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Sample Medical Coding Report 1 Pre-op Diagnosis: 1. Nasal septal fracture Post-op Diagnosis: same as above Procedure: 1. Closed reduction nasal septal fracture with internal and external fixation Anesthesia Type: GETA Surgeon: Anesthesiologist: Assistant 1: Estimated blood loss (mL): 50 Complications: None apparent Indication and consent: patient is a 35-year-old gentleman who suffered an nasal … Read more
Medical coding Sample Chart 1 PREOPERATIVE DIAGNOSIS: Recurrent streptococcal adenotonsillitis POSTOPERATIVE DIAGNOSIS: Same ANESTHESIA: General by endotracheal tube. COMPLICATIONS: None. OPERATION/PROCEDURE: Traditional tonsillectomy and adenoidectomy. FINDINGS:Tonsils: 3+, significant scar to superior constrictor muscle Adenoids: 1+ INDICATION: Recurrent streptococcal adenotonsillitis DESCRIPTION OF PROCEDURE: After informed consent was obtained in the preoperative holding area, the patient was … Read more
Sample Medical coding chart 1 Pre-op Diagnosis: vitreous hemorrhage left eye Post-op Diagnosis: vitreous hemorrhage left eye, multiple horseshoe tears left eye Procedure: PPV/EL/FAx + gas left eye Implants: none Anesthesia Type: GETA Estimated blood loss (mL): 0.1 Findings: see below Specimens: none Complications: none Indication and consent: The patient presented to the Retina Center … Read more
Sample Chart 1 EXAM DESCRIPTION: IR spine myelogram cervical CLINICAL HISTORY: Neck pain, intrathecal injection for CT cervical spine (CT cervical myelogram) CONSENT: The procedure, risks, benefits, and alternatives were discussed with the patient, and all questions were answered. Informed consent was obtained verbally and in writing. NURSING/MEDICATIONS: Continuous cardiorespiratory monitoring was provided throughout the … Read more
Medical Coding Example Sample coded Report 1 PREOPERATIVE DIAGNOSIS: Lumbar radiculopathy, central and subarticular stenosis at L2-L3. POSTOPERATIVE DIAGNOSIS: Lumbar radiculopathy, central and subarticular stenosis at L2-L3. PROCEDURE: Bilateral L2-L3 laminectomy, partial medial facetectomy, and foraminotomy. SURGEON: ASSISTANT: INDICATIONS FOR SURGERY: Briefly, this is a 61-year-old woman with the above- mentioned diagnosis.She additionally has … Read more
Medical coding Surgery Sample coded Chart 1 PREOPERATIVE DIAGNOSIS: Chalazion. POSTOPERATIVE DIAGNOSIS: Chalazion. PROCEDURE: Chalazion excision. I have explained the indications, alternatives, risks, and potential benefits of the procedure to the patient, and she fully understands and has given informed consent. SURGEON: DESCRIPTION OF PROCEDURE: The skin around the affected lid was prepped and draped in … Read more
Medical coding Sample Chart 1 PROCEDURE PERFORMED: Left and right heart cardiac catheterization. Selective coronary angiography. Left ventriculography. Performed from right radial artery and right brachial vein without complication. PREOPERATIVE DIAGNOSES: Severe tricuspid regurgitation. Rheumatic mitral valve disease with mitral regurgitation. Preoperative workup for tricuspid valve replacement. POSTOPERATIVE DIAGNOSES: Mildly elevated left heart filling pressure. … Read more
Surgery Medical coding Sample Coded Chart for Coders PREOPERATIVE DIAGNOSIS: Extruded vaginal mesh. POSTOPERATIVE DIAGNOSIS: Extruded vaginal mesh. PROCEDURE: 1.Excision of vaginal mesh. 2.Cystoscopy. SURGEON: ANESTHESIA: General. ANESTHESIOLOGIST: BLOOD LOSS: 10 mL. COMPLICATIONS: None. IMPLANTS PLACED: None. SPECIMEN SENT: Extruded vaginal mesh as well as surrounding vaginal tissue were sent for pathology. INDICATION FOR SURGERY: This … Read more
Vascular Coding Practice Chart 1 Visceral arteriography: Indication: Lower GI bleeding TECHNIQUE: Informed consent was obtained. The right common femoral artery was catheterized using a modified Seldinger technique and a micropuncture set. A 5 French sheath was inserted. Through this a 4 French Motarjamie catheter was used to select the inferior mesenteric artery. The mesenteric arteriogram was performed … Read more
PREOPERATIVE DIAGNOSIS: Torn right medial and lateral menisci. POSTOPERATIVE DIAGNOSES: Torn right medial and lateral menisci, degenerative arthritis of medial femoral condyle, and chondromalacia patella. PROCEDURES PERFORMED: DISPOSITION: The patient tolerated the procedure very well. OPERATIVE PROCEDURE: The patient was brought to the operating room. He was properly identified and correct extremity was marked. The … Read more