Sample coded Surgery Medical coding charts Part 10
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