Medical Coding Example Report 1

PREOPERATIVE DIAGNOSIS:   Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic.

POSTOPERATIVE DIAGNOSIS:   Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic.

PROCEDURE:  

1. Left small saphenous vein radiofrequency ablation.
2. Phlebectomy of left lower extremity varicose veins with 6 incisions.

ANESTHESIA:   General.

ESTIMATED BLOOD LOSS:   Minimal.

COMPLICATIONS:   None.

OPERATIVE FINDINGS:  

The patient had a patent left popliteal vein upon completion of the procedure with good compression. She had multiple friable varicosities in the subcutaneous tissues of the left lower leg. 

INDICATIONS FOR SURGERY:   The patient is a 56-year-old woman with symptomatic left lower extremity varicose veins and associated left small saphenous vein insufficiency. She failed conservative therapy trial and therefore intervention was recommended. The procedure of radiofrequency ablation of the left small saphenous vein as well as phlebectomy was discussed with the patient, who appeared to understand and agreed to undergo the procedure.

PROCEDURE IN DETAIL:  

The patient was brought to the operating room and placed on the table in supine position. After appropriate monitoring devices were placed, she was given anesthesia. She was then placed in a prone position in order to allow us to access her left small saphenous vein. We marked the course

of the left small saphenous vein with ultrasound guidance. It appeared to enter the popliteal vein at the level of the popliteal fossa. The vein was then accessed in the mid calf using a micropuncture kit. A 0.018-inch wire was passed centrally and a 7-French short sheath introduced into the vein. Intraluminal placement of the sheath was confirmed by aspiration of venous blood

and with imaging with ultrasound. The VNUS ClosureFAST catheter was selected and prepared. The length of the catheter was marked on the skin. The catheter was then advanced through the sheath to the saphenopopliteal junction. The tip was confirmed to be at least 2 cm away from the saphenopopliteal junction.

Tumescence was then instilled around the vein in the small saphenous compartment throughout the treated length in order to provide a clear halo for the vein for external compression and to assure that the vein was at least 2 cm in depth from the skin. The patient was then placed in Trendelenburg position and radiofrequency energy was applied as the catheter was pulled back. The settings remained optimal during pullback. The table was then flattened and the vein reinspected with ultrasound demonstrating no spontaneous flow in the vein and a widely patent deep vein system with a patent popliteal vein that was compressible. The sheath was then removed and pressure held over the access site to gain hemostasis.

We then directed our attention towards phlebectomy. Six small incisions were made over vein clusters and varicosities excised. The majority of which were on the posterior calf and few on the posterior thigh. Total of 6 incisions were made. Direct pressure was held over the incisions to achieve hemostasis. Larger veins were ligated with 3-0 silk ligatures. The larger incisions were

closed with interrupted 4-0 Monocryl suture and smaller incisions were closed with Steri-Strips. The incisions were then dressed with Steri-Strips, 2 x 2 gauze, and Tegaderm. A compression dressing was then applied to the leg. The patient tolerated the procedure well and was transported to the recovery area in stable condition. All sponge, needle, and instrument counts were found to be correct at the end of the procedure.

CPT 36475-LT Ablation therapy of incompetent vein, percutaneous, radiofrequency; first vein treated

37799 Unlisted procedure, vascular surgery,

ICD 10 code :I83.812

I87.2

Medical coding Example 2

Procedure: Flexible Sigmoidoscopy

Anesthesia: None

Indications: Rectal hemorrhage

Findings:– A few diverticula were found in the sigmoid colon.

                    – Internal hemorrhoids were found during retroflexion. The hemorrhoids were mild.

                    – The exam was otherwise without abnormality.

Impression:         – Diverticulosis in the sigmoid colon.

                    – Internal hemorrhoids.

                    – The examination was otherwise normal.

                    – No specimens collected.

Complications:No immediate complications. Estimated blood loss: None.

Estimated Blood Loss: Estimated blood loss: none.

Procedure:

Pre-Anesthesia Assessment:  – Prior to the procedure, a History and Physical was performed, and patient medications and allergies were reviewed. The patient’s tolerance of previous anesthesia was also reviewed. The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered, and informed consent was obtained. Prior Anticoagulants: The patient has taken no previous anticoagulant or  antiplatelet agents. ASA Grade Assessment: III – A patient with severe systemic disease. After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.

After obtaining informed consent, the endoscope was passed under direct vision. Throughout the procedure, the patient’s blood pressure, pulse, and oxygen saturations were monitored continuously. The Colonoscope was introduced through the anus and advanced to the left transverse colon. The flexible sigmoidoscopy was accomplished without difficulty. The patient tolerated the procedure fairly well. The quality of the bowel       preparation was good.

Procedure Code(s): —

45330, Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Diagnosis Code(s): —

K64.8, Other hemorrhoids

K62.5, Hemorrhage of anus and rectum

K57.30, Diverticulosis of large intestine without perforation or abscess without bleeding —

Medical coding Example 3

PREOPERATIVE DIAGNOSIS:   Right renal stone status post stent placement and

treatment for urinary tract infection.

POSTOPERATIVE DIAGNOSIS:   Large right renal stone.

PROCEDURE:   Right ureteroscopy, laser fragmentation of stone, attempted basket

removal of stone, and placement of indwelling ureteral stent.

ANESTHESIA:   General.

COMPLICATIONS:   None.

DRAINS:   A 4.8-French variable length double-J stent.

ESTIMATED BLOOD LOSS:  

Negligible.

The patient was brought to the operating room and she was given a general anesthetic. She was given 2 g of Ancef IV as a preoperative urine culture demonstrated mixed urogenital flora only. She was placed in lithotomy position and prepped with Betadine and draped in a normal fashion. Cystoscopy was performed through a 22-French sheath and her right ureteral stent was grasped

with biopsy forceps and brought to the urethral meatus. A wire was passed into this but would not pass to the tip of the stent for reasons that were unclear. I therefore forced to remove the wire and stent together. I was able to cannulate the ureteral orifice using the ureteroscope and I passed a wire back up into the renal pelvis. I then passed over this the 12/14 ureteral access

sheath. I was able to advance this without difficulty up to the level of the renal pelvis. I then performed flexible ureteroscopy.

The large stone had migrated laterally and was located in the lower pole calyx. I was able to demonstrate this with retrograde pyelogram. I was able to flex the scope adequately to get into the lower pole calyx where I was able to fragment the stone. A portion of the stone, however, fell into a dependent area that was impossible to access with the scope. I used the irrigation as well as possible to dislodge fragments so that they could be further fragmented. I introduced a 3 wire basket with the hope that I could snare the stone and bring it into a more favorable position. This was not effective either. It is possible that these small fragments are far down into a depending calyx that they will not pass. A total of 4604 joules were delivered to the stone to achieve fragmentation and it looked as though the majority of the stone had been reduced to dust.

At this point, after attempting to fragment the stone for approximately 30 minutes, I elected to place a stent. This was placed and the bladder was drained. The stent position was confirmed fluoroscopically.

My plan is to check KUB in a week or so. If there are significant stone fragments remaining, I will discuss with the patient’s mother shockwave lithotripsy, stent removal leaving the stone in the lower pole, and repeat ureteroscopy. Following the procedure, I discussed this with the patient’s

mother and her sister.

CPT code : 52356 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

Medical Coding Example 4

PREOPERATIVE DIAGNOSIS:  

1. Pelvic pain.
2. Stenotic cervix.
3. Suspected hematometra on pelvic ultrasound.

POSTOPERATIVE DIAGNOSIS:  

1. Pelvic pain.
2. Stenotic cervix.
3. Mucous filled cervical and endometrial canal.
4. Endometrial cavity partially scarred closed, post endometrial ablation.

OPERATIVE PROCEDURE:   diagnostic hysteroscopy and dilation and curettage

INDICATIONS FOR SURGERY:  

The patient is a 49-year-old female, who is status post endometrial ablation in 2007, who presented with feelings of urinary urgency, menstrual cramps, and enlarged tender uterus on bimanual exam. On transvaginal ultrasound, there was a stenotic cervix with dilated fluid-filled endocervical canal and lower dilation of the endometrial canal.

Operative Findings:   Anteverted 8-10 week size uterus no appreciable adnexal masses. Cervix stenotic and once first dilator inserted mucinous clear fluid drained from the cervix. Endometrial cavity was partially scarred closed, but tissue was normal in appearance. No endometrial or cervical polyps noted.

Fluid deficit 400 mL, though significant percent of fluid deficit was on the operating room floor.

ESTIMATED BLOOD LOSS:   Minimal.

URINE OUTPUT:   None.

COMPLICATIONS:   None.

DISPOSITION:   Home after recovery in PACU.

OPERATIVE PROCEDURE:  

Preoperative antibiotics, Ancef, was administered given fluid in the endocervical and endometrial canal. The patient was brought back to the operating room where general anesthesia was obtained without difficulty. She was then prepped and draped in the usual sterile fashion in the dorsal lithotomy position. A speculum was placed in the vagina, and cervix grasped with single-tooth tenaculum on the anterior lip. A 0.25% bupivacaine without epinephrine was used to perform paracervical block. Small Hegar dilators were used to dilate the cervix and on entry of the first dilator, clear mucus poured out of the cervix. With continued dilation, more fluid poured out of the cervix with a total of at least 5 to 10 mL of fluid expelled from the cervix. At this point, the uterus was sounded to 6 cm. The operative hysteroscope was attempted to be inserted several times because the outside of the cervix was very stenotic. It was difficult to get the hysteroscope through the cervix externally. The cervix was dilated up to 17-French. I eventually was able to insert the hysteroscope using the guide to get in through the external cervix. This over dilation of the cervix lead to fluid pouring out of the cervix during hysteroscopy which lead to large fluid deficit on floor. The endometrial canal appeared scarred and fluffy with no ability to see either tubal ostia. Limited bedside ultrasound was done to confirm that I was truly in the endometrial canal and not in a false passage given the appearance of the endometrium. It was confirmed that it was truly in the endometrial canal and that the endometrial canal was scarred shut at the fundus. A gentle sharp curettage was performed of the accessible endometrial cavity, and this was sent to Pathology. At this point, the procedure was terminated. Silver nitrate was used to obtain hemostasis of the tenaculum sites. The patient went to the recovery room in stable condition.

CPT 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C

ICD 10 code

R10.2

N85.8

N882

Medical coding Example 5

PREOPERATIVE DIAGNOSIS: Dense urethral stricture.
POSTOPERATIVE DIAGNOSIS: Dense urethral stricture.
PROCEDURE: Direct-vision internal urethrotomy with cystoscopy.
INDICATIONS FOR PROCEDURE: 

The patient has worsening lower urinary tract
symptoms.

He has severe comorbidity with chronic obstructive pulmonary disease. He has
reactive airways.
PROCEDURE:
The patient received a breathing treatment. He then undergoes general anesthesia without incident and was placed in a low lithotomy position and the penis prepped and draped in a sterile fashion. He had received preoperative antibiotics. A surgical time-out was undertaken.

The 0 degree lens and visual urethrotome was inserted into the urethra. There is a 2 cm long tight bulbourethral stricture. This was widely opened at the dorsal position using the visual urethrotome. I take care to spare the membranous urethra.

I then performed cystoscopy with a 22-French cystoscope which enters easily.  The prostate was well resected. There were no recurrent bladder cancers seen with thorough inspection using a 30 and 70 degree lenses. The ureteral orifices appeared to be normal.

A 16-French Foley catheter was placed to dependent drainage and this will be left in place over the weekend. The patient is awakened and brought stable to recovery room.
ESTIMATED BLOOD LOSS:
Nil.

CPT – 52276 Cystourethroscopy with direct vision internal urethrotomy

ICD 10 – N35.9