BOOK
The Next Step: Advanced Medical Coding and Auditing, 2015 Edition - E-Book
(2015)
Additional Information
Book Details
Abstract
Moving on to advanced medical coding is easy with Carol J. Buck's proven, step-by-step method! The Next Step: Advanced Medical Coding and Auditing, 2015 Edition helps you master coding skills for services such as medical visits, diagnostic testing and interpretation, treatments, surgeries, and anesthesia. Real-world patient cases give you hands-on practice with advanced, physician-based coding. Enhance your decision-making skills and learn to confidently pull the right information from medical documents, select the right codes, determine the correct sequencing of those codes, properly audit cases, and prepare for the transition to ICD-10 with the help of coding author and educator Carol Buck!
- Dual coding addresses the transition to ICD-10 by providing practice as well as coding answers for both ICD-9 and ICD-10.
- UNIQUE! Evaluation and Management (E/M) audit forms, developed to determine the correct E/M codes, simplify the coding process and help to ensure accuracy.
- UNIQUE! Netter anatomy illustrations in each chapter help you understand anatomy and how it affects coding.
- Realistic patient cases simulate your first year of coding by using actual medical records (with personal patient details changed or removed), allowing you to practice coding with advanced material.
- From the Trenches boxes highlight the experiences of real-life professional medical coders and include photographs, quotes, practical tips, and advice.
- Auditing cases prepare you to assign correct codes to complicated records, as well as audit records for accuracy.Â
- More than 180 full-color illustrations depict and clarify advanced coding concepts.
- UPDATED content includes the latest coding information available, to promote accurate coding and success on the job.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front cover | Cover | ||
| Evolve | i | ||
| AD | i | ||
| Front matter | v | ||
| 2015 the next step advanced medical coding and auditing | vii | ||
| Copyright | viii | ||
| Dedication | ix | ||
| Collaborators and reviewers | xi | ||
| Table of contents | xiii | ||
| Preface | xv | ||
| Types of codes | xv | ||
| A. determining the appropriate primary diagnosis code for diagnostic tests ordered due to signs and/or symptoms | xvi | ||
| Content | xvi | ||
| Case numbering system | xvii | ||
| Report format | xix | ||
| Multiple modifiers | xx | ||
| Use of modifiers -26 and -tc | xxi | ||
| Pathology and laboratory | xxi | ||
| Glossary | xxiii | ||
| Evaluation | xxiii | ||
| Web | xxiii | ||
| A special note | xxiii | ||
| The top 10 list for coders | xxiv | ||
| Acknowledgments | xxv | ||
| List of physicians | xxvii | ||
| 1 Evaluation and management services | 1 | ||
| E/m review—the basics | 2 | ||
| Three factors of e/m code | 2 | ||
| Place of service | 2 | ||
| Type of service | 2 | ||
| Patient status | 2 | ||
| Key components | 2 | ||
| History | 3 | ||
| Chief complaint.  | 3 | ||
| History of present illness.  | 3 | ||
| Review of systems (ros).  | 4 | ||
| 2 Medicine | 77 | ||
| Immune globulins/immunizations/vaccines (90281-90749) | 78 | ||
| Diagnoses coding for vaccinations and immune globulins | 79 | ||
| Hydration, (96360, 96361); and therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy a ... | 80 | ||
| Hydration | 81 | ||
| Therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or ... | 81 | ||
| Psychiatry | 82 | ||
| Dialysis | 84 | ||
| Peritoneal dialysis | 86 | ||
| Complications | 87 | ||
| Noninvasive vascular diagnostic studies | 89 | ||
| Late effects | 90 | ||
| Cardioversion | 92 | ||
| Ultrasound | 92 | ||
| Codes reviewed elsewhere | 93 | ||
| Central nervous system assessments/tests (e.g., neurocognitive, mental status, speech testing) | 93 | ||
| Dementia | 93 | ||
| Health and behavior assessment/intervention | 95 | ||
| Chemotherapy administration (96401-96549) | 95 | ||
| Diagnosis coding for chemotherapy | 95 | ||
| Photodynamic therapy | 96 | ||
| Physical medicine and rehabilitation | 97 | ||
| Medical nutrition therapy | 99 | ||
| Osteopathic and chiropractic manipulative treatment | 99 | ||
| Special services, procedures, and reports | 99 | ||
| Hcpcs level II modifiers | 100 | ||
| 3 Radiology | 105 | ||
| Positions and placement | 106 | ||
| Component coding | 109 | ||
| Interventional radiology | 110 | ||
| Contrast | 110 | ||
| Facility specifics | 111 | ||
| Diagnostic radiology | 111 | ||
| Hemodialysis catheter placement | 111 | ||
| Types of catheters | 112 | ||
| Nasogastric tube | 113 | ||
| Cine-pharyngoesophagram | 115 | ||
| Cat/ct scans | 116 | ||
| Reconstruction | 117 | ||
| Congestive heart failure | 117 | ||
| Hypoxemia | 117 | ||
| CT guidance | 123 | ||
| Ultrasound | 124 | ||
| Modes and scans | 124 | ||
| Ultrasound guidance | 127 | ||
| Radiation oncology | 128 | ||
| Clinical treatment planning | 128 | ||
| Simulation | 128 | ||
| Radiation treatment management | 129 | ||
| Proton beam treatment delivery | 129 | ||
| Hyperthermia | 129 | ||
| Clinical brachytherapy | 129 | ||
| Treatment delivery | 132 | ||
| Nuclear medicine | 133 | ||
| Interventional radiology | 135 | ||
| Central venous access procedures | 135 | ||
| 4 Pathology and laboratory | 142 | ||
| Types of services | 143 | ||
| Superbill/requisition form | 143 | ||
| Organ- or disease-oriented panels | 145 | ||
| Therapeutic drug assays | 147 | ||
| Urinalysis, molecular pathology and chemistry | 148 | ||
| Urine/stool | 148 | ||
| Timed urine | 149 | ||
| Molecular pathology | 149 | ||
| Chemistry | 149 | ||
| Calculations | 149 | ||
| Chromatography | 151 | ||
| Hematology and coagulation | 153 | ||
| Laboratory use only | 153 | ||
| Coagulation | 156 | ||
| Immunohematology | 157 | ||
| Immunology | 158 | ||
| Body fluid | 159 | ||
| Office testing | 160 | ||
| Other laboratory and pathology services | 161 | ||
| Presumptive drug class screening | 161 | ||
| Diagnoses coding in drug test and drug abuse | 161 | ||
| Evocative/suppression testing | 162 | ||
| Transfusion medicine | 163 | ||
| Microbiology | 163 | ||
| Anatomic pathology | 164 | ||
| Consultations (clinical pathology) | 164 | ||
| Cytopathology and cytogenetic studies | 165 | ||
| Surgical pathology | 165 | ||
| Other procedures | 166 | ||
| 5 Integumentary system | 180 | ||
| Debridement | 181 | ||
| Skin tags | 184 | ||
| Lesion excision | 185 | ||
| Keratosis | 185 | ||
| Nails | 191 | ||
| Repair (closure) | 193 | ||
| Modifier -59 | 195 | ||
| Adjacent tissue transfers or rearrangements | 199 | ||
| Skin grafts | 201 | ||
| Other procedures | 204 | ||
| Pressure ulcers | 206 | ||
| Breast procedures | 207 | ||
| 6 Cardiovascular system | 221 | ||
| Evaluation and management services | 222 | ||
| Arteriosclerosis | 222 | ||
| Coronary artery bypass grafts | 224 | ||
| Pacemaker | 226 | ||
| Sick sinus syndrome | 227 | ||
| Echocardiography | 228 | ||
| Valve insufficiencies | 229 | ||
| Holter | 231 | ||
| Preimplantation, implantation, and postimplantation | 233 | ||
| Stress tests | 233 | ||
| Myocardial perfusion scan | 234 | ||
| Review of previous history | 236 | ||
| Cardiac catheterization | 241 | ||
| Miscellaneous reports | 251 | ||
| Cardioversion | 251 | ||
| 7 Digestive system, hemic/lymphatic system, and mediastinum/diaphragm | 262 | ||
| Digestive system | 263 | ||
| E/m services | 264 | ||
| Intestinal obstruction | 264 | ||
| External procedures | 266 | ||
| Hemorrhoids | 268 | ||
| Catheters | 269 | ||
| Endoscopy procedures | 270 | ||
| Gastritis and duodenitis | 270 | ||
| Ulcer | 270 | ||
| Hernia | 271 | ||
| Rectal procedures | 271 | ||
| Polyps | 272 | ||
| Abnormal findings | 273 | ||
| Abdominal pain | 274 | ||
| Cytomegalovirus | 281 | ||
| Laparoscopic procedures | 284 | ||
| Closed procedures converted to open procedures | 284 | ||
| Cholecystectomy | 285 | ||
| Incisional (open) surgical procedures | 292 | ||
| Crohn’s disease | 296 | ||
| Crohn’s disease diagnosis | 296 | ||
| Hernia | 302 | ||
| Hemic/lymphatic system | 304 | ||
| Diagnosis coding of hematopoietic and lymphatic neoplasms | 305 | ||
| 8 Musculoskeletal system | 313 | ||
| Arthrocentesis | 314 | ||
| Fractures | 315 | ||
| Fixation | 316 | ||
| Excision | 318 | ||
| Repair, revision, and reconstruction | 323 | ||
| Sprains and strains | 323 | ||
| Late effects | 327 | ||
| Fractures | 328 | ||
| Amputation | 329 | ||
| Arthroscopy | 334 | ||
| 9 Respiratory system | 345 | ||
| E/m services | 346 | ||
| Enzyme immunoassay | 347 | ||
| Residents | 348 | ||
| Medicine services | 358 | ||
| Spirometry | 359 | ||
| 94010 spirometry | 359 | ||
| 94060 spirometry with bronchodilator | 359 | ||
| 94070 spirometry with agents | 360 | ||
| Prebronchodilator flow | 360 | ||
| Postbronchodilator values | 360 | ||
| 94727 frc (functional residual capacity), also known as a nitrogen washout (lung volume determination) | 360 | ||
| 94726 tgv (thoracic gas volume), also known as plethysmography lung volume or lung volumes, includes (spirometry) | 360 | ||
| Single-breath lung volumes | 360 | ||
| Airway collapse or air trapping | 360 | ||
| 94729 dlco (diffusion capacity of carbon monoxide), also known as transfer factor (diffusing capacity) | 360 | ||
| 94726/94728 airway resistance (lung volume determination) | 360 | ||
| Sleep studies | 361 | ||
| Symptoms, signs, and ill-defined conditions | 361 | ||
| Symptoms as diagnoses | 361 | ||
| Nonspecific abnormal findings | 362 | ||
| Pulmonary stress test | 368 | ||
| Septoplasty and turbinates | 369 | ||
| Thoracentesis | 371 | ||
| Tracheostomy | 372 | ||
| Endoscopic procedures | 372 | ||
| 10 Urinary, male genital, and endocrine systems | 389 | ||
| Urinary system | 390 | ||
| Chronic renal failure | 390 | ||
| Diagnosis coding | 390 | ||
| Nephrostomy tube | 391 | ||
| Nephrectomy | 392 | ||
| Urinary system subcategories | 392 | ||
| Urinary system cysts | 392 | ||
| Renal calculus | 393 | ||
| Urodynamics | 393 | ||
| Stress incontinence | 395 | ||
| Bladder rupture | 396 | ||
| Hydronephrosis | 397 | ||
| Bladder stones | 397 | ||
| Urethral and ureteral strictures | 399 | ||
| Male genital system | 400 | ||
| Hemangioma | 400 | ||
| Diagnosis coding of hemangioma | 400 | ||
| Balanitis and circumcision | 401 | ||
| Vasectomy | 402 | ||
| Hydrocele | 403 | ||
| Prostate-specific antigen | 404 | ||
| Prostate cancer | 405 | ||
| Staging | 406 | ||
| Cryoablation | 407 | ||
| Endocrine system | 408 | ||
| 11 Female genital system and maternity care/delivery | 417 | ||
| FEMALE GENITAL SYSTEM | 418 | ||
| Evaluation and Management | 418 | ||
| Pains and Other Female Genital Organ Symptoms | 418 | ||
| Surgical Procedures | 419 | ||
| Menopausal and Postmenopausal Disorders | 419 | ||
| Colposcopy | 419 | ||
| Pelvic Pain | 425 | ||
| Endometriosis | 426 | ||
| Dysfunctional Uterine Bleeding | 429 | ||
| MATERNITY CARE/DELIVERY | 431 | ||
| Routine Obstetric Care | 431 | ||
| Admission for Normal Delivery | 431 | ||
| Echography | 432 | ||
| Cesarean Section | 433 | ||
| 12 Nervous system | 449 | ||
| Twist drill or burr holes | 450 | ||
| Craniotomy | 451 | ||
| Subdural hematoma | 451 | ||
| Stealth surgery | 453 | ||
| Cranioplasty | 457 | ||
| Shunts | 458 | ||
| Lumbar puncture | 458 | ||
| Pump implantation | 459 | ||
| Laminotomy and foraminotomies | 462 | ||
| Spinal fusion | 467 | ||
| Neurology and neuromuscular procedures | 469 | ||
| 13 Eye and auditory systems | 476 | ||
| Eye | 477 | ||
| Eye examinations | 477 | ||
| Cataracts | 479 | ||
| Photocoagulation | 480 | ||
| Ectropion and entropion | 481 | ||
| Epiphora | 482 | ||
| Ear | 483 | ||
| Office services | 483 | ||
| Myringotomy and tympanostomy | 484 | ||
| 14 Anesthesia | 493 | ||
| Introduction | 494 | ||
| Anesthesia | 494 | ||
| Types of anesthesia | 494 | ||
| Central technique | 494 | ||
| Peripheral technique | 494 | ||
| Intravenous regional technique (bier block) | 494 | ||
| Anesthesia care and bundled services/procedures | 495 | ||
| Anesthesia care and separately reported services | 495 | ||
| Base units | 496 | ||
| Physical status modifiers | 496 | ||
| Concurrent care modifiers | 496 | ||
| Positioning | 497 | ||
| Qualifying circumstances | 497 | ||
| Anesthesia time | 497 | ||
| Calculation of charge/payment | 497 | ||
| Summary | 498 | ||
| Pain management | 498 | ||
| Obstetrics | 498 | ||
| Labor | 498 | ||
| Delivery | 498 | ||
| Hysterectomy | 499 | ||
| Critical care | 499 | ||
| Moderate (conscious) sedation | 499 | ||
| Patient-controlled analgesia | 499 | ||
| Anesthesia services in the hospital setting | 499 | ||
| Figure credits | 522 | ||
| APPENDIX A E/m audit form | 523 | ||
| APPENDIX B CMS ab-01-144 | 525 | ||
| Introduction | 525 | ||
| A. determining the appropriate primary ICD-9-CM11Although this memorandum specifies ICD-9-CM, it is applicable to ICD-10-C ... | 525 | ||
| B. instruction to determine the reason for the test | 526 | ||
| C. incidental findings | 526 | ||
| D. unrelated/co-existing conditions/diagnoses | 526 | ||
| E. diagnostic tests ordered in the absence of signs and/or symptoms (e.g., screening tests) | 527 | ||
| F. use of ICD-9-CM to the greatest degree of accuracy and completeness | 527 | ||
| APPENDIX C Resources | 528 | ||
| APPENDIX D Abbreviations | 529 | ||
| APPENDIX E Answers to every other case | 534 | ||
| Chapter 1 | 534 | ||
| Evaluation and management services | 534 | ||
| Case 1-1 | 534 | ||
| 1-1a initial hospital care | 534 | ||
| 1-1b discharge summary | 534 | ||
| Case 1-3 | 534 | ||
| 1-3a initial hospital service | 534 | ||
| 1-3b consultation | 534 | ||
| 1-3c radiology report | 534 | ||
| 1-3d radiology report | 534 | ||
| Case 1-5 | 534 | ||
| 1-5a initial hospital care | 534 | ||
| 1-5b progress report | 534 | ||
| Case 1-7 | 535 | ||
| 1-7a progress report | 535 | ||
| Case 1-9 | 535 | ||
| 1-9a discharge summary | 535 | ||
| Case 1-11 | 535 | ||
| 1-11a consultation | 535 | ||
| Case 1-13 | 535 | ||
| 1-13a critical care | 535 | ||
| Case 1-15 | 535 | ||
| 1-15a critical care | 535 | ||
| Case 1-17 | 535 | ||
| 1-17a critical care admission | 535 | ||
| Case 1-19 | 535 | ||
| 1-19a office visit | 535 | ||
| 1-19b office visit | 535 | ||
| 1-19c clinic progress note | 535 | ||
| Case 1-21 | 535 | ||
| 1-21a newborn care | 535 | ||
| Case 1-23 | 536 | ||
| 1-23a office visit | 536 | ||
| 1-23b office visit | 536 | ||
| 1-23c office visit | 536 | ||
| Case 1-25 | 536 | ||
| 1-25a office visit | 536 | ||
| Chapter 2 | 536 | ||
| Medicine | 536 | ||
| Case 2-1 | 536 | ||
| 2-1a chart note | 536 | ||
| Case 2-3 | 536 | ||
| 2-3a chart note | 536 | ||
| Case 2-5 | 536 | ||
| 2-5a chart note | 536 | ||
| Case 2-7 | 536 | ||
| 2-7a hemodialysis progress report | 536 | ||
| Case 2-9 | 536 | ||
| 2-9a duplex carotid artery study | 536 | ||
| Case 2-11 | 537 | ||
| 2-11a arterial doppler test | 537 | ||
| Case 2-13 | 537 | ||
| 2-13a electrical cardioversion | 537 | ||
| Case 2-15 | 537 | ||
| 2-15a cognitive function assessment | 537 | ||
| Case 2-17 | 537 | ||
| 2-17a infusion | 537 | ||
| Case 2-19 | 537 | ||
| 2-19a physical therapy evaluation | 537 | ||
| Case 2-21 | 537 | ||
| 2-21a office procedure | 537 | ||
| 2-21b clinic progress note | 537 | ||
| Chapter 3 | 537 | ||
| Radiology | 537 | ||
| Case 3-1 | 537 | ||
| 3-1a radiology report, chest | 537 | ||
| Case 3-3 | 537 | ||
| 3-3a radiology report, abdomen | 537 | ||
| Case 3-5 | 537 | ||
| 3-5a radiology report, femur | 537 | ||
| Case 3-7 | 537 | ||
| 3-7a radiology report, shoulder | 537 | ||
| Case 3-9 | 537 | ||
| 3-9a video swallow | 537 | ||
| Case 3-11 | 537 | ||
| 3-11a CT scan, sinuses | 537 | ||
| Case 3-13 | 537 | ||
| 3-13a CT scan, chest | 537 | ||
| Case 3-15 | 538 | ||
| 3-15a CT scan, chest | 538 | ||
| Case 3-17 | 538 | ||
| 3-17a CT scan, abdomen | 538 | ||
| Case 3-19 | 538 | ||
| 3-19a ct-guided kidney biopsy | 538 | ||
| Case 3-21 | 538 | ||
| 3-21a ultrasound, right lower quadrant | 538 | ||
| Case 3-23 | 538 | ||
| 3-23a ultrasound, renal | 538 | ||
| Case 3-25 | 538 | ||
| 3-25a ultrasound, renal | 538 | ||
| Case 3-27 | 538 | ||
| 3-27a ultrasound, retroperitoneal | 538 | ||
| Case 3-29 | 538 | ||
| 3-29a radiation oncology consultation note | 538 | ||
| 3-29b radiation oncology treatment planning note | 538 | ||
| 3-29c radiation oncology simulation note | 538 | ||
| 3-29d radiation oncology progress note—week 1, 5 days | 538 | ||
| 3-29e radiation oncology progress note—week 2, 5 days | 538 | ||
| Case 3-31 | 539 | ||
| 3-31a ventilation-perfusion lung scan | 539 | ||
| Case 3-33 | 539 | ||
| 3-33a gastrojejunostomy catheter placement | 539 | ||
| Case 3-35 | 539 | ||
| 3-35a gastrojejunostomy catheter placement | 539 | ||
| Chapter 4 | 539 | ||
| Pathology and laboratory | 539 | ||
| Case 4-1 | 539 | ||
| 4-1a basic metabolic panel (calcium, total) | 539 | ||
| 4-1b comprehensive metabolic panel | 539 | ||
| 4-1c hepatic function panel | 539 | ||
| 4-1d lipid panel | 539 | ||
| 4-1e general health panel | 539 | ||
| Case 4-3 | 540 | ||
| 4-3a chemistry tests | 540 | ||
| Case 4-5 | 540 | ||
| 4-5a coagulation | 540 | ||
| Case 4-7 | 540 | ||
| 4-7a immunology | 540 | ||
| Case 4-9 | 540 | ||
| 4-9a office testing | 540 | ||
| Case 4-11 | 540 | ||
| 4-11a evocative/suppression testing | 540 | ||
| Case 4-13 | 541 | ||
| 4-13a microbiology | 541 | ||
| Case 4-15 | 541 | ||
| 4-15a consultations (clinical pathology) | 541 | ||
| Case 4-17 | 541 | ||
| 4-17a surgical pathology report | 541 | ||
| Case 4-19 | 541 | ||
| 4-19a pathology and laboratory section review | 541 | ||
| Chapter 5 | 543 | ||
| Integumentary system | 543 | ||
| Case 5-1 | 543 | ||
| 5-1a operative report, excision fat necrosis | 543 | ||
| Case 5-3 | 543 | ||
| 5-3a operative report, skin tags | 543 | ||
| Case 5-5 | 543 | ||
| 5-5a operative report, lesions | 543 | ||
| Case 5-7 | 543 | ||
| 5-7a operative report, nevus | 543 | ||
| Case 5-9 | 543 | ||
| 5-9a operative report, keratosis excision | 543 | ||
| Case 5-11 | 543 | ||
| 5-11a operative report, squamous cell carcinoma | 543 | ||
| Case 5-13 | 543 | ||
| 5-13a clinic progress note | 543 | ||
| Case 5-15 | 543 | ||
| 5-15a operative report, laceration | 543 | ||
| Case 5-17 | 543 | ||
| 5-17a operative report, umbilicoplasty | 543 | ||
| Case 5-19 | 543 | ||
| 5-19a operative report, dermabrasion | 543 | ||
| Case 5-21 | 544 | ||
| 5-21a operative report, wide excision, basal cell carcinoma | 544 | ||
| Case 5-23 | 544 | ||
| 5-23a operative report, split-thickness autograft | 544 | ||
| Case 5-25 | 544 | ||
| 5-25a operative report, full-thickness skin graft | 544 | ||
| Case 5-27 | 544 | ||
| 5-27a operative report, composite graft | 544 | ||
| Case 5-29 | 544 | ||
| 5-29a operative report, post skin graft | 544 | ||
| Case 5-31 | 544 | ||
| 5-31a operative report, breast biopsy | 544 | ||
| 5-31b pathology report | 544 | ||
| 5-31c progress note | 544 | ||
| Case 5-33 | 544 | ||
| 5-33a operative report, breast biopsy with needle localization | 544 | ||
| 5-33b pathology report | 544 | ||
| Case 5-35 | 544 | ||
| 5-35a preoperative consultation | 544 | ||
| 5-35b operative report, modified radical mastectomy | 544 | ||
| 5-35c pathology report | 544 | ||
| 5-35d discharge summary | 544 | ||
| 5-35e progress note | 544 | ||
| Case 5-37 | 545 | ||
| 5-37a operative report, mammoplasty | 545 | ||
| Chapter 6 | 545 | ||
| Cardiovascular system | 545 | ||
| Case 6-1 | 545 | ||
| 6-1a cardiothoracic surgery consultation | 545 | ||
| Case 6-3 | 545 | ||
| 6-3a cardiology follow-up note | 545 | ||
| Case 6-5 | 545 | ||
| 6-5a holter report | 545 | ||
| 6-5b radiology report, preimplantation | 545 | ||
| 6-5c operative report, pacemaker implantation | 545 | ||
| 6-5d radiology report, postimplantation | 545 | ||
| Case 6-7 | 545 | ||
| 6-7a cardiology consultation | 545 | ||
| 6-7b hospital service | 545 | ||
| 6-7c radiology report, chest | 545 | ||
| 6-7d cardiothoracic surgical consultation | 545 | ||
| 6-7e radiology report, chest | 545 | ||
| Case 6-9 | 546 | ||
| 6-9a cardiology consultation | 546 | ||
| Case 6-11 | 546 | ||
| 6-11a hospital admission | 546 | ||
| 6-11b general chemistry | 546 | ||
| 6-11c hematology | 546 | ||
| 6-11d electrocardiography | 546 | ||
| 6-11e radiology report, chest | 546 | ||
| Case 6-13 | 546 | ||
| 6-13a cardioversion | 546 | ||
| Case 6-15 | 546 | ||
| 6-15a operative report, thromboendarterectomy | 546 | ||
| Case 6-17 | 546 | ||
| 6-17a operative report, arteriovenous fistula | 546 | ||
| Case 6-19 | 546 | ||
| 6-19a operative report, femoral artery laceration | 546 | ||
| Chapter 7 | 547 | ||
| Digestive system, hemic/lymphatic system, and mediastinum/diaphragm | 547 | ||
| Case 7-1 | 547 | ||
| 7-1a inpatient consultation | 547 | ||
| Case 7-3 | 547 | ||
| 7-3a operative report, intersphincteric abscess | 547 | ||
| Case 7-5 | 547 | ||
| 7-5a operative report, hemorrhoidectomy | 547 | ||
| Case 7-7 | 547 | ||
| 7-7a operative report, esophagogastroduodenoscopy | 547 | ||
| Case 7-9 | 547 | ||
| 7-9a operative report, sigmoidoscopy | 547 | ||
| Case 7-11 | 547 | ||
| 7-11a operative report, colonoscopy | 547 | ||
| 7-11b surgical consultation | 547 | ||
| 7-11c operative report, hemicolectomy | 547 | ||
| 7-11d pathology report | 547 | ||
| Case 7-13 | 547 | ||
| 7-13a operative report, appendectomy | 547 | ||
| Case 7-15 | 547 | ||
| 7-15a outpatient consultation | 547 | ||
| 7-15b emergency and outpatient record | 547 | ||
| 7-15c outpatient consultation | 547 | ||
| 7-15d operative report, ulcer and cholecystitis | 547 | ||
| 7-15e intraoperative cholangiogram | 547 | ||
| 7-15f pathology report | 547 | ||
| 7-15g discharge summary | 547 | ||
| Case 7-17 | 547 | ||
| 7-17a operative report, hemicolectomy | 547 | ||
| Case 7-19 | 548 | ||
| 7-19a operative report, gastrojejunostomy/tracheostomy | 548 | ||
| Case 7-21 | 548 | ||
| 7-21a hospital inpatient service | 548 | ||
| 7-21b operative report, cecectomy | 548 | ||
| 7-21c discharge summary | 548 | ||
| Case 7-23 | 549 | ||
| 7-23a hospital inpatient service | 549 | ||
| 7-23b operative report, right inguinal hernia repair | 549 | ||
| 7-23c pathology report | 549 | ||
| Case 7-25 | 549 | ||
| 7-25a operative report, axillary node dissection | 549 | ||
| 7-25b pathology report | 549 | ||
| Case 7-27 | 549 | ||
| 7-27a bone marrow biopsy | 549 | ||
| Chapter 8 | 549 | ||
| Musculoskeletal system | 549 | ||
| Case 8-1 | 549 | ||
| 8-1a orthopedic consultation | 549 | ||
| Case 8-3 | 549 | ||
| 8-3a operative report, hardware removal | 549 | ||
| Case 8-5 | 549 | ||
| 8-5a operative report, carbuncle removal | 549 | ||
| Case 8-7 | 550 | ||
| 8-7a operative report, nevus removal | 550 | ||
| Case 8-9 | 550 | ||
| 8-9a operative report, shoulder mass excision | 550 | ||
| 8-9b pathology report | 550 | ||
| Case 8-11 | 550 | ||
| 8-11a operative report, ganglion cyst | 550 | ||
| Case 8-13 | 550 | ||
| 8-13a consultation, tendon rupture | 550 | ||
| 8-13b radiology report, shoulder | 550 | ||
| 8-13c operative report, open tendon repair | 550 | ||
| 8-13d discharge summary | 550 | ||
| Case 8-15 | 550 | ||
| 8-15a operative report, arthroplasty | 550 | ||
| Case 8-17 | 550 | ||
| 8-17a operative report, open reduction | 550 | ||
| 8-17b radiology report, WRIST | 550 | ||
| Case 8-19 | 551 | ||
| 8-19a radiology report, right femur | 551 | ||
| 8-19b orthopedic consultation, thigh pain | 551 | ||
| 8-19c operative report, femur repair, intramedullary nailing | 551 | ||
| 8-19d discharge summary | 551 | ||
| Case 8-21 | 551 | ||
| 8-21a operative report, amputation | 551 | ||
| Case 8-23 | 551 | ||
| 8-23a operative report, debridement | 551 | ||
| Case 8-25 | 551 | ||
| 8-25a operative report, acromioplasty | 551 | ||
| 8-25b operative report, debridement and irrigation | 551 | ||
| Case 8-27 | 551 | ||
| 8-27a operative report, knee | 551 | ||
| Chapter 9 | 552 | ||
| Respiratory system | 552 | ||
| Case 9-1 | 552 | ||
| 9-1a evening clinic, sore throat | 552 | ||
| 9-1b laboratory, respiratory cultures | 552 | ||
| Case 9-3 | 552 | ||
| 9-3a thoracic medicine/critical care consultation | 552 | ||
| 9-3b thoracic medicine/critical care progress note | 552 | ||
| 9-3c radiology report, chest | 552 | ||
| 9-3d thoracic medicine/critical care progress note | 552 | ||
| 9-3e thoracic medicine/critical care progress note | 552 | ||
| 9-3f radiology report, chest | 552 | ||
| 9-3g discharge summary | 552 | ||
| Case 9-5 | 552 | ||
| 9-5a consultation/transfer of care | 552 | ||
| Case 9-7 | 553 | ||
| 9-7a overnight oxygen desaturation study | 553 | ||
| 9-7b nocturnal polysomnogram | 553 | ||
| 9-7c multiple sleep latency study | 553 | ||
| Case 9-9 | 553 | ||
| 9-9a pulmonary function study | 553 | ||
| 9-9b cardiothoracic consultation | 553 | ||
| 9-9c operative report, lung mass | 553 | ||
| 9-9d pathology report | 553 | ||
| 9-9e thoracic medicine/critical care note | 553 | ||
| 9-9f radiology report, chest | 553 | ||
| 9-9g thoracic medicine/critical care progress report | 553 | ||
| 9-9h radiology report, chest | 553 | ||
| 9-9i pulmonary function study | 553 | ||
| 9-9j discharge summary | 553 | ||
| Case 9-11 | 554 | ||
| 9-11a operative report, thoracentesis | 554 | ||
| Case 9-13 | 554 | ||
| 9-13a operative report, septoplasty, turbinoplasty, and ethmoidectomy | 554 | ||
| Case 9-15 | 554 | ||
| 9-15a thoracic medicine and critical care consultation | 554 | ||
| 9-15b thoracic medicine and critical care progress report | 554 | ||
| 9-15c thoracic medicine and critical care progress report | 554 | ||
| 9-15d radiology report, chest | 554 | ||
| 9-15e operative report, esophagogastroduodenoscopy | 554 | ||
| 9-15f ct-guided lung biopsy | 554 | ||
| 9-15g pathology report | 554 | ||
| 9-15h ultrasound marking for thoracentesis | 554 | ||
| 9-15i operative report, thoracentesis | 554 | ||
| 9-15j pathology report | 554 | ||
| 9-15k oxygen desaturation study | 554 | ||
| 9-15l radiology report, chest | 554 | ||
| 9-15m operative report, thoracostomy | 554 | ||
| Case 9-17 | 555 | ||
| 9-17a operative report, bronchoscopy | 555 | ||
| Chapter 10 | 555 | ||
| Urinary, male genital, and endocrine systems | 555 | ||
| Case 10-1 | 555 | ||
| 10-1a operative report, kidney biopsy | 555 | ||
| Case 10-3 | 555 | ||
| 10-3a operative report, nephrectomy | 555 | ||
| Case 10-5 | 555 | ||
| 10-5a urodynamic assessment | 555 | ||
| Case 10-7 | 555 | ||
| 10-7a operative report, intraperitoneal bladder rupture | 555 | ||
| Case 10-9 | 555 | ||
| 10-9a operative report, ureteroscopic stone extraction | 555 | ||
| Case 10-11 | 555 | ||
| 10-11a operative report, meatotomy | 555 | ||
| Case 10-13 | 555 | ||
| 10-13a operative report, circumcision | 555 | ||
| Case 10-15 | 555 | ||
| 10-15a operative report, vasectomy | 555 | ||
| Case 10-17 | 556 | ||
| 10-17a transrectal ultrasound for prostate volume determination and biopsy | 556 | ||
| Case 10-19 | 556 | ||
| 10-19a operative report, lymphadenectomy, prostatectomy, and plastic repair | 556 | ||
| Case 10-21 | 556 | ||
| 10-21a operative report, left thyroid mass | 556 | ||
| Chapter 11 | 556 | ||
| Female genital system and maternity care/delivery | 556 | ||
| Case 11-1 | 556 | ||
| 11-1a emergency department services | 556 | ||
| Case 11-3 | 556 | ||
| 11-3a history and physical examination | 556 | ||
| 11-3b operative report, ureteral stents | 556 | ||
| 11-3c operative report, hysterectomy | 556 | ||
| 11-3d pathology report | 556 | ||
| 11-3e discharge summary | 556 | ||
| Case 11-5 | 556 | ||
| 11-5a operative report, dilatation and curettage | 556 | ||
| Case 11-7 | 556 | ||
| 11-7a real-time ultrasound | 556 | ||
| 11-7b sonogram | 556 | ||
| 11-7c operative report, cesarean section | 556 | ||
| 11-7d discharge summary | 556 | ||
| Case 11-9 | 557 | ||
| 11-9a ob/gyn consultation | 557 | ||
| 11-9b duplex venous examination | 557 | ||
| 11-9c ultrasound | 557 | ||
| 11-9d biophysical profile | 557 | ||
| 11-9e doppler umbilical arterial | 557 | ||
| 11-9f ob ultrasound | 557 | ||
| 11-9g ob ultrasound | 557 | ||
| 11-9h operative report, amniocentesis | 557 | ||
| 11-9i ob ultrasound | 557 | ||
| 11-9j operative report, cesarean section | 557 | ||
| 11-9k pathology report | 557 | ||
| Chapter 12 | 558 | ||
| Nervous system | 558 | ||
| Case 12-1 | 558 | ||
| 12-1a operative report, ventriculostomy | 558 | ||
| Case 12-3 | 558 | ||
| 12-3a operative report, craniectomy | 558 | ||
| 12-3b pathology report | 558 | ||
| Case 12-5 | 558 | ||
| 12-5a operative report, pterygocraniotomy and cranioplasty | 558 | ||
| Case 12-7 | 558 | ||
| 12-7a operative report, cranioplasty | 558 | ||
| Case 12-9 | 558 | ||
| 12-9a operative report, lumbar puncture | 558 | ||
| Case 12-11 | 558 | ||
| 12-11a preoperative consultation | 558 | ||
| 12-11b operative report, intrathecal catheter placement | 558 | ||
| 12-11c operative report, removal of bard port | 558 | ||
| 12-11d discharge summary | 558 | ||
| Case 12-13 | 559 | ||
| 12-13a operative report, hemilaminectomy and foraminotomy | 559 | ||
| Case 12-15 | 559 | ||
| 12-15a operative report, cage fusion | 559 | ||
| Case 12-17 | 559 | ||
| 12-17a operative report, discectomy | 559 | ||
| Case 12-19 | 559 | ||
| 12-19a electroencephalogram report | 559 | ||
| Chapter 13 | 559 | ||
| Eye and auditory systems | 559 | ||
| Case 13-1 | 559 | ||
| 13-1a clinic progress note, eye examination | 559 | ||
| Case 13-3 | 559 | ||
| 13-3a clinic progress note, senile cataracts | 559 | ||
| Case 13-5 | 559 | ||
| 13-5a clinic progress note, eye examination | 559 | ||
| 13-5b clinic progress note, photocoagulation | 559 | ||
| Case 13-7 | 559 | ||
| 13-7a operative report, nasolacrimal duct probing | 559 | ||
| Case 13-9 | 560 | ||
| 13-9a operative report, pressure equalization tube removal | 560 | ||
| Case 13-11 | 560 | ||
| 13-11a operative report, tube removal | 560 | ||
| Case 13-13 | 560 | ||
| 13-13a operative report, tympanoplasty | 560 | ||
| Chapter 14 | 560 | ||
| Anesthesia | 560 | ||
| Case 14-1 | 560 | ||
| 14-1a operative report, flaps and grafts | 560 | ||
| Case 14-3 | 560 | ||
| 14-3a operative report, fusion with autograft | 560 | ||
| Case 14-5 | 560 | ||
| 14-5a operative report, excision of right carotid body tumor | 560 | ||
| Case 14-7 | 560 | ||
| 14-7a operative report, hysteroscopy, dilatation, and curettage | 560 | ||
| Case 14-9 | 560 | ||
| 14-9a operative report, nasolacrimal duct probing | 560 | ||
| Case 14-11 | 560 | ||
| 14-11a operative report, lesions | 560 | ||
| Case 14-13 | 560 | ||
| 14-13a operative report, ulcer and cholecystitis | 560 | ||
| Case 14-15 | 560 | ||
| 14-15a operative report, tendon repair | 560 | ||
| Case 14-17 | 560 | ||
| 14-17a operative report, closed reduction | 560 | ||
| Case 14-19 | 560 | ||
| 14-19a operative report, entropion and ectropion repair | 560 | ||
| Case 14-21 | 560 | ||
| 14-21a operative report, cesarean section | 560 | ||
| Glossary | 561 | ||
| Inside back cover | i | ||
| Index | 565 | ||
| A | 565 | ||
| B | 566 | ||
| C | 566 | ||
| D | 568 | ||
| E | 569 | ||
| F | 571 | ||
| G | 571 | ||
| H | 571 | ||
| I | 572 | ||
| K | 573 | ||
| L | 573 | ||
| M | 574 | ||
| N | 575 | ||
| O | 575 | ||
| P | 575 | ||
| Q | 577 | ||
| R | 577 | ||
| S | 578 | ||
| T | 578 | ||
| U | 579 | ||
| V | 579 | ||
| W | 579 | ||
| X | 579 | ||
| Z | 579 |