MCCG262 Professional Coder Practicum Documentation Presentation (Medical Billing and Coding)

Nurse Addendum

Anesthetist

Related encounter: Anesthesia Event from 7/11/2014 in

MRN

GI ENDOSCOPY

• 1

Department of Anesthesiology Pre-operative Evaluation Record

Patient Name I

Admit Date: 7/11/2014 Sex: male Age: 70 y.o.

Sex

Male

DOB

Page 1 of 2

Age

70

Anesthesia Pre-op Service date: Evaluation 07/11/2014 4:22 PM

!System Evaluation and Medical History: HPI: 70 yo male who had colonoscopy at 4/11/2014. Multiple resected polyps diagnosed as tubulovillous adenomas and tubular adenoma's. Patient states that not all areas were resected and he is presenting for colonoscopy with endoscopic mucosa\ resection 7/18/2014.

Anesthetic Complications: No history of anesthetic complications. Pulmonary: Asthma (reports asthma is brought on by allergies to pollen. Uses Advair when needed. Last used 4 months ago.) and sleep apnea (no OSA diagnosis). The asthma frequency is rare. The asthma required none ED Visit(s). Denies PND. Able to lie flat without breathing/back issues. Stop Bang Score: 4. OSA:. Neuro/Psych: The patient has no chronic pain history. The patient has no seizures of type. The patient has no CVA history. Cardiovascular: Cardiac history includes: hypertension (taking terazosin, amlodipine and benazepril). No past Ml. The hypertension is well controlled. The patient has no CAD history. METS:. METS comments: Able to climb two flights of stairs and walk 1 mile. Denies CP, SOB or DOE .. The patient has No CHF history. GI/Hepatic: acid reflux (taking omeprazole. Denies history of frank reflux.). GERO controlled with medication. Endo/Other: diabetes (patient does not monitor blood sugars at home. Last fasting glucose 107 on 4/30/2014. Taking glipizide). The patient has type 2 diabetes. The patient uses Oral hypoglycemics to control the diabetes. No Known Allergies !Vitals: There were no vitals filed for this visit. BMI: 34.5 Height: Height: 162.6 cm (5' 4") (07/11/14 1624) Wei ht: Wei ht: 91.173 k 201 lb 07/11/14 1624 Physical Exam: Airway: Mallampati: Ill. Mouth opening: >3 FB. TM distance: > 6 cm. Neck ROM: full. Cardiovascular: cardiovascular exam normal GCS: Eye: 4. Verbal: 5. Motor: 6. GCS Score: 15. S1 a·nd S2, RRR Dental: Upper dentures and lower dentures. Pulmonary: Breath sounds clear to auscultation. BMI: obesit . Existin Vascular Access: eri heral. Communications Communications: 1. Labs: Scanned to Media tab

2. EKG 7/9/2014: Sinus rhythm, 79 bpm

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NPOand medication instructions, directions for check-in DOSgiven. Instructedhe take terazosin, omeprazole and amlodipine morning of procedure. Instructedhe holdall other medications and benazepril evening prior as well.

ASAairway assessment, consent and review of today's evaluation to be done by anesthesia DOS prior to surgery.

Beta blocker:no . Consent on chart: informed consent obtained . no sur icalconsent.

ASAScore: 3 NPO:> 8 hours Anesthesia Plan: MAC MAC Reason: Deep or markedlyinvasive procedure( G8) Anesthetic planand risks discussed with: patient. Outstanding issues: none. Post-operativepain management: IV meds. Discussed anesthetic planwith : CRNA and attending .

Revision History .. .

Date/Time 07/18/20148:45AM

07/11/20145:04 PM

View DetailsReport

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RN 7/11/2014 4:24 PM

User Addend

KN Sign

Action

.. 1 of2

MRN Sex DOB Age 70Male

SURGEON Signed GI H&P

Department of Medicine Division of Gastroenterology, Hepatology & Nutrition

Procedure Planned: Colonoscopy with EMR Reason for Procedure: Surveillance for personal history of polyps

History:

Service date: 07/18/201 4 8:55 AM

year old male with recent colonoscopy (6/11/14) CRCSin and found to have multiple colon polyps, large Polyp (Tubulovillos adenoma 3 em) in ascending colon with partial resection followed by clip/placemen).

No FHx of colon polyps or CRC NOaspirin or plavix or coumadin recently

Past Medical History Diagnosis

Diabetes mellitus Hypertension Thyroid disease Asthma

PastSurgical History Procedure

Rotator cuff repair Joint replacement

THA Back surgery

Date

fusion and discectomy- lumbar spine

I have reviewed the past medical and surgical , history.

Home Medications: Prescriptions prior to admission Medication

amLODIPine(NORVASC)5 MG tablet benazepril (LOTENSIN)20 MG tablet fluticasone-salmeterol (A OVAl R) 100-50MCG/DOSEdiskus inhaler glipiZIIDE (GLUCOTROL)5 MG tablet levothyroxine (SYNTHROID, LEVOTHROID)50 MCGtablet omeprazole (PriLOSECOTC)20 MG tablet simvastatin (ZOCOR)40MG tablet terazosin (HYTRIN)2 MG

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Sig Take by mouth daily.

Take by mouth daily.

Inhale2 times daily. Rinse mouth well and spit after each use.

Take by mouth 2 times daily (before breakfast and dinner). Take by mouth every morning (1 hr before breakfast) . Take by mouth daily.

Take by mouth nightly at bedtime. Take by mouth nightly at

Laterality Date Left Right

Dispense Refil l

8/19/201 4

capsule bedtime.

Current HospitalMedications: Scheduled: Continuous Infusions: PRN:

Allergies: has No Known Allergies.

Review of Systems Allsystems are negative except for: Gastrointestinal : positive for dyspepsia

Airway: Open,uncompromised

NPOsince: Lastnight

Labs: CXR: ECG:

PhysicalExam

Chest: CTAbilaterally CV:S1 and S2normal Gl: soft, non tender, BS+

Assessment I Diagnosis:

Large tubulovillosadenoma in ascending colonwith partialresection ... Requires re-evaluation and possibleEMR

ASA: 3

Previous Anesthesia: None known

Any Contraindications for Sedation?: no

Anesthetic/Sedation Plan:General/MAC Anesthesia requested

Optionsand risks discussed with Patient

Sedation consent signed and in Medical Record: yes

Inlight of the above evaluation, Ibelieve this patient is an acceptable candidate for the procedure planned as outlined above.

7/18/2014 8:55AM

Cosigned b y. 10:38 AM!

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PATHOLOGY CONSULTATION REPORT

Report Type: NGS Molecular

Referrina Phvsic;ian(s)/Surgeon(s):

Patient Name:

Medical Record #:

DOB: .1 ·

Age, Gender: 70, M

Accession#:

Received Date: 7/22/2014 10:20AM

Collection Date: 7/18/2014

£><:terna/ Lab #:

,.

SPECIMEN(S) SUBMITTED/ PROCEDURES ORDERED: A. Material for NGS Analysis A. NGS BRAF Mutation Analysis (81210NGUF) A NGS EGFR Mutation Analysis (81235NGUF) A. NGS-ERBB2 Mutation Analysis (81479NGUF) A. NGS KRAS Mutation Analysis (81275NGUF) A. NGS NRAS Mutation Analysis (81404NGUF) A. NGS PIK3CA Mutation Analysis (81479NGUF)

CLINICAL HISTORY: Colon cancer test for NGS

LABORATORY FINDINGS: TESTING SUMMARY BRAF MUTATION (NGS): EGFR MUTATION (NGS): ERBB2 MUTATION (NGS): KRAS MUTATION (NGS): NRAS MUTATION (NGS): PIK3CA MUTATION (NGS):

RESULTS AND CLINICAL INTERPRETATION

POSITIVE FOR KRAS MUTATION in CODON 12.

Specific Mutation: KRAS G12D

Implications For Targeted Therapeutics:

Colorectal carcinoma:

NEGATIVE INDETERMINATE INDETERMINATE POSITIVE

INDETERMINATE INDETERMINATE

Multiple studies have now shown that patients with tumors harboring mutations in KRAS are unlikely to benefit from anti-EGFR antibody therapy, either as monotherapy (Amado et al. 2008) or in combination with chemotherapy (Bokemeyer el al. 2009; Bokemeyer et al. 2011; Douillard et al. 201 O; Lievre et al. 2006; Peeters et al. 2010). However, the presence of this specific KRAS mutation was not evaluated in these trials.

Source and additional information available at: http://www.mycancergenome.org/content/disease/colorectal­ cancer/kras/

NEXT GENERATION SEQUENCING DETAILS

GENES EVALUATED AND REPORTED:

BRAF EGFR ERBB2 KRAS NRAS PIK3CA

A complete list of all variants detectable by this NGS assay are available upon request or at http://pathlabs.ufl.edu/services/molecular-pathology.

Unless specified above, no pathogenic mutation was detected in the amplicons analyzed in the genes listed above. Variants that are regarded as benign variants or variants lacking clinical significance will not be reported

SPECIFIC TARGETS BELOW ADEQUATE COVERAGE THRESHOLD

ServiceDate: 7/18/2014 UDI DocType: UNDEFINED DOC TYPE Report

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Patient Name: Medical Record Accession #: 1

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All ampliconswere lowcoverage. There was very littletissue on the block. KRAS and BRAFwere confirmed by pyrosequencing TUMORCHARACTERISTICS: Tumor Type: ColorectalAdenocarcinoma Tumor Site: Colorectal Tumor.% in microdissected area: 30%

METHODOLOGY:

NEXT GENERATIONSEQUENCING(NGS): The area of tumor is first localizedusing a corresponding H-E slide in which the area of tumor is encircledand the percentage of tumor in this area is noted. Additional characteristics includingpresence of necrosis and amount of tumor are estimated . Following manual microdissection of the area enriched for tumor the genomic DNA is extracted using the Qiagen FFPEDNA isolation Kit. The genes and targets detectable in this assay are listed elsewhere. Using the lon AmpliSeqkit, next generation sequencing was performed on the ion Torrent Personal Genome Machine and analyzed with the Torrent SuiteSoftware.DNA sequences used as references can be found at http://www.ncbi.nlm.nih.gov/refseq/rsg/. The mutation nomenclature is based on the convention recommended by the Human Genome Variation Society(http://www.hgvs.org/mutnomen/).

This assay will only detect alterations in those amplicons targeted, as these genes are not entirely sequenced. The limit of detection is 5% at 500X coverage and 10%at 250Xcoverage . Amplicon regions are not covered to a depth of at least 250Xwill be listed in the report and the user should be aware of the possibility of false negatives that may be present at a frequency of lessthan 10%of the tumor. Mutations present belowthe level of detection of this assay will not be identified. Variants that are most likely considered to be non-pathogenic will be reported as a variant of no known clinical significance though it cannot be completely excludedthat these will be deemed significant in the future. This assay is intended to detect somatic alterations present in tumor cells and is not to be used to determine or report germline alterations. If there is a clinicalconcern that an alteration reported in this assay is a germ linealteration, this should be .evaluated by a separate clinically validated test whose purpose is the detection of germ line alterations .

KRAS MUTATIONALANALYSISPYROSEQUENCING)

Tumor DNA was manually microdissected from the formalin-fixed paraffin embedded tissue sample using a corresponding H-E stained tissue slide as a reference. This is performed to enrich the sample for tumor. Following dissection, PCRamplification of codons 12 and 13 of the KRAS gene was performed. Pyrosequencing was performed to analyze for mutations in codon 12 and 13 of the KRAS gene. This test detects 7 KRAS gene mutations in codon 12 and 13. The mutations in these two codons are linked to resistance to cancer therapies that target the EGFR pathway in colorectal and other pathways. The followingmutations are detected using this assay: GLY12SER(C.34 G>A), GL Y12CYS (C.34 G>T), GL Y12ARG (C.34 G>C), GLY12SP(C.35 G>A), GLY12VAL (C.35 G>T), GLY12ALA (C.35 G>C), GLY13ASP(C.38 G>A). Tests were developed and their performance characteristics were determined by the University of Florida PathologyLaboratories (UF PathLabs). The U.S.Food and Drug Administration has not approved or cleared these tests; however, FDA approval or clearanceis not required for clinical use. These tests should not be regarded as investigational or for research use. The results are not intended to be used as the sole means for clinical diagnosis or patient management decisions. The University of Florida PathologyLaboratories is authorized to perform high complexity testing. The testing was performed at the University of Florida PathologyLaboratories, 4800SW 35th St. Gainesville, FL 32608

BRAF MUTATIONANALYSISPYROSEQUENCING)

Test description Tumor DNA was microdissected from the sample using a corresponding H-E stained tissue slide as a reference. DNA was extracted and exon 15 of the BRAF gene was amplified by polymerase chain reaction (PCR). The presence or absence of a BRAF mutation was analyzed using pyrosequencing. Analytical sensitivity: 5% tumor in 95% normal. Reference range: No mutation present (normal)

This test was developed and its performance characteristics were determined by the University of Florida PathologyLaboratories (UF PathLabs). The U.S. Food and Drug Administration has not approved or cleared this test; however, FDA approval or clearance is not required for clinical use. This test should not be regarded as investigational or for research use. The results are not intended to be used as the sole means for clinical diagnosis or patient management decisions. The University of Florida PathologyLaboratories is authorized to perform high complexity testing. The testing was performed at the University of Florida PathologyLaboratories, APPENDIS: For all non-FDA approved tests listed above unless specified above, UF Health PathologyLaboratories (UFHPL)test have been developed and their performance characteristics determined by UFHPL These tests have not been clearedor approved by the U.S.Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. Tests are used for clinical purposes and should not be regarded as investigational or for research purposes. UFHPLis certified under the Clinical Laboratory ImprovementAmendments of 1988 (CLIA)as qualified to perform high complexity clinical testing.

Decisions on patient care and treatment must be based on the independent medical judgment of the treating physician, taking into considerations all applicableinformation concerning the patient's condition including family history, physical examination, patient preferences and other diagnostic tests in accordance with the applicablestandard of care. Treatment decisions should not be made based solely on the information contained in this report. The presence of a genomic alteration that has been reported to show response to a particular therapy is no guarantee that the agent will show efficacy in any given patient.

ServiceDate: 7/18/2014 / UDN: DocType: Report

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Patient Name: Medical Record#: Accession #:

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Any reference to clinicaltrialsor treatment options is based on the currently availablepublic knowledgeaggregated by publically availablewebsites which we do not provide or update content nor are we responsible for monitoring the update of content. Treatingphysician certifies by receiving this report that the patient has been adequately counseled about the resultsof this genetics test in according with all applicablelaws.

Resident/Prosector/Pathologist: ICD9Codes: 153.9

Note T estsystemshavebeendevelopedandtheirperformancecharacteristicsdetermined by UniversityofFloridaPathologyLaboratories. Sometestshavenot beenclearedorapprovedby the U.S.Foodand DrugAdministration. TheFDA hasdeterminedthatsuchclearanceisnot necessary Thesetestsareusedforclinicalpurposesand shouldnotbo regardedas investigationalor for research Thislaboratoryis certifiedunder theClinicalLaboratoryImprovementAmendmentsof 1988 (CLIA-88)asqualified to perform high complexityclinicallaboratorytesting.

signed

ServiceDate: A DocType: UNDEFINED Report

,.

Results SCANNEDPATHOLOGY(Order) Result Information

Status Final result(8/13/2014 1:48PM)

Entry Date 8/13/2014

Results- SCANNEDPATHOLOGY Scanon 8/13/2014 1:48 PM by Scanned,Document Onb: UNDEFINEDDOCTYPEReport

Transcription Type ID Date and Time PathologyReport 154297355 8/13/2014 1 :48 PM

Signedby Scanned, Document Onbon 08/13/14at 1352

Document Text

Author Scanned,Document Onb

Display only: Transcription on 8/13/2014 1:48 PMby Scanned, Document Onb

Statusof OtherOrders Order Glucose (Meter) ORSurgicalPathology Tissue SURGICALPATHOLOGYTISSUE

Lab Status Abnormal Final result

No Resu lt Edited Result -

Result Date ProviderStatus 7/18/2014 Ordered

Ordered 8/13/2014 Reviewed

FINAL Fri Aug 15, 2014 9:00

SCANNEDPATHOLOGY Cancer Genetics

Standing Glucose (Meter) ORSurgicalPathology Tissue

Interval: ONCEE

Final result Final result

Remaining 0of 1 0of 1

Vital Signs- Onarrival to floor [Pended] 1 of 1 Interval POST-OP/PRO

Vital signs -At 1 hour after arrival to floor 1 of 1 [Pended]

Interval: POST-OP/PRO Vital signs -At 2 hours after arrival to floor 1 of 1 [Pended]

Interval : POST-OP/PRO Vital signs -At 3 hours after arrival to floor 1 of 1 [Pended]

Interval : POST-OP/PRO Vital signs - At 4 hours after arrival to floor 1 of 1 [Pended] . Interval: POST-OP/PRO

Incentive spirometry - nurs ing [Pended] 1 of 1 Interval: ONCE

Post-Procedure Pulse Oximetry - Continuous 1 of 1 [Pended]

Interval: CONTINUOUS SURGICALPATHOLOGUTISSUE 0of 1

AM 7/21/2014 Not Reviewed 8/13/2014 Reviewed

Fri Aug 15, 2014 9:00 AM

Last Release

7/18/2014

Page 1 of 2

Cancer Genetics 0of 1

CanCanceled Notify Physician Glucose(Meter) POC(if patient is diabetic) Isopropylalcoholwipes for anti-emetic purposes Post-Procedure Pulse'Oximetry - Continuous Post-Procedure OxygenTherapy Notify Physician Glucose(Meter) POC(if patient is diabetic) isopropylalcoholwipes for anti-emetic purposes Post-Procedure PulseOximetry-Continuous Post-Procedure OxygenTherapy Patient is stableand can be releasedfrom PACU Patient is stableand can be releasedfrom PACU

Order OrderProviders

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AdditionalInformation Associated Reports View Encounter Priorityand OrderDetails

SCANNED PATHOLOGY

by 2 of 2

N Registered Nurse

MRN Sex Male

Progress Notes

DOB

1 of 1

Age 70

Servicedate: 07/18/2014 12:16PM

Pthad ascending colonpolypthat was liftedin mucosa with 5 ml normalsalineand 10ml of normal saline/metholinebluesolution.

8/19/2014

1 of 1

Medication Administration Report fo as of 08/19/140731 1 Day 3 Days 7 Days 10 Days Today

+l Leaend: Medications 07/09 07/10 07/11 07/12 07/13 07/14 07/15 07/16 07/17 07/18Me

Com pleted Medications Medications 07/09 07/10 07/11 07/12 07/13 07/14 07/15 07/16 07/17 07/18 acetaminophen (OFIRMEV)IV1,000mg 1239 Dose1,000mg Freq: ONCE Route: IV (1 ,000 Start: 07/18/141245 End 07/18/141254 mg)

Discontinued Medications Medications 07/09 07/10 07/11 07/12 07/13 07/14 07/15 07/16 07/17 07/18 HYDROmorphone HCI PF (DILAUDID) injection 0.2-0.5mg Dose: 0.2-0.5mg Freq: PRN Route: IV PRN Reason: other PRN Comment: For moderate to severe pain (pain scale rating of 5 or greater. Start: 07/18/14 1234 End: 07/18/141608

Admin Instructions: May give every 4 minutes PRN

Not to exceed 2 mg/hr in PACU. Hold for resp less than 12, SpO2less than 92%, NN, sleep. **Look- Alike /Sound- AlikeAlert, Use Caution** nalOXone(NARCAN) injection 0.2mg Dose: 0.2 mg Freq: PRN Route: IV PRN Reason: other PRN Comment: Resp less than 10and SpO2less than 90%on 100%FiO2. Start: 07/18/14 1234 End: 07/18/14 1608

Admin Instructions: Begin mask ventilation and prepare to intubate. Call Anesth STAT Mav repeat X 1 ondansetron (ZOFRAN)injection 4 mg Dose: 4 mg Freq: PRN Route: IV PRN Reasons: nausea,vomiting Start: 07/18/141234 End 07/18/14 1608 Medications 07/09 07/10 07/11 07/12 07/13 07/14 07/15 07/16 07/17 07/18

by at 8/19/2014 7:31:57 AM