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PREOPERATIVE DIAGNOSIS: 1. Closed Left Tibial Plateau Fracture POSTOPERATIVE DIAGNOSIS: 1. Same PROCEDURES PERFORMED: 1. Closed Reduction with placement of external fixator: Left tibial plateau ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Minimal COMPLICATIONS: None. DRAINS: None. SPECIMENS: None. TOURNIQUET: None. HPI & INDICATIONS FOR PROCEDURE: The patient is a who presented to the emergency department s/p motor … Read more
Pre-op Diagnosis: Primary osteoarthritis of left knee [M17.12] Post-op Diagnosis: Same as Pre-op Procedure(s): Left – TOTAL KNEE REPLACEMENT ROBOTIC ASSISTED – Wound Class: Clean Proc. Description(s) & CPT Code(s): TOTAL KNEE REPLACEMENT ROBOTIC ASSISTED: Stryker components: Size 2 cemented tibia, size 2 Press-Fit femur, size 9 mm posterior cruciate retaining tibial polyethylene insert. Patella not resurfaced Anesthesia: General Complications: None … Read more
Pre-op Diagnosis: End stage renal disease (CMS/HCC) [N18.6] Post-op Diagnosis: Same as Pre-op Procedure(s): Left – LEFT AV FISTULA CREATION (CEPHALIC ADEQUATE) – Wound Class: Clean Proc. Description(s) & CPT Code(s): LEFT AV FISTULA CREATION (CEPHALIC ADEQUATE): Anesthesia: General Complications: There were no complications Findings: There is a thrill in the graft and a thrill in the vein distal to the graft. … Read more
Report 1 BILATERAL NEPHROSTOGRAMS PLACEMENT OF NEPHROURETERAL CATHETERS MODERATE CONSCIOUS SEDATION, FLUOROSCOPY CAN ULTRASOUND GUIDANCE AND UTILIZATION OF A STERILE SURGICAL TRAY.: INDICATION: Bilateral nephrolithiasis TECHNIQUE: Ultrasound and fluoroscopy guidance, fluoroscopy time is 14.7 minutes COMPARISON: None. FINDINGS: Having obtained informed consent prepping and draping the flanks in the usual aseptic fashion 1% lidocaine was … Read more
Below are the Question and Answers for the released August 2023 CPT assistant edition. Questions and Answers Evaluation and Management (E/M) Guidelines Question: When is the conversation between an emergency room (ER) physician and the admitting physician counted as an element in medical decision making (MDM) from the perspective of the ER physician? Answer: In … Read more
Surgery Medical coding Chart 1 PREOPERATIVE DIAGNOSIS: Adenocarcinoma in situ of cervix. POSTOPERATIVE DIAGNOSIS: Awaiting pathology report. PROCEDURE: Cold conization of cervix. SURGEON: ASSISTANT: None. ANESTHESIA: Dr. PACKS: Vaginal pack of half-inch plain gauze placed in endocervix and vagina. DRAINS: None. ESTIMATED BLOOD LOSS: Less than 50 cc. FINDINGS OF PROCEDURE: The patient was brought … Read more
Chief Complaint & History of Present Illness : 87 year old female presents with right posterior thigh pain of gradual onset this morning. Pain is sharp/stabbing, sometimes radiates down to her knee. She felt a similar pain one week ago which improved significantly with leg exercises prescribed by her physiotherapist. Denies any numbness, tingling or weakness. … Read more
Chief Complaint & History of Present Illness : Chief complaint: Right hand/wrist pain History of present illness: The patient is a 29 year old female presenting with right hand/wrist pain that started last night after she accidentally hit her and gets basketball rim. Pain is worse at the lateral aspect along the little finger. Pain … Read more
Sample Medical Coding Report 1 PREOPERATIVE DIAGNOSIS: Right trimalleolar ankle fracture. POSTOPERATIVE DIAGNOSIS: Right ankle fracture in light of osteoporosis and subacute presentation. PROCEDURE: Open reduction and internal fixation of right trimalleolar ankle fracture. ANESTHESIA PERFORMED: General with 20 cc of 0.25% Marcaine ANTIBIOTICS: Cefazolin 2 g IV. ESTIMATED BLOOD LOSS: Less than … Read more
Chief Complaint & History of Present Illness : cc: I have something in my eye HPI: this is a 67 yo female who has the sensation that something is in her eye. It began gradually last night. It is more irritated if she opens her eye but light does not bother it. SHe denies any … Read more