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 the usual sterile fashion.The lid was infiltrated with 2% lidocaine with epinephrine.The lid was everted.A #11 blade was used to make a vertically oriented incision through the tarsal conjunctiva into the chalazion, and the chalazion material was disrupted with a curette.The lid was returned to normal orientation.Hemostasis was achieved with gentle pressure.The eye was treated with antibiotic ophthalmic ointment.The patient tolerated the procedure well and left the treatment room in stable condition.
CPT code 67808-E1 Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple
H0014 Chalazion left upper eyelid
Medical coding Surgery Sample coded Chart 2
PREOPERATIVE DIAGNOSIS:
Phimosis.
POSTOPERATIVE DIAGNOSIS:
Phimosis.
PROCEDURE:
Sleeve circumcision.
SURGEON:
ANESTHETIC: General, supplemented by 10 cc and 0.25% Marcaine without epinephrine.
ESTIMATED BLOOD LOSS: None.
SPECIMENS REMOVED: None.
DRAINS: None.
COMPLICATIONS: None.
PROCEDURE IN DETAIL:
The patient was brought to the operating room, he was given a general anesthetic.He was not given antibiotics on account of a possible anaphylactic reaction to cephalosporins and penicillin based antibiotics.His genitalia were prepped and he was draped in a normal fashion. It should note that with prepping the patient developed him a slight erection. There was some rightward curvature and rotation of the penis that is likely due to congenital asymmetry of the corpora cavernosa.The remainder of his examination was normal with the exception of phimotic foreskin.
I marked the planned skin incision sites with a pen, and then infiltrated these incision lines with Marcaine.I then performed a sleeve circumcision in the
standard manner, excising the phimotic prepuce.I preserved as much of the shaft skin as possible without compromising the correction of phimosis.After removal of the skin, I achieved complete hemostasis using a gentle electrocautery.I then re-created the attachment of the prepuce to the ventral glans with a vertical suture line of 5-0 chromic.I then reapproximated the shaft and preputial skin and advanced these together, completing the closure with interrupted 4-0 and 5-0 suture.This achieved a very satisfactory cosmetic result.Antibiotic ointment was applied and a fluff dressing was applied.The patient was then awakened, transferred to a stretcher, and brought to recovery room in good condition.
CPT code 54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age
N471 Phimosis
Medical coding Surgery Sample coded Chart 3
PREOPERATIVE DIAGNOSIS:
Painful retained orthopedic hardware from operative fixation of left ankle fracture.
POSTOPERATIVE DIAGNOSIS:
Painful retained orthopedic hardware from operative fixation of left ankle fracture.
PROCEDURE:
Hardware removal, left ankle.
SURGEON:
ASSISTANT:
None.
ANESTHESIOLOGIST:
ANESTHESIA:
General with 20 mL of 0.25% Marcaine.
PREOPERATIVE ANTIBIOTICS: Invanz IV.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: NONE
IMPLANTS: None.
INDICATIONS FOR SURGERY:
The patient is a 14-year-old male who injured _____ bimalleolar fracture.Intraoperative fixation _____ removed.The risks, benefits, and potential complications were described and the patient decided to proceed.
DESCRIPTION OF PROCEDURE:
The patient was met in the preoperative holding area, where consent form was once again reaffirmed by the patient.His extremity was marked for surgery.The patient was brought back to the operative suite, placed supine on the operative table.The patient succumbed to general anesthesia. Left lower extremity was prepped and draped in the usual sterile manner.Prior to proceeding, a formal time-out was performed by all team members present.IV antibiotics were administered.Under fluoroscopic guidance, we marked out his incision.This was anesthetized with 0.25% Marcaine.We first proceeded by removing the syndesmotic TightRope through a stab incision on both the medial and lateral side.We made a separate incision _____ 2 interlocking screws were removed.A separate incision was made over the distal tip of the lateral malleolus.Guidewire was then advanced followed by extracting device._____ was then used to deactivate _____.Ankle was stressed to show no instability. The wound was copiously irrigated, anesthetized with 0.25% Marcaine.The wounds were then closed with 3-0 nylon.Sterile dressing applied.At the end of the case, all counts were accounted for.The patient was awakened from anesthesia and transferred to the PACU in stable condition.
POSTOPERATIVE PLAN:
The patient will be weightbearing as tolerated.DVT prophylaxis, with ambulation.Pain p.o. He will follow up in my clinic in 2 weeks for wound check.
CPT code 20680 Removal of implant; deep
T8484XA Pain due to internal orthopedic prosthetic devices, implants and grafts, initial encounter
Medical coding Surgery Sample coded Chart 4
PREOPERATIVE DIAGNOSIS:
Chronic left ankle instability as well as left knee pain.
POSTOPERATIVE DIAGNOSIS:
Chronic left ankle instability as well as left knee pain.
PROCEDURE:
1.Left ankle modified Brostrom internal brace.
2.Left iliac crest bone marrow aspiration with injection of BMAC into the left ankle as well as PRP injection into the left knee.
SURGEON:
ASSISTANT: None.
ANESTHESIOLOGIST:
ANESTHESIA:
General with popliteal and adductor canal nerve block with 10 cc 0.25% Marcaine.
PREOPERATIVE ANTIBIOTICS: Cefazolin 2 g IV.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: None.
SPECIMENS REMOVED: None.
IMPLANTS: Arthrex internal brace.Arthrex FiberTak suture anchors x2 and Arthrex BMAC harvesting system from Angel.
INDICATIONS FOR SURGERY:
The patient is a pleasant 19-year-old female who plays soccer at Dominican, was having chronic left ankle pain and instability, failed conservative measure as well as left knee pain.Given that she had failed conservative measures, surgical interventions offered and the patient decided to proceed.
DESCRIPTION OF PROCEDURE:
The patient was met in the preoperative holding area where the consent form was once again reaffirmed by the patient.Her extremity was marked for surgery.The patient was brought back to the operative suite, placed supine on the operative table, where the anesthesia team performed a peripheral nerve block.She has been succumbed to general anesthesia.The left iliac crest was prepped and draped in the usual sterile manner.Prior to proceeding, a formal time-out was performed by all team members present and IV antibiotics administered.Using the Angel Arthrex System, 60 cc of bone marrow was aspirated from the left iliac crest.Sterile dressings applied.The anesthesia team also withdrew 60 mL of blood for PRP.Her left ankle was then prepped and draped in the usual sterile manner.Prior to proceeding, a second procedural time-out was performed by all team members present.Under fluoroscopic guidance, we marked out anterolateral incision, this was anesthetized with 0.25% Marcaine.The skin was incised.Dissection was carried down to the fascia.The fascia as well as the native ATFL was incised in line with the skin incision.The superficial peroneal nerve was identified and protected throughout the case.We roughened up the anterior and inferior aspect of the lateral malleolus _____ we placed the guidewire.Fluoroscopic images confirmed excellent placement.We then drilled and tapped for an internal brace with FiberTak suture anchors placed above and below.We then drilled and tapped for the dorsal and lateral aspect of the talus under fluoroscopic guidance.The internal brace was affixed.2 mm internal brace were passed from deep to superficial capturing the native ATFL with a free needle.The 4 limbs of the FiberTak suture anchors were passed deep to superficial capturing the native ATFL as well as the inferior extensor retinaculum.We then proceeded with a Brostrom repair with 0 Vicryl suture in pants-over-vest fashion.All wounds were irrigated.The foot was placed at neutral dorsiflexion and maximal eversion, the FiberTak suture anchors, followed by the 0 Vicryls that were tied sequentially with the foot resting in physiologic equinus position.The internal brace was then affixed to the fibula with Bio-Tenodesis screw.The wound was irrigated, the BMAC was then injected into the repair site. Subcutaneous tissue was closed with 4-0 Vicryl, skin with 4-0 nylon.Sterile dressing applied.We then prepped her left knee on the superior medial side and injected the PRP.Sterile dressings applied.At the end of the case, all counts were accounted for.The patient was awakened from anesthesia and transferred to the PACU in stable condition.
POSTOPERATIVE PLAN:
The patient will be weightbearing as tolerated.DVT prophylaxis with ambulation.Pain, p.o. CAM boot as needed.Follow up in clinic in 2 weeks for wound check.
CPT code 27695-LT
Repair, primary, disrupted ligament, ankle; collateral
Diagnostic bone marrow; aspiration(s)
M25372 Other instability, left ankle
M25562 Pain in left knee