Sample Coded Report 1
Pre-op Diagnosis: Peripheral vascular disease, unspecified (CMS/HCC)
Post-op Diagnosis: Severe left SFA stenosis with only moderate right SFA atherosclerotic stenosis
Procedure(s): Bilateral – Angiogram Extremity Bilateral
Proc. Description(s) & CPT Code(s): Angiogram Extremity Bilateral:
Anesthesia: Procedural Sedation
Estimated Blood Loss: Minimal
Quantitative Blood Loss: No data recorded
Drain: None
Total IV Fluids: mL
Specimens: No specimens
Complications:
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Findings: Left 80% focal distal SFA stenosis with 2 vessel runoff. Right SFA moderate stenosis.
Technique: Abdominal aortogram. Bilateral lower extremity angiogram. Left SFA stent angioplasty with 6 x 5 via Bond post dilated to 4 mm
Right femoral artery accessed over the femoral head. Guidewire passed the 5 French sheath placed. Guidewire and Omni flush catheter advanced to the abdominal aorta and abdominal aortogram performed (75625 done). Catheter pulled down to the bifurcation iliac angiography performed. Right lower extremity angiogram performed through the sheath and catheter went up and over to perform left lower extremity angiogram (75716 done). Findings are patent abdominal aorta and renal arteries common internal external iliac arteries are patent. The right common femoral and profunda are patent. The right SFA has some mild atherosclerotic disease but no occlusive disease. Popliteal is patent with three-vessel runoff.
The left common femoral and profunda are patent left SFA is patent and in the mid to distal portion of the left SFA has a focal 80% stenosis and then the distal SFA popliteal are patent with three-vessel runoff. We went up and over the bifurcation with a 6 French sheath cross the SFA lesion on the left side with a Regalia wire and pre-dilated that with a 4 by 40 AngioSculpt balloon. Repeat angiogram showed resolution of the stenosis but there appeared to be perforation with some extravasation within did a long inflation with a 4 mm drug coated balloon. Repeat angiogram showed persistent extravasation and then we covered that with a 6 x 5 via Bond and post dilated that with a 4 mm balloon repeat angiogram showed excellent flow through the stent (37226 done) with no extravasation. Trifurcation vessels are all patent with no evidence of embolization. Right femoral sheath exchanged out for short 6 French sheath and sheath angiogram performed and Mynx closure.
Disposition: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
Condition: doing well without problems
CPT codes:
CPT 37226- LT Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
75716 – 26, XU Angiography, extremity, bilateral, radiological supervision and interpretation
75625– 26 Aortography, abdominal, by serialography, radiological supervision and interpretation
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Sample Coded Report 2
Pre-op Diagnosis: CHOLELITHIASIS
Post-op Diagnosis: Acutely inflamed cholecystitis
Procedure(s): CHOLECYSTECTOMY LAPAROSCOPIC – Wound Class: Clean Contaminated
Proc. Description(s) & CPT Code(s): CHOLECYSTECTOMY LAPAROSCOPIC:
Anesthesia: General
Estimated Blood Loss: less than 50 mL
Quantitative Blood Loss: 25cc
Drain: None
Implants: * No implants in log *
Complications: none
Findings: acutely inflamed cholecystitis
Technique: Patient was brought to the operative suite placed in supine fashion administered general anesthesia endotracheally intubated. Patient’s abdomen was entered with a 5 mm incision and optiview trocar in the infraumbilical site. Once in the abdomen, insufflation was performed with 8 mm of mercury pressure CO2 and 3 liters/minute of flow. A 2 mm mini lap grasper was then placed in the right upper quadrant after anesthetized with anesthetic. There was severe inflammation and a thick rind was noted. A 5 mm trocar was then placed in a subxiphoid position after anesthetized. The gallbladder was grasped pulled superiorly and anteriorly after the patient was placed in reverse Trendelenburg and banked to the left. The fundus was then grasped and pulled. Over an hour was dissection was meticulously performed in this severely inflamed gallbladder bed. After meticulous dissection the cystic duct, cystic artery, infundibulum and liver bed were all identified for the critical view after dissection was complete. The cystic duct and artery were clipped and ligated the gallbladder was removed from the liver bed with electrocoagulation and cauterization of the liver bed with placement of Surgicel. There was no signs of active hemorrhage after the dissection was complete. The gallbladder was placed in an Endo-Catch bag, pulled through the subxiphoid port site which had to be dilated and extended to remove the large gallbladder and sent for pathologic review. There were no signs of active hemorrhage and no other obvious abnormalities. The ports were desufflated and removed with closure of the subxiphoid fascial incision with a 0 Vicryl figure-of-eight in the fascia and the skin incisions with 4-0 Monocryl subcuticular stitches and again they were injected with anesthetic and dressed appropriately. Patient tolerated the procedure well with no complications. Blood loss was 25 cc.
CPT codes:
CPT 47562 Laparoscopy, surgical; cholecystectomy
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Sample Coded Report 3
PERIPHERAL ANGIOGRAM PROCEDURE REPORT
INDICATION: Claudication, Abnormal lower extremity arterial duplex
PROCEDURE: The risks of the procedure including bleeding, infection, MI, stroke and death were explained to the patient. The patient verbalized their understanding of the procedure, the risks, benefits and alternatives and wished to proceed.
After informed consent was obtained the patient transported to the cardiac catheterization laboratory. In the cardiac catheterization laboratory the patient was prepped and draped in usual sterile fashion. After infiltration of the right groin using 1% Xylocaine solution the right common femoral artery was cannulated with a 6 French cordis introducer. Through the sheath a 6 French pigtail catheter was placed in the descending aorta above the renal arteries and aortography was performed (75625 done), the pigtail catheter was pulled back to the iliac artery bifurcation and a distal runoff was performed of the lower extremities. . Hemodynamic pressure tracings were recorded. The patient tolerated the procedure well without complications. Findings were as follows.
FINDINGS:
Aorta: Calcification throughout the length descending aorta. No dilatation noted
Renal Arteries: No hemodynamically significant stenoses bilaterally.
RIGHT
Common iliac artery: no significant disease
External iliac artery: no significant disease
Internal iliac artery: no significant disease
Common femoral artery: Previous stent placement which appears to be patent. Calcification through out the length of the specimen.
Profunda: no significant disease
SFA: Total obstruction of the superficial femoral artery with collateral flow to the popliteal artery.
Popliteal: no significant disease
Two vessel runoff:
LEFT
Common iliac artery: no significant disease
External iliac artery: no significant disease
Internal iliac artery: no significant disease
Common femoral artery: no significant disease calcification noted throughout the length of this vessel.
Profunda: no significant disease
SFA: no significant disease previous stent placed which appears to be patent.
Popliteal: no significant disease
3 vessel runoff : patent with no significant disease
CONCLUSIONS: 1. Total obstruction of the right superficial femoral artery with reconstitution to the popliteal artery.
2. Patent stent in the left superficial femoral artery.
3. Aorta with diffuse calcification throughout his sling, no dilatation or dissection noted.
4.*-Renal arteries breathing is significant stenoses.
CPT codes:
CPT 36200 Introduction of catheter, aorta
75625-26 Aortography, abdominal, by serialography, radiological supervision and interpretation
75716-26 Angiography, extremity, bilateral, radiological supervision and interpretation