lisanewton1
case 2-12, chapter 15. Im taking insurance billing, and I have…
case 2-12, chapter 15.
Im taking insurance billing, and I have a case study that says, special notes: Dr. Cardiac is the attending physician. Dr. Stitcher is the surgeon. Care was provided at Goodmedicine Hospital, 1 Provider St, Anywhere, NY 1234-2345. Generate two separate claims due to two physicians. My question is , since Dr. Stitcher is the surgeon, do I put this doctor down as a referral physician? or shall I leave it blank? Block 33# as for the biller provider, do I type in Goodmedicine Hospital, 1 provider St, Anywhere NY 1234-2345 or do I leave it blank? One is the Hospital and the other is a clinic. AS for the PNI, do I need to type the surgeon doctor that is part of the member group or type the dr. cardiac md..
I also have a patient record! It states, APPLE, JAMES ADMITTING PROGRESS NOTE 06/19/YYYY 7:00 AM – 8:10 AM Patient admitted with acute appendicitis. Dr. Stitcher called in as surgeon. Refer to documented history and physical examination. Patient is cleared for surgery. Henry C. Cardiac, M.D. APPLE, JAMES
OPERATIVE REPORT 06/19/YYYY.
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Acute appendicitis.
OPERATION: Laparoscopic exploration with appendectomy. SURGEON: T.J. Stitcher, M.D.
PROCEDURE: Patient anesthetized with general anesthesia via endotracheal tube. Abdomen prepped and draped in sterile fashion. Because of patient’s size (he is quite small) it was not possible to place a catheter in the bladder. Patient was placed in Trendelenburg position. Abdominal wall was palpated, no masses felt. Incision was made below the umbilicus, and Verres needle inserted toward the pelvis. This was tested with normal saline; when it appeared to be in the peritoneal cavity, the abdomen was insufflated with 3 liters of CO2. A 1/2 cm camera was introduced through this opening. There was no evidence of injury from the needle or trocar, and the area of the appendix was visualized and some exudates and free fluid in the area noted. Under direct vision, a 1/2-cm trocar was passed through the right edge of the rectus sheath in the mid-abdomen. Using blunt and sharp dissection, the appendix and cecum were mobilized. The mesoappendix was serially ligated with hemoclips and then divided and the appendix freed to its base. The base was identified by the fact it was supple and it lay at the convergence of the tinea. A single 0 chromic suture was laced approximately 1 cm distally, and then the appendix divided between and through the 11 mm trocar. The abdomen was irrigated with normal saline, and the contents aspirated. Skin closed with 4-0 Vicryl, and Benzoin and SteriStrips applied. Estimated blood loss was 10 cc. Sponge and needle counts were correct. Patient tolerated the procedure well and returned to the recovery room awake and in stable condition. T.J. Stitcher, M.D.
APPLE, JAMES DISCHARGE PROGRESS NOTE 06/20/YYYY Patient was unremarkable postoperatively. Discharged 9 AM today. Mother was given standard, written pediatric appendectomy discharge sheet. Patient to be seen in the office of J.H. Cutdown, M.D., in 5 days for postop follow-up.
As I read the report, will my diagnosis be acute appendicitis? The procedure was laparoscopic appendectomy stiticher. Would there be any symptoms?
