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PREOPERATIVE DIAGNOSIS: 1. Suspected abdominal wall abscess POSTOPERATIVE DIAGNOSIS: 1. Abdominal wall abscess PROCEDURE: 1. Exploration of abdominal wall post op fluid collection, incidion and drainage of abdominal wall abscess ANESTHESIA: General INDICATION FOR PROCEDURE: This unfortunate 63y.o. lady underwent free flap reconstruction of her left arm wound with an abdominal donor site. She is … Read more
Ultrasound guided right thoracentesis Indication: Pleural effusion Findings: Written informed consent was obtained from the patient after explanation of risks, benefits and alternatives. Limited ultrasound scanning over the back for localization of the right pleural effusion. Overlying skin posteriorly was marked with ultrasound and then sterilely prepped and draped. Local anesthesia with 1% lidocaine. A … Read more
Postoperative Diagnosis: Malignant recurrent pleural effusions Procedure(s): PleurX catheter placement Indications for Procedure: This is a 75 year old female with metastatic lung adenocarcinoma with recurrent malignant pleural effusions. Given patient has required multiple thoracentesis and has symptomatically improved with each one. She was deemed a candidate for PleurX catheter. Estimated Blood Loss: None Procedure … Read more
Question 1. Which is another term for “comfort care”? Elder care Respite care Palliative care Home healthcare Rationale: “Comfort care” is also called “palliative care”. The goal of palliative care is not to cure or actively treat the condition. It is to control pain or to alleviate other distressing symptoms to make a terminally ill … Read more
Since, we are here to learn about medical coding, we have to go through the charts as well. The medical coding charts are little difficult to understand in the beginning but once you become in reading the report then their won’t be any problem. Some of the medical coding examples or sample charts i am … Read more
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: Read also: … Read more
Medical coding Sample Coded Report 1 Pre-op Diagnosis: Nodular sclerosis Hodgkin lymphoma of lymph nodes of multiple regions (CMS/HCC) [C81.18] Post-op Diagnosis: Same as Pre-op Procedure(s): Right – VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT – Wound Class: Clean Proc. Description(s) & CPT Code(s): VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT: Anesthesia: General Estimated Blood Loss: Minimal … Read more
Pre-op Diagnosis: Abscess of right ring finger [L02.511] Post-op Diagnosis: Same as Pre-op Procedure(s): Right – INCISION AND DRAINAGE RIGHT RING FINGER – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers Proc. Description(s) & CPT Code(s): INCISION AND DRAINAGE RIGHT RING FINGER: Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: less than 50 … Read more
Sample Coded report (CPT 11043, 11046) Pre-op Diagnosis: Open wound of right knee, subsequent encounter [S81.001D] Post-op Diagnosis: Same as Pre-op Procedure(s): Right medial knee irrigation and debridement Right medial knee wound VAC application Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: less than 50 mL Drain: woundvac Specimens: ID Type Source Tests Collected by Time … Read more
Pre-op Diagnosis: Prostate cancer (CMS/HCC) [C61] Post-op Diagnosis: Same as Pre-op Procedure(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION – Wound Class: Clean Contaminated Proc. Description(s) & CPT Code(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION: Anesthesia: General Estimated Blood Loss: less than 100 mL Quantitative Blood Loss: No data recorded Implants: * No implants in log … Read more