A finished HIM-355 Topic 7 full operative report coding example, coding one composite report for the hospital and the surgeon with each assignment justified from quoted narrative. Searches like "him 355 topic 7 assignment example", "him355 topic 7 sample" and "him-355 topic 7 example" land here.
What a finished HIM-355 Topic 7 full operative report coding looks like
The finished example is the report, two coded lists and a justification under every code. The composite report is titled partial colectomy, but its narrative describes removal of the entire sigmoid colon with the remaining ends joined, plus a wedge biopsy of a separate liver lesion. On the ICD-10-PCS side, the colon procedure is coded as Resection, because the sigmoid colon is its own body part value and all of it was removed; the anastomosis is not coded, being a step in closing the operative site; the liver biopsy is coded separately as a diagnostic Excision of a different body part. On the CPT side, the surgeon's procedure is selected from descriptors that already include the anastomosis, and the biopsy is checked against the descriptors and edits before it is reported. Each line cites the numbered sentence that supports it.
How an HIM-355 Topic 7 example is structured
The coded report is arranged in the order a reviewer would check it. First comes the composite report in full, with sentences numbered so every code can cite its source. An abstraction grid follows, one row per action, carrying body part, objective, approach, device and specimen, which applies the work of an earlier topic. The inpatient list comes next, each ICD-10-PCS code described character by character in words, with the root operation defended against the title where the two disagree. The professional list follows, with the primary CPT procedure, any additional reportable service and any modifier, each justified by numbered sentences. A reconciliation passage compares the two lists and explains why they count the session differently. The final section names anything the narrative left unclear and drafts a neutral query to the surgeon, to be answered before the claim goes out.
Sentences numbered for citation
The composite report is reproduced with numbered sentences, so every code on both lists can point to the exact line of narrative that supports it.
Title overruled by the narrative
A report headed partial colectomy describes removal of the whole sigmoid colon, and the example codes the Resection the narrative supports instead of the heading.
Closing steps left uncoded
Joining the remaining ends of the bowel is treated as part of closing the operative site, which the inpatient guidelines do not code as a separate procedure.
A second body part, a second code
The wedge biopsy of the liver lesion is coded separately as a diagnostic Excision, since it involves a different body part from the main procedure.
The surgeon's claim built separately
CPT descriptors are chosen for the professional list on their own terms, including what each descriptor already contains, rather than translated from the inpatient codes.
Two lists reconciled at the end
The example explains why the hospital and surgeon claims count the same session differently, so a reviewer comparing them sees design rather than error.
Where marks go in HIM-355 Topic 7
Coding the heading instead of the narrative loses the first and largest block of marks, because partial colectomy points toward Excision and the narrative says otherwise. Reporting the anastomosis as its own procedure on the inpatient list shows the guideline on components was skipped. Dropping the liver biopsy, or folding it into the colon procedure, misses a separate body part with its own diagnostic objective. On the professional side, translating the inpatient codes into CPT rather than reading the descriptors produces a code that does not describe the service. Codes presented without numbered narrative support cannot be checked, and checking is the point of the exercise. A frequent final loss is leaving an unclear detail unresolved in silence, when the gap in the report calls for a written query to the surgeon.
Get an HIM-355 Topic 7 example written to your instructions
Send the HIM-355 Topic 7 instructions, your classroom rubric and the operative report or case you were assigned. We write a custom example to those criteria, with the report numbered, an abstraction grid, both code lists justified sentence by sentence and the two claims reconciled, back in 24 to 48 hours. The first one is free.
HIM-355 Topic 7 questions, answered
Can the inpatient codes be translated into CPT?
No, and attempting it produces codes that describe neither the service nor the operation. A root operation and a CPT descriptor divide the same surgical work differently, so no one-to-one path runs from a code on the inpatient list to a code on the professional list. The example reads the numbered narrative twice, once for each claim, and builds each list from its own tables or descriptors rather than converting one into the other.
What if the title and the narrative disagree?
The narrative governs, and the disagreement is worth recording. Titles are written before surgery or dictated as summaries, while the narrative describes what was done to which body part. When they point to different root operations, the example codes the narrative, quotes the sentence that decides it, and notes the discrepancy so the surgeon can correct the heading if organizational policy calls for an amendment.
When should the coder ask the surgeon?
Whenever the narrative leaves open a detail that changes a code, such as how much of a structure was removed, which segment was involved or whether a device remained. The question is written neutrally, quoting the relevant sentences and offering the reasonable possibilities, and it never suggests the answer that would pay more. The example drafts one such question for the composite report and codes the affected procedure only after the answer.