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Medical Coding Sample Chart 1 Preoperative Diagnosis: Umbilical hernia Postoperative Diagnosis: Umbilical hernia Procedure: Open umbilical hernia repair with mesh (Covidien Parietex mesh patch, 8.6 cm). Anesthesia: GETA plus 0.25% Marcaine local Estimated Blood Loss: Scant Complication: None Indication for Procedure: He is a 55-year-old gentleman seen by me in November 2018 with complaints of … Read more
In radiology coding, we usually come across CT,CTA, MRI, X-ray reports etc. charts which are very common in this facility. Radiology coding is not difficult if you know how to read and code a medical report. Yes, we don’t have to take any training or clear any CPC certification exam to be a radiology coder. If … Read more
Medical Coding Sample Chart 1 Procedure: CERVICAL FACET INJECTION LEFT C5-6 and C6-7 Diagnosis: Cervical Spondylosis The patient has been referred to the Pain Management Center for cervical facet injection treatment of chronic axial neck pain. The patient has had long standing cervical pain thought to be facet joint generated and which has been refractory … Read more
Sample Chart 1 Reason For Exam cancer;Other Report PROCEDURE: PICC PLACEMENT USING ULTRASOUND AND FLUOROSCOPIC-GUIDANCE: CLINICAL INFORMATION: Malignant neoplasm of tonsil. FINDINGS: This central venous catheter was inserted with all elements of maximal sterile barrier technique, cap and mass and sterile gown and sterile gloves and sterile full body drape and hand hygiene and 2% … Read more
1. What Z code is used to represent an encounter for a routine child health examination with abnormal findings? A. Z00.00 B. Z01.818 C. Z00.121 D. Z01.419 2. If the provider’s assessment indicates an overweight patient has been binge eating with vomiting, which code is most appropriate? A. F50.2 B. F50.81 C. F50.02 D. F50.82 … Read more
Sample Medical coding Chart 1 INDICATION: 49-year-old male with HCC TECHNIQUE: Under direct ultrasound guidance a micropuncture needle was advanced into the common femoral artery and a microwire advanced. The needle was removed and a micropuncture sheath advanced over the wire. An 035 wire was advanced into the abdominal aorta and a 5 French sheath … Read more
1. A patient receives two vaccines that are administered intramuscularly and two vaccines that are administered orally. The patient receives no counseling on the vaccines. Which codes should be used to report these services? A. 90471 x2, 90473 x2 B. 90471, +90472, 90473, +90474 C. 90471, +90472, +90474 x2 D. 90460, +90461 x3 2. A … Read more
Medical coding Sample report 1 Pre-op Diagnosis: Left hip recurrent acetabular labral tear Post-op Diagnosis: Same Procedure: Left hip acetabular labral reconstruction using semi tendinosis allograft 6 mm in diameter. Revision cam resection or femoral osteoplasty Implants: Five cinch lock anchors and 1 NanoTack anchor from Stryker Anesthesia Type: GETA and regional (Fascia iliacus block) … Read more
Medical coding Sample Report 1 EXAM: MAMMO US BIOPSY LYMPH NODE RT COMPARISON: None REASON FOR EXAM: N63.10-Breast mass, right ADDITIONAL HISTORY: . INFORMED CONSENT: Prior to the procedure in an non-coercive space, the patient was advised as to the nature of the procedure including placement of markers, alternatives, benefits, and risks including but not … Read more
Medical coding Sample Report 1 EXAM DESCRIPTION: IR cvc port removal CLINICAL HISTORY: Port removal CONSENT: The procedure, risks, benefits, and alternatives were discussed with thepatient, and all questions were answered. Informed consent was obtained verbally and in writing. NURSING/MEDICATIONS: Continuous cardiorespiratory monitoring was provided throughout the examination. Local anesthesia only PROCEDURE: The patient was … Read more