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 right proximal lower extremity weakness as well as numbness and paresthesias.The patient had failed extensive nonoperative treatment.In the preoperative area, the H and P was updated, surgical site was marked, and consent was confirmed.Risks, benefits, and alternatives were discussed with the patient and I answered all of their questions.No guarantees were made regarding the surgical outcome.
I re-explained all risks, benefits, complications, and the surgical procedure to the patient.The risk and complications included death, neurovascular injury, paralysis, myocardial infarction, thrombophlebitis, pulmonary embolus, blindness, kidney failure, cardiopulmonary collapse, stroke/CVA, and blindness.
I told the patient that there was always a chance of future surgery, particularly if same level degeneration occurs requiring a little fusion.I also talked to the patient about hospital stay, pain control, potential need for pain management physician, and the need for rehabilitation.I discussed the risk of a postoperative infection in great detail, including the need for repeated washouts, antibiotic treatment, and additional surgery.I also informed the patient that the mid-level providers may be involved in their
surgical care including hoping to staff the case.I also answered all the patient’s questions in great detail and she understood the proposed surgical plan and accepted the risk of surgery.Also discussed the long-term issues including the known rates of improvement, recovery, need for rehabilitation and long-term outcomes of spine surgery.The patient was identified in the preoperative holding area where the H and P was updated, her surgical site was marked and her consent was confirmed.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and underwent general anesthesia.The patient was placed prone on the operating room table with her peripheral nerves, face, eyes, and bony prominences all well protected.We prepped and draped the posterior lumbar region in our standard fashion with alcohol, ChloraPrep, and Ioban drape.A time-out was performed and documented.The patient received preoperative antibiotics.A preoperative lateral x-ray was used to localize the incision.We made a midline incision, exposing the posterior spinal elements of lumbar levels at L2 and L3.The incision was carried through subcutaneous tissue with cautery.The fascia was incised and subperiosteal dissection carried over the lamina.The self- retaining McCullough retractor was placed and a Woodson instrument was positioned under the lamina.A lateral localization fluoroscopic image was taken to reconfirm the level.Bilaterally at L2-L3, a high-speed bur was used to make a laminotomy up to the insertion of the ligamentum flavum.The ligamentum flavum was resected with a combination of up-biting curettes andKerrison rongeurs.A partial medial facetectomy was performed, more than what is normally needed for a discectomy.This enabled visualization of the traversing nerve root.The traversing nerve root was protected and gently retracted medially.Foraminotomies were performed at the exiting and traversing nerve root levels.Foraminal decompression was confirmed with easy passage of the Murphy probe into the corresponding foramen.Hemostasis was achieved.The wound was then copiously irrigated and vancomycin powder was placed in the wound.At the conclusion of the decompression, the traversing and exiting nerve roots appeared to be fully decompressed bilaterally.No spinal fluid leaks were identified.She had improvement in her lower extremity signals per report by neuromonitoring.The wound was then closed in layers.Dermabond and a sterile dressing were applied.The patient
was awakened and taken to the recovery room in stable condition.I was present for all portions of the case.There were no intraoperative complications noted.Sponge and needle counts were correct at the conclusion of the case.
SPECIMENS REMOVED: No specimens.
CONDITIONS OF PATIENT POST-OP: The patient was taken to the PACU in stable condition.
CPT code:
63047 Laminectomy, facetectomy and foraminotomy, single vertebral segment; lumbar
M5416 Radiculopathy, lumbar region
Medical Coding example Sample coded Report 2
PREOPERATIVE DIAGNOSES:
1.Cardiomyopathy with acute systolic congestive heart failure.
2.Moderate systolic dysfunction by echocardiogram.
POSTOPERATIVE DIAGNOSES:
1.Nonischemic cardiomyopathy.
2.Moderate LV systolic dysfunction.Ejection fraction 30% to 35%.
3.Mild mitral regurgitation.
4.Mild coronary atherosclerosis with no significant epicardial coronary artery disease.
5.Elevated left heart filling pressure.
COMPLICATIONS:
None.
DESCRIPTION OF PROCEDURE:
The patient was brought to cardiac catheterization laboratory in the fasting state after signed informed consent was obtained.The right wrist was prepped and draped in sterile fashion.Allen’s test was normal.
Xylocaine 1% used for local anesthesia.A 6-French introducer sheath placed percutaneously.Intra-arterial heparin, verapamil, lidocaine were administered. Diagnostic left heart catheterization and selective coronary angiography were performed with a 6-French JR4, 6-French JL3.5, and 6-French angled pigtail catheter in multiple views using hand injections and power injection used for left ventriculography.At the end the procedure, all catheters were removed over a wire.The sheath was pulled and a vascular band placed for hemostasis.
FINDINGS:
Hemodynamics:
1.Left ventricular end-diastolic pressure 34, left ventricular systolic pressure 130, and aortic pressure 130/71.
2.Intraventricular nitroglycerin was administered which slowed left ventricular end-diastolic pressure from 34 to 26 mmHg.
Left ventriculography: The left ventricle is enlarged.There is moderate global hypokinesis with ejection fraction of 30% to 35%.Mild mitral regurgitation.
Coronary angiogram:
1.Left main moderate caliber vessel.No significant angiographic stenosis.
2.Left anterior descending: Moderate caliber vessel with mild luminal
irregularities and no high-grade focal stenosis.
3.Left circumflex large caliber dominant vessel with mild luminal irregularities and no high-grade focal stenosis.
Right coronary artery: Nondominant vessel with no stenosis.
CONCLUSION:
1.Mild coronary atherosclerosis with no significant epicardial disease.
2.Elevated left heart filling pressure.
3.Nonischemic cardiomyopathy with moderate systolic dysfunction.
4.Mild mitral regurgitation.
CPT code:
93458
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
I2510 Atherosclerotic heart disease of native coronary artery without angina pectoris
Medical Coding example Sample coded Report 3
PREOPERATIVE DIAGNOSIS:
Left breast bloody nipple discharge.
POSTOPERATIVE DIAGNOSIS:
Left breast bloody nipple discharge.
PROCEDURE:
Left breast central duct excision.
SURGEON:
ASSISTANT:
ANESTHESIA:
1.Dr. administered IV sedation.
2.Local anesthesia with 20 mL of 1:1 combination of 1% lidocaine with epinephrine 0.25% Marcaine plain.
ESTIMATED BLOOD LOSS:
Minimal.
FINDINGS:
1.Left neural ductal bloody nipple discharge.
2.Intraoperative review of the MRI showing a small area of enhancement at the right periareolar 8 o’clock position 1 cm from the nipple.This area was completely excised during the surgery.
PROCEDURE IN DETAIL:
Prior to surgery, the planned operation, risks, benefits, alternatives reviewed with the patient.Her questions were answered.Consents were reviewed.She agreed to proceed.She was brought to the operating room where IV sedation was administered and found to be adequate.The MRI was reviewed in the room.She was prepped and draped in normal sterile fashion in the dorsal supine position.A lateral periareolar incision was marked and injected with local anesthetic.The incision was made with a scalpel carried through the underlying dermis with the Bovie.Subcutaneous fat under the areola was carefully separated to isolate the central ductal tissue.The needle ductal bloody nipple discharge was identified within the specimen area.The tissue was then transected just underneath the dermis at the nipple.The central portion of the ductal system was then removed from the underlying breast tissue about 1.5 cm deep into the breast.The specimen was oriented and passed off for pathology.The cavity was copiously irrigated.Hemostasis was meticulously achieved.The underlying tissue was reapproximated with 3-0 Vicryl suture.The skin was closed with 3-0 Vicryl deep dermals and 4-0 subcuticular Monocryl.
The patient tolerated the procedure well.Sponge, lap, needle, and instrument counts were correct x2.She was placed in a chest binder at the conclusion of procedure.Left breast central duct tissue.
CPT code:
19120-LT
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion, open, male or female, 1 or more lesions
N6452 Nipple discharge
Medical Coding example Sample coded Report 4
PREOPERATIVE DIAGNOSIS:
1.FIGO grade 1 endometrioid adenocarcinoma.
2.Hypertension, poorly controlled on 3 agents.
POSTOPERATIVE DIAGNOSIS:
1.FIGO grade 1 endometrioid adenocarcinoma.
2.Hypertension, poorly controlled on 3 agents.
PROCEDURE:
1.Diagnostic laparoscopy.
2.Robotic assisted total laparoscopic hysterectomy.
3.Bilateral salpingo-oophorectomy.
4.Pelvic sentinel lymph node mapping and dissection.
5.Peritoneal washings.
SURGEON:
SERVICE: Gynecologic Oncology.
ASSISTANT:
DESCRIPTIONS OF FINDINGS:
1.Examination under anesthesia was notable for a small mobile cervix and uterus with no palpable pelvic masses. 2.Diagnostic laparoscopy was notable for no evidence of extrauterine disease. The patient had a prior history of inguinal mesh placements, which was evident laparoscopically.There was no other peritoneal disease.There is some adhesive disease related to the prior history of mesh placement. 3.Bilateral ovaries and fallopian tubes were normal to gross inspection. 4.Bowel mesentery, omentum, liver edge, and peritoneal surfaces were all smooth and without evidence of disease.
5.The bilateral ureters were seen to peristalse spontaneously throughout the course in the retroperitoneal dissection beds.
6.Pelvic sentinel lymph node mapping was successful and identified a sentinel lymph node on the left-hand side in the obturator space and on the right-hand side at the midportion of the external iliac artery and vein in each hemipelvis.
INDICATIONS FOR SURGERY:
The patient is a 69-year-old, para 5 female, who developed some spotting in 2018. She was seen by Dr. and on 05/14/2019, she had a pelvic ultrasound that demonstrated mixed echogenic lesion filling the
endometrial cavity measuring up to 1.6 cm. There was some vascularity that extended from the myometrium into the fundus.She was taken to the operating room on 06/14/2019 for hysteroscopy and D and C. University of California, San Francisco review of this pathology demonstrated a FIGO grade 1 endometrioid adenocarcinoma.She presented to me in August for initial consultation, at that time had no bleeding.In terms of her surgical candidacy, she has hypertension on 3 agents.She has a history of laparoscopic cholecystectomy and bilateral inguinal hernia repair with mesh.Her body mass index is 27.She was counseled regarding the role of surgery and recommended to undergo a CT of the abdomen and pelvis that was notable for no obvious evidence of metastatic disease.As such, she was taken to the operating room for the above-named procedure.
PROCEDURE IN DETAIL:
The patient was taken to the operating room where general ndotracheal anesthesia was obtained without difficulty.She was then prepped and draped in the dorsal lithotomy position in the usual sterile fashion.A time-out was performed with all relevant personnel prior to start of procedure. She was giving antibiotics for perioperative skin prophylaxis and 5000 subcu heparin for thromboprophylaxis.A Foley catheter was placed in the bladder under sterile conditions.
A sterile speculum was introduced into the vagina and the uterine cervix was grasped with single-tooth tenaculum.The cervical os was identified and infiltrated with indocyanine green 2 mL of 1.25 mg/dL.Dilute solution was injected into the 3 and 9 o’clock of the indocyanine green solution with 1 mL
placed deep and 1 mL placed superficially into the stomal mucosa.VCare uterine manipulator was introduced into the uterine cavity and deployed per the manufacturer’s instructions.The speculum was removed from the vagina and surgeons re-gloved and directed our attention to the abdomen.
A 5 mm skin incision was made 2 to 3 cm below the costal margin in the midclavicular line.Optiview trocar with 5 mm laparoscope was then introduced into the abdomen under direct visualization.Peritoneal entry was confirmed visually and the peritoneal cavity was then insufflated with CO2 gas.A survey of the abdomen and pelvis was then performed with the above findings.There was no injury to visceral structures with laparoscopic entry.
The remainder of the robotic and laparoscopic ports were then placed under direct visualization in a semilunar shape in the patient’s mid upper abdomen. The patient was placed in steep Trendelenburg.Peritoneal washings were obtained.The robot was then docked to the left of the patient and the robotic arms were secured to the ports.The robotic camera was introduced through the
supraumbilical port and the bipolar, monopolar, and Cartier grafting instruments were introduced under direct visualization through the robotic ports.I then unscrubbed inside of the robotic console.
Physiologic and surgically related adhesive disease of the left and right colon were then dissected away from the upper pelvis to expose the left and right pelvic brim.The pelvic retroperitoneum was then opened bilaterally to identify the bilateral pelvic sentinel lymph nodes.Peritoneum overlying the external iliac artery was incised with electrocautery.The ureter was identified in the retroperitoneal space and mobilized medially away from the pelvic vessels to develop the pararectal space.The superior vesicle artery was then mobilized medially to open the obturator space.I used the fluorescent filter on the robotic camera to identify the sentinel lymph node, which on the left-hand side were located in the obturator space.The obturator lymph nodes, there was one that was FDG avid and then one distal that appeared slightly enlarged and both lymph nodes were removed, and then removed dissected away from the underlying vascular structures with cautery and then placed into the retroperitoneum for
removal after the hysterectomy.I then directed my attention to the right-hand side and in similar fashion developed the pararectal and obturator spaces to mobilizing the ureter medially and the superior vesicle artery also medially.Using the fluorescent filter, I was able to identify pelvic sentinel lymph node at the mid to proximal portion of the external iliac artery on the right-hand side.This was elevated away from the vascular structure.The alveolar tissue was dissected and this sentinel lymph node was also placed into the obturator space for removal after the hysterectomy.I then proceeded with hysterectomy in avascular planes.The ureter was excised to isolate the gonadal artery and vein.This was occluded with a hemoclip and then fulgurated and transected. Procedure was performed on the right-hand side.The posterior peritoneum was then dissected bilaterally to the level of the uterine artery insertion.I then proceeded to dissect the vesicouterine, peritoneum, and bladder away from the lower uterine segment and cervix.This required a separation of the mesh from the bilateral round ligaments of the uterus.The VCare cervical cup was then able to be identified and the bladder was mobilized sufficiently away from the lower uterine segment and cervix.The bilateral uterine arteries and veins were then isolated, fulgurated, and transected.The cardinal ligaments and uterosacral ligaments were similarly fulgurated and transected.Vagina was excised over the cervical cup and specimens were removed from the vagina and sent to pathology for review.Previously dissected lymph nodes were then removed from the vagina and marked and sent to pathology for review.
The vagina was reapproximated with 0 PDS.All pedicles were reinspected and noted to be hemostatic.I placed some FloSeal into the pelvis to ensure excellent hemostasis.
All instruments were removed from the abdomen under direct visualization.The robot was undocked and removed from the patient’s bedside.0 Vicryl was used to close the fascia of any port measuring more than 7 mm, and the skin was closed with 4-0 Monocryl.The patient tolerated the procedure without any complications.She was returned to supine position, extubated, and taken to the post anesthesia care unit in stable condition.
Sponge, lap, and needle counts were correct x2.The patient had an estimated blood loss of 50 mL. Please see the anesthetic record for further details of fluid administration.
CPT code:
58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)
38531-50 Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
49084-XU Peritoneal lavage, including imaging guidance, when performed
C569 Malignant neoplasm of unspecified ovary