SURGERY CODING EXERCISES –Abstractors Training
- Patient first presented to your facility on 2/14/13 and underwent colonoscopy with biopsy of rectal mass that was positive for invasive adenocarcinoma. Patient returned to your facility on 2/17/13 and underwent APR with lymph node dissection. Surgical margins were clear on the pathology report. A total of 14 perirectal lymph nodes were removed.
Non-definitive surgery codes
Type of Tx _____
Course of Tx _____
Date Tx started _____
Tx facility _____
Tx at this facility? _____
Tx code _____
Tx text _____
Definitive surgery codes
Tx Type _____
Tx Course _____
Date Tx Started _____
Tx Facility_____
Tx Local Hosp ID_____
Surgery Primary Site (FORDS)_____
Surgical Approach (FORDS)_____
Scope Regional LN (FORDS)_____
Surgery Other Site (FORDS)_____
Surgical Margins (FORDS)_____
Tx Notes______
______
______
______
- Patient underwent colonoscopy with partial polypectomy of a large adenomatous polyp in the cecum at another facility (ID #123456) on 1/22/13. Path report showed invasive adenocarcinoma arising in an adenomatous polyp. Patient returned to your facility on 1/27/13 and underwent a right hemicolectomy. Inspection of liver negative for masses. No gross evidence of mets in the small bowel or abdomen. Path report revealed a 3.5 cm invasive adenocarcinoma with clear margins and a total of 17 pericolonic lymph nodes removed.
Non-definitive surgery codes
Type of Tx _____
Course of Tx _____
Date Tx started _____
Tx facility _____
Tx at this facility? _____
Tx code _____
Tx text _____
Definitive surgery codes
Tx Type _____
Tx Course _____
Date Tx Started _____
Tx Facility_____
Tx Local Hosp ID_____
Surgery Primary Site (FORDS)_____
Surgical Approach (FORDS)_____
Scope Regional LN (FORDS)_____
Surgery Other Site (FORDS)_____
Surgical Margins (FORDS)_____
Tx Notes______
______
______
______
- Patient presented to your facility on 3/2/13 with severe abdominal pain and was found to have a probable bowel obstruction with possible perforation on CT scan. Patient was taken to the OR on the same day and underwent exploratory laparotomy that revealed a large, obstructive malignant-appearing tumor in the rectosigmoidcolon . Due to the extensive involvement of other areas of the colon, proceeded with a total proctocolectomy with ileostomy and pouch. Path report revealed high grade adenocarcinoma involving the circumferential radial margin. 5 out of 17 perirectal lymph nodes positive for metastatic adenocarcinoma.
Non-definitive surgery codes
Type of Tx _____
Course of Tx _____
Date Tx started _____
Tx facility _____
Tx at this facility? _____
Tx code _____
Tx text _____
Definitive surgery codes
Tx Type _____
Tx Course _____
Date Tx Started _____
Tx Facility_____
Tx Local Hosp ID_____
Surgery Primary Site (FORDS)_____
Surgical Approach (FORDS)_____
Scope Regional LN (FORDS)_____
Surgery Other Site (FORDS)_____
Surgical Margins (FORDS)_____
Tx Notes______
______
______
______
- Patient underwent colonoscopy with biopsy of a right colon mass on 7/1/12 at another facility (hosp ID #123456) that was positive for adenocarcinoma. CT scans revealed a single metastatic tumor in the right lobe of the liver. Patient returned to your facility on 7/11/12 and underwent a right hemicolectomy with wedge resection of the metastatic liver tumor. Surgical margins were clear. 5/17 pericolonic lymph nodes were positive for metastatic carcinoma.
Non-definitive surgery codes
Type of Tx _____
Course of Tx _____
Date Tx started _____
Tx facility _____
Tx at this facility? _____
Tx code _____
Tx text _____
Definitive surgery codes
Tx Type _____
Tx Course _____
Date Tx Started _____
Tx Facility_____
Tx Local Hosp ID_____
Surgery Primary Site (FORDS)_____
Surgical Approach (FORDS)_____
Scope Regional LN (FORDS)_____
Surgery Other Site (FORDS)_____
Surgical Margins (FORDS)_____
Tx Notes______
______
______
______
SURGERY CODING EXERCISES – ANSWER KEY
- Patient first presented to your facility on 2/14/13 and underwent colonoscopy with biopsy of rectal mass that was positive for invasive adenocarcinoma. Patient returned to your facility on 2/17/13 and underwent APR with lymph node dissection. Surgical margins were clear on the pathology report. A total of 14 perirectal lymph nodes were removed.
Non-definitive surgery codes
Type of Tx N = Non-definitive surgery – incisional biopsy of rectal mass on 2/4/13 for diagnostic purposes
Course of Tx F = First course
Date Tx started 2/4/13
Tx facility Enter your facility’s hospital ID/FIN since the bx was done at your hosp
Tx at this facility? Enter your facility’s hospital ID/FIN since the bx was done at your hosp
Tx code 02 = Incisional biopsy of primary site (rectum) leaving gross residual disease
Tx text 2/14/13 Facility Name – Colonoscopy with biopsy of rectal mass.
Definitive surgery codes
Tx Type S = Definitive surgery – resection (removal) of the rectal tumor on 2/17/13
Tx Course F = First course
Date Tx Started 2/17/13
Tx FacilityEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Tx Local Hosp IDEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Surgery Primary Site (FORDS)50 = Abdominoperineal resection (APR)
Surgical Approach (FORDS)5 = Open
Scope Regional LN (FORDS)5 = Dissection of regional lymph nodes with at least 4 lymph nodes identified in the surgical specimen (no sentinel lymph node biopsy performed)
Surgery Other Site (FORDS)0 = No surgical resection of a non-primary surgical site
Surgical Margins (FORDS)0 = All margins are grossly and microscopically negative as documented by the pathologist on the resection pathology report
Tx Notes2/17/13 Facility Name – APR with perirectal LN dissection. Path report showed surgical margins to be clear and a total of 13 perirectal LNs removed.
- Patient underwent colonoscopy with partial polypectomy of a large adenomatous polyp in the cecum at another facility (ID #123456) on 1/22/13. Path report showed invasive adenocarcinoma arising in an adenomatous polyp. Patient returned to your facility on 1/27/13 and underwent a right hemicolectomy. Inspection of liver negative for masses. No gross evidence of mets in the small bowel or abdomen. Path report revealed a 3.5 cm invasive adenocarcinoma with clear margins and a total of 17 pericolonic lymph nodes removed.
Non-definitive surgery codes
Type of Tx N = Non-definitive surgery – partial polypectomy of adenomatous polyp in the cecum for diagnostic purposes on 1/22/13 Note: For a polypectomy, if the surgical margins are clear or if only microscopic disease remains after resection of the primary site (iehemicolectomy), the polypectomy becomes a definitive surgery; in this case, the entire polyp could not be removed by the surgeon and the tumor found in the resection specimen was 3.5 cm which was obvious macroscopic tumor making the polypectomy a diagnostic procedure only
Course of Tx F = First course
Date Tx started 1/22/13
Tx facility 123456 = ID/FIN of the facility where the polypectomy was performed
Tx at this facility? 0 = Non-definitive surgery (partial polypectomy) was not performed at your facility
Tx code 02 = Incisional biopsy of primary site/partial polypectomy (cecum) leaving gross residual disease
Tx text 1/22/13 Facility Name – Colonoscopy with partial polypectomy of a large adenomatous polyp. Gross residual polyp remained.
Definitive surgery codes
Tx Type S = Definitive surgery – Resection/removal of cecal tumor on 1/27/13
Tx Course F = First course
Date Tx Started 1/27/13
Tx FacilityEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Tx Local Hosp IDEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Surgery Primary Site (FORDS)40 = Hemicolectomy
Surgical Approach (FORDS)5 = Open
Scope Regional LN (FORDS)5 = Dissection of regional lymph nodes with at least 4 lymph nodes identified in the surgical specimen (no sentinel lymph node biopsy performed)
Surgery Other Site (FORDS)0 = No surgical resection of a non-primary surgical site
Surgical Margins (FORDS)0 = All margins are grossly and microscopically negative as documented by the pathologist on the resection pathology report
Tx Notes1/27/13 Facility Name – Rt hemicolectomy. Findings: Liver, small bowel and abdomen showed no evid of mets. Path report revealed clear surgical margins and a total of 17 pericolonic LNs removed.
- Patient presented to your facility on 3/2/13 with severe abdominal pain and was found to have a probable bowel obstruction with possible perforation on CT scan. Patient was taken to the OR on the same day and underwent exploratory laparotomy that revealed a large, obstructive malignant-appearing tumor in the rectosigmoid colon. Due to the extensive involvement of other areas of the colon, proceeded with a total proctocolectomy with ileostomy and pouch. Path report revealed high grade adenocarcinoma involving the circumferential radial margin. 5 out of 17 perirectal lymph nodes positive for metastatic adenocarcinoma.
Non-definitive surgery codes
Type of Tx You would not create a non-definitive surgical record since there was no diagnostic biopsy prior to definitive surgery
Course of Tx
Date Tx started
Tx facility
Tx at this facility?
Tx code
Tx text
Definitive surgery codes
Tx Type S = Resection/removal of rectosigmoid tumor on 3/2/13
Tx Course F = First course
Date Tx Started 3/2/13
Tx FacilityEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Tx Local Hosp IDEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Surgery Primary Site (FORDS)66 = Total proctocolectomy with ileostomy and pouch
Surgical Approach (FORDS)5 = Open
Scope Regional LN (FORDS)5 = Dissection of regional lymph nodes with at least 4 lymph nodes identified in the surgical specimen (no sentinel lymph node biopsy performed)
Surgery Other Site (FORDS)0 = No surgical resection of a non-primary surgical site
Surgical Margins (FORDS)2 = Microscopic residual tumor as documented by the pathologist on the resection pathology report (there is no mention of grossly visible/macroscopic [can be seen by the naked eye] tumor by the pathologist)
Tx Notes3/2/13 Facility Name – Expl lap w/ total proctocolectomy and ileostomy with pouch. CRM microscopically positive per path report. A total of 17 perirectal LNs were removed.
- Patient underwent colonoscopy with biopsy of a right colon mass on 7/1/12 at another facility (hosp ID #123456) that was positive for adenocarcinoma. CT scans revealed a single metastatic tumor in the right lobe of the liver. Patient returned to your facility on 7/11/12 and underwent a right hemicolectomy with wedge resection of the metastatic liver tumor. Surgical margins were clear. 5/17 pericolonic lymph nodes were positive for metastatic carcinoma.
Non-definitive surgery codes
Type of Tx N = Non-definitive surgery – incisional biopsy of rt colon mass on 7/1/12 for diagnostic purposes
Course of Tx F = First course
Date Tx started 7/1/12
Tx facility 123456 = ID/FIN of the facility where the diagnostic biopsy was performed
Tx at this facility? 0 = Non-definitive surgery was not performed at your facility
Tx code 02 = Incisional biopsy of primary site (rt colon) leaving gross residual disease
Tx text 7/1/12 Facility Name – Colonoscopy w/bxrt colon mass that was positive for adenoca.
Definitive surgery codes
Tx Type S= Resection/removal of rt colon tumor on 7/11/12
Tx Course F = First course
Date Tx Started 7/11/12
Tx FacilityEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Tx Local Hosp IDEnter your facility’s hospital ID/FIN since the resection was done at your hosp
Surgery Primary Site (FORDS)40 = Hemicolectomy
Surgical Approach (FORDS)5 = Open
Scope Regional LN (FORDS)5 = Dissection of regional lymph nodes with at least 4 lymph nodes identified in the surgical specimen (no sentinel lymph node biopsy performed)
Surgery Other Site (FORDS)4 = Non-primary surgical resection of distant site (wedge resection of solitary liver tumor)
Surgical Margins (FORDS)0 = All margins are grossly and microscopically negative as documented by the pathologist on the resection pathology report
Tx Notes7/11/12 Facility Name - Rt hemicolectomy w/wedge resection of liver. Surgical margins negative per resection path report, and a total of 17 pericolonic LNs were recovered in the surgical specimen.