Surgery Medical coding Chart 1

PREOPERATIVE DIAGNOSIS:
Adenocarcinoma in situ of cervix.

POSTOPERATIVE DIAGNOSIS:
Awaiting pathology report.

PROCEDURE:
Cold conization of cervix.

SURGEON:

ASSISTANT:
None.

ANESTHESIA:
Dr. PACKS: Vaginal pack of half-inch plain gauze placed in endocervix and vagina.

DRAINS:
None.

ESTIMATED BLOOD LOSS:
Less than 50 cc.

FINDINGS OF PROCEDURE: The patient was brought to the operating room where she was identified, anesthetized, and placed in low lithotomy position, prepped and draped in usual manner.Time-out was taken.She was given 2 g of Ancef IV. The exam under anesthesia revealed normal pelvic exam with healed LEEP.A bivalve speculum was placed and visibility was not good, so a posterior weighted speculum was placed and the anterior cervical lip was grasped with a single- tooth tenaculum.A paracervical block of 10 cc with 0.5% Marcaine was placed. Following that, a silk suture was placed to mark the anterior and posterior cervical lips.The cervical lip posteriorly was shortened a lot from the LEEP procedure.A knife was used to get a posterior conization with much of it being vaginal mucosa with perhaps part of the cervix and then a 2nd piece of what is obviously cervix was able to be removed by sharp &dissection.Anterior cervical LEEP was performed using a knife.Prior to doing either of those procedures, a hemostatic lateral suture was placed using 0 chromic.There was bleeding posteriorly and a single suture going from vaginal mucosa to endocervix to Vaginal mucosa was placed and tied posteriorly and this obtained excellent hemostasis.The same type of suture was placed anteriorly.There was good hemostasis and a 0.5 inch plain packing was placed in the endocervical canal and the vagina was then packed and this was brought to the external vaginal opening. The patient was notified of the packing.The patient’s father was notified to remind her to remove the packing in a.m., Tuesday, 06/18.

CPT code: 57520
Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser

ICD 10: C539 Malignant neoplasm of cervix uteri, unspecified

Surgery Medical coding Chart 2

Medicare Patient Age-71

EXAM: CT SACROILIAC JOINT INJ RT; CT SACROILIAC JOINT INJ LT

REASON FOR STUDY:
Pain, : ; : si joint pain, :

CLINICAL HISTORY:
Low back pain.Request for SI joint injection bilaterally.

COMPARISON:
None.

TECHNIQUE:
The patient is referred for CT-guided SI joint steroid injection.Prior imaging was reviewed.The benefits and risks of the procedure were discussed with the patient, including the possibility of infection, hemorrhage, and cord injury.The patient was given the opportunity to ask questions, and wished to proceed.Written informed was obtained.The patient was placed prone on the CT table, and unenhanced localizer images were obtained.The skin was prepped and dressed in the usual sterile fashion.4 mL of lidocaine 1% was administered for local anesthesia.Under CT guidance, 9 cm 22-gauge spinal needles were advanced to the bilateral sacroiliac joints.20 mg of Kenalog with 1 mL of 0.5% bupivacaine was injected into each sacroiliac joint under CT fluoroscopy. The needles were withdrawn and a sterile dressing was applied. CTDIvol max: 5.7 mGy DLP total: 45 mGy-cm

FINDINGS:
The procedure was well tolerated, and no immediate complications were encountered.Following routine observation, the patient was discharged home in stable condition, with postprocedure instructions.

IMPRESSION:
1.Technically successful CT-guided bilateral sacroiliac steroid injection. No immediate complications were encountered.

Procedure Code: G0260-LT
Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

G0260-RT
Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography

ICD 10: M461 Sacroiliitis, not elsewhere classified

Surgery Medical coding Chart 3

EXAM:
SAT STEREO BIOPSY RT; SAT MAM POST PROC RIGHT W CAD ACCESSION:

EXAM DATE AND TIME: 9:10 am; 10:00 am

COMPARISON:
June 10, , SAT mam 3D mag comp spot right performed at Breast Health Center.May 30, , bilateral SAT mam 3D screen bilat performed at Breast Health Center.May 6, , SAT mam screen bilateral performed at Breast Health Center.February 19, , SAT mam screen bilateral performed at Breast Health Center.

CLINICAL HISTORY:
Left breast mammographic architectural distortion, 10-11 o’clock, 6.5 cm from the nipple, recommended for biopsy

FINDINGS:
Images were obtained using Full-Field Digital & Mammography.This study was performed in an ACR Breast Center of Excellence facility.Medication reconciliation form reviewed and any changes related to this procedure resolved.

(TECHNIQUE)-Procedure was explained in detail to the patient.Risks (including risks of pain, infection, bleeding, non-recovery of targeted lesion, possible need for further intervention for diagnostic purposes, intent to place post-biopsy marking clip discussed, as well as alternative of surgical excision), benefits, and alternatives discussed.All questions were answered. Written and verbal informed consent obtained. Target: Left breast mammographic architectural distortion, 10-11 o’clock, 6.5 cm from the nipple. The patient was imaged in the prone position on a dedicated stereotactic core biopsy table and the calcifications were targeted.Maximal Sterile Barrier Technique utilized.The patient was prepped and draped in the usual sterile fashion.Utilizing a lateral to medial approach, the overlying soft tissues were infiltrated with 1% Lidocaine with and without dilute epinephrine.A small nick was made in the skin and a 9-gauge &vacuum-assisted core biopsy needle was introduced to the target utilizing tomosynthesis guidance.Pre and post-fire images demonstrated transgression of the needle through the biopsy target.A total of 8 biopsy specimens were obtained.A post-biopsy marking clip was placed with stereotactic confirmation of deployment.The needle was withdrawn and hemostasis was achieved with manual compression.The patient tolerated the procedure without complications and was discharged home in satisfactory condition with post-procedure instructions. A post-procedure &mammogram demonstrates the buckle marker clip at the expected biopsy site.

PATHOLOGY RESULT PENDING: Yes

IMPRESSION:
Successful stereotactic core biopsy.Pathology pending.

ASSESSMENT: Post Procedure Mammograms for Marker Placement Right

Clinical Data:
54 year old female, right breast architectural distortion 10-11:00/6.5 cm from nipple.(JL1,sar) Gross Description: One specimen is received in formalin labeled with the patient’s name, date of birth and “right breast”.It consists of a 2.0 cm in greatest dimension aggregate of multiple yellow-tan, fibrofatty tissue cores. Submitted in toto in one cassette. &Fixation Time Time tissue excised:  Time tissue placed in formalin: 1005 on 6/18/19 (JL1,jl1)
Diagnosis:

MICROSCOPIC DIAGNOSIS: Right breast, 10:00-11:00, 6.5 cm from nipple, stereotactic core biopsy: Proliferative fibrocystic change with focal radial scar. Minute microcalcifications associated with benign ducts, see comment./* I (IC1,ic1)

CPT code: 19081
Biopsy, breast, with placement of breast localization device(s), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

ICD 10: R920 Mammographic microcalcification found on diagnostic imaging of breast

Surgery Medical coding Chart 4

PREOPERATIVE DIAGNOSIS:
Pilonidal cyst.

POSTOPERATIVE DIAGNOSIS:
Pilonidal cyst.

PROCEDURE:
Complete excision of pilonidal cyst.

SURGEON:
ASSISTANT:
None.

DRAINS:
None.
COMPLICATIONS:
None.

SPECIMENS REMOVED: Pilonidal cyst.
ANTIBIOTICS:
Ancef 2 g.

ANESTHESIA:
MAC, local.

INDICATIONS FOR SURGERY:
The patient is a pleasant 22-year-old gentleman who presented to my office with complaints of a pilonidal cyst which was persistently draining.It was causing him pain and discomfort, he desired to have it excised.We discussed the risks of the procedure to include bleeding, infection, and chance for recurrence.I explained that we will completely and widely excise the pilonidal cyst and all associated tunnels and tracts.We will leave the wound open to heal by secondary intention, and he will be responsible for b.i.d. dressing changes.He is willing to proceed, therefore, we scheduled him for surgery.

DESCRIPTION OF OPERATION:
After informed consent was obtained, the patient was taken to the operating room, placed on the table in the prone jack-knife position.Monitored anesthesia care was given, and the patient’s buttock was taped and prepped and draped in the usual sterile manner.I then used a lacrimal probe to probe the 2 small tracts, which were over the superior gluteal cleft.We marked the margins of the pilonidal cyst.It was relatively small. I then injected local anesthetic around the area.Using a 15 blade scalpel, made an elliptical &incision around the pilonidal cyst as well as encompassing the tracts and tunnels.Cautery was then used to dissect down through the dermis and subcutaneous tissue.We lifted the pilonidal cyst and undermined under the cyst to completely excise it and the tracts and tunnels.It was passed off for specimen.The wound was then irrigated with saline.Exparel was injected to the surrounding surgical area.Cautery was used for hemostasis.A wet-to-dry saline gauze dressing was then applied.He tolerated the procedure well without any complications and was transferred to recovery room in stable condition.

CPT code: 11770
Excision of pilonidal cyst or sinus; simple

ICD 10: L0591 Pilonidal cyst without abscess