient was given a spinal anesthetic and prepped and draped in the supine postion. A 20-french foley catheter was inserted into the bladder and placed to straight drainage. A Lower abdominal midline incision was made. The Omni retractor was used for exposure.
10-19A OPERATIVE REPORT, LYMPHADENECTOMY, PROSTATECTOMY, AND PLASTIC REPAIR
Professional Services:
ICD-10-CM DX: __________,___________,_________
