Table of Contents

Sample Medical Coding Report 1

DIAGNOSES:

1. Right shoulder osteoarthritis.

2. Right shoulder rotator cuff tear, subscapularis.

3. Grade 4 chondromalacia glenohumeral articulation.

4. Degenerative labral tear.

5. Type 2 SLAP tear.

6. Impingement.

7. AC joint arthritis.

8. Soft tissue mass.

9. Conjoined tendon, subscapularis.

PROCEDURE PERFORMED:

1. Right shoulder arthroscopic rotator cuff repair, subscapularis;

glenohumeral debridement extensive, subacromial decompression, distal clavicle resection,

2. Right shoulder Open biceps tenodesis, open soft tissue mass excision 4 cm,

conjoined tendon subscapularis.

BRIEF HISTORY:

The patient is a 55-year-old gentleman who presented to the clinic with signs of symptoms, MRI and CT scans as the above diagnosis. He failed prolonged conservative treatment. He was made aware of the risks and benefits, both long and short term, of the above procedure and decided to go forward.

PROCEDURE NOTE: The patient was met in the preoperative area. The preoperative area was identified and marked as correct surgical site. The patient then transferred to the operative theater by Anesthesia. Time-out was called. Preoperative antibiotics were administered. An Interscalene catheter was placed by Dr. Hirsh. General endotracheal anesthesia was induced. The patient was placed in the beach chair position. The right shoulder was prepped and draped in a sterile fashion.

A standard posterior portal was introduced and a diagnostic arthroscopy performed with the following findings:

1. Grade 4 chondromalacia glenohumeral articulation, most significant to the posterior glenoid and humeral head.

2. Pan-circumferential degenerative labral tear.

3. Type 2 SLAP tear.

4. Partial full-thickness tear, superior aspect subscapularis.

Anterior portal was introduced under direct visualization. An extensive anterior-posterior debridement was performed with use of an arthroscopic shaver. Tissue debrided included degenerative labral tear, type 2 SLAP tear, chondromalacia, loosing cartilage flaps for chondromalacia, glenohumeral articulation as well as a general portion of subscapularis to the lesser tuberosity. The biceps tendon was tenotomized from its origin on the superior labrum.

Mitek 4.5 Healix anchor was placed in the superior aspect of the lesser tuberosity. Using a simple suture technique, the subscapularis was anatomically reconstructed and completed the arthroscopic rotator cuff repair. The arthroscope was then placed in the subacromial space. Extensive debridement was continued. Findings at time included intact supra and infraspinatus tendon.

The anterolateral lip of the acromion was identified with electrocautery with an arthroscopic bur, 4 mm of bone was resected completing subacromial decompression.

Findings at time included significant osteophyte formation as well as spurring of the AC joint and supraspinatus muscle belly. An additional portal was introduced directly anterior to the AC joint. Arthroscopic bur 4 mm x 1 cm of bone was resected completing the distal clavicle resection.

All portal incisions were closed with interrupted nylon suture and the procedure converted to an open procedure. A standard deltopectoral approach was utilized to access the coracoid process.

Findings at this time included 4 cm mass and imbedded soft tissue of the conjoined tendon and subscapularis inferior to the coracoid process. A careful technical dissection was utilized to resect the soft tissue mass which was removed laterally from the coracoid process. The mass was sent to pathology for evaluation.

Attention was finally turned to the biceps tendon. The biceps tendon was retrieved. A Mitek 4.5 Healix anchor was placed in superior aspect of the bicipital groove using standard locking suture technique. All 4 sutures were passed in the biceps tendon was effectively tenodesed. Wound was copiously irrigated. The deltopectoral split was closed with 0 Vicryl subcuticular fat and skin closed with 2-0 Vicryl. Skin closed with staples. Sterile dressing applied to the wound. The patient awoken from general endotracheal anesthesia, transferred to PACU in stable condition.

COMPLICATIONS: None.

FINDINGS: As above.

ESTIMATED BLOOD LOSS:

Minimal.

I was present for and performed the entire procedure.

CPT codes:

29827 : Arthroscopy, shoulder, surgical; with rotator cuff repair

+29826 : Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament release, when performed

29823 : Arthroscopy, shoulder, surgical; debridement, extensive

29824-RT : Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface

23430 : Tenodesis of long tendon of biceps

23071 : Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater

ICD 10 codes:

M75101 Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic

M19011 Primary osteoarthritis, right shoulder

M94211 Chondromalacia, right shoulder

S43431A Superior glenoid labrum lesion of right shoulder, initial encounter

Sample Medical Coding Report 2

PREOPERATIVE DIAGNOSIS: Right chronic proximal hamstring rupture, S76.312A.

POSTOPERATIVE DIAGNOSIS: Right chronic proximal hamstring rupture, S76.312A.

PROCEDURE:

SURGICAL PROCEDURE: Right proximal hamstring repair/reconstruction with graft,

27386-22 (22 modifier) due to dramatic increase in difficulty due to chronicity

of the injury necessitating significant increased time and complexity of

surgical fixation/repair. Please add 100% to surgical fee.

ANESTHESIOLOGIST:

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS:

None apparent.

JUSTIFICATION: 41-year-old male, status post a water skiing injury to his right proximal thigh 4 months ago. The patient with persistent pain, weakness, and limitations with activities of daily living. MRI subsequent confirmed a 3 tendon tear of the ischium of his proximal hamstring tendons. Given this patient’s young age, continued problems, and limitations, the patient necessitated surgical intervention. We explained the patient and his wife on several occasions, the surgical procedure as well as all the risks, benefits, complications, alternatives, as well as the postoperative rehabilitative course in detail. We are very clear with him given the chronicity of this would be significantly more difficult repair, significantly longer recovery along with increased risk of complications, especially possible sciatic nerve injury as well as posterior cutaneous nerve injury. In addition, this was a possibility of failure, stiffness, and persistent weakness. He stated he understood, consented to proceed as planned.

PROCEDURE IN DETAIL:

The patient was seen preoperatively as to identify the appropriate site. He identified his right side with an X, as this was initialed by myself. He was given preoperative antibiotics. He had an ICD placed to his nonoperative extremity. He was instructed to start full strength aspirin preoperatively and continue postoperatively for DVT prevention, especially trained nonweightbearing and immobilization times. Taken to the operating room on the transport bed, a time-out was performed. He was then placed in general anesthesia without complication. With the assistance, the patient was then turned into the prone position. Cervical spine was placed in the neutral rotation, eyes were padded, arms were padded, all extremities were properly padded. This was checked several times to assure proper padding, positioning, and stabilization. At this point in time, a prep and shave were performed. The right leg starting from the buttock region all the way down was then prepped and draped in usual sterile fashion. Another time-out was performed. We then established a transverse incision in the gluteal fold. We then dissected down to the fascial layer which was incised with Bovie electrocautery. Hemostasis was obtained. Through the cautery, a large hematoma and seroma was removed, this area was irrigated. At this point in time, the patient had significant retraction and significant scarring of the hamstring tendons distally. With great difficulty, this was subsequently cleared and mobilized. There did not appear to be any sciatica nerve adhesions at this point in time. At this point in time, we isolated the ischium and cleared it of significant amount of scar tissue and adhesions. At this point in time, hemostasis was obtained. We had to necessitate using 2 vials of FloSeal. At this point in time, we then placed 2 anchors in the ischium in the inferior portion. These were 4.75 mm Arthrex SwiveLock anchors. These sutures were then passed through the tendon in a whip stitch fashion. We then placed a 3rd anchor in the lateral aspect of the ischium in a suture bridge technique, placed the initial 4 sutures from the 2 anchors placed them into the 3rd anchor, and this subsequently reinforced in a double row type of technique of the repair. At this point in time, we then passed the sutures and as well as the stay sutures back through the tendinous portion for reinforcement. Still only fair quality of the tendon, we then placed an Arthrex amniopatch on top of the repair followed by a dermal graft that was reinforced with sutures into the hamstring repair. We then copiously irrigated throughout the case with antibiotic solution. At this point in time, the knee was in extension with moderate tension on the repair. We then closed the deep fascial layer with 0 Vicryl, 2-0 Vicryl for the subcutaneous tissues. Dermabond for the skin. We then injected 30 cc of 0.25% Marcaine with epinephrine along with 1 dose of Exparel into the deep areas. A JumpStart dressing was then applied followed by sterile dressing. The patient was then placed into a range of motion brace in 45 degrees of flexion to decrease tension on the repair. He was then subsequently placed back onto the transport bed in the supine position, extubated, taken to the recovery room in stable condition with a palpable dorsalis pedis pulse.

CPT code:

27386 :Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft

ICD 10 :

S76311A: Strain of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, initial encounter

Sample Medical Coding Report 3

REASON FOR STUDY: Disorder of pleura

CLINICAL HISTORY: Right-sided pleural effusion

COMPARISON: None.

TECHNIQUE: The study was performed in an ACR accredited facility. Medication reconciliation form reviewed and any changes related to this procedure resolved.

REPORT: The procedure of a thoracentesis was explained to the patient including the risks, benefits, and possible complications. The patient was given the opportunity to ask questions, wished to proceed, and signed the written informed consent form. Using ultrasound guidance, a safe route of access was identified into the right pleural space. The site was then prepped and draped using maximal sterile barrier technique. 1% Lidocaine was used for local anesthetic. With sonographic guidance, a 5-French Yueh needle catheter device was placed with return of pleural fluid. The needle was placed into the pleural space. Approximately 1.8 liter of pleural fluid was removed. The patient tolerated the procedure well without any immediate complications.

IMPRESSION: 1. Successful thoracentesis with removal of approximately 1.8 liter of pleural fluid.

CPT code :

32555 : Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance

ICD 10 :

J90 Pleural effusion, not elsewhere classified

Sample Medical Coding Report 4

REASON FOR STUDY: hepatic hydrothorax

CLINICAL HISTORY: Ascites.

COMPARISON: None.

TECHNIQUE: The study was performed in an ACR accredited facility. Medication

reconciliation form reviewed and any changes related to this procedure resolved.

REPORT: Sonographic images of the abdomen performed to identify extent of ascites. The risks, benefits, and alternatives were discussed with the patient who was given the opportunity ask questions and wished to proceed. The written informed consent form was signed. Using ultrasound guidance, a mark was then made on the skin overlying a large pocket of fluid in the right lower quadrant. The right lower quadrant was prepped in the usual sterile fashion. 1% Lidocaine was used for local anesthesia. A skin &incision was made with an 11-blade scalpel. A 19-gauge Yueh needle catheter device was advanced with return of yellow fluid. The needle was removed and the catheter was connected to vacuum bottle suction. Hemostasis was achieved with manual pressure. There were no immediate complications. Fluid Removed: 2.6 L

IMPRESSION: 1. Successful ultrasound-guided paracentesis.

CPT code :

49083 :Abdominal paracentesis; with imaging guidance

R18.8 Other ascites

Sample Medical Coding Report 5

PREOPERATIVE DIAGNOSIS: Peripheral arterial disease.

POSTOPERATIVE DIAGNOSIS: Peripheral arterial disease.

PROCEDURE: Ultrasound-guided access of the left common femoral artery, left iliac angiogram, left external iliac artery angioplasty (6 mm and 9 mm balloon).

INDICATIONS FOR SURGERY:

The patient is an 82-year-old man with PAD. He has had a right leg angioplasty, right iliac stenting, and left femoral popliteal bypass in the past and on routine surveillance imaging, now several years

later, he has developed a high-grade stenosis of the left external iliac inflow. He is actually not walking far enough at this point to elicit symptoms because of back pain, but I am concerned about maintaining patency of his bypass and avoiding critical limb ischemia, so I talked with him about an iliac angioplasty. We have reviewed Indications, alternatives, and risks and he has consented to proceed.

PROCEDURE IN DETAIL:

After written and informed consent were obtained, the patient was placed supine on the operating table and general anesthetic commenced. The abdomen and both groins were prepped and draped widely in the usual sterile fashion. We used ultrasound guidance to identify a good area of approach. The common femoral artery was widely patent. There were some focal calcific plaquing in the distal external iliac, but this was obviously not flow limiting. We could see the hood of the bypass graft. The common femoral was accessed on a single pass using a single wall puncture technique. A 0.018 wire was passed centrally and we met the point of obstruction. The micropuncture dilator and sheath were advanced over the wire and then used to upsize to a 0.035 Glidewire and 5-French short sheath. Through the sheath, an angiogram was obtained. This showed a critical, but very focal stenosis in the proximal external iliac artery just beyond the takeoff of the hypogastric. There was

also moderate stenosis in the hypogastric on that side. I estimated the external iliac stenosis to be in the 90% to 95% range. The artery looked good both above and below it. There was moderate calcific plaquing, which appeared to be circumferential. I thought this could be treated with an angioplasty. We started with a 6 mm balloon, which I knew would be undersized, but I thought it made sense to do serial dilatations. I was realizing at this point that we would probably not stent this unless we had an unfavorable result because it was so focal and so close to the takeoff of the hypogastric. We used first a 6 mm and then upsized to a 9 mm balloon, which I thought was actually size appropriate. We had good insufflation of the balloon. There was a clear waist with insufflation of balloon which eradicated fully with complete balloon insufflation. We held for a minute and then deflated the balloon and took a completion angiogram, which showed a dramatic improvement with now brisk filling through this area. The stenosis went from over 90% to less than 10%. There was return of a bounding femoral pulse. Thus satisfied, the sheath was removed and pressure held over the access site for hemostasis. The site was dressed with a 2 x 2 and Tegaderm. The patient tolerated the procedure well, and was extubated at the close of the case, and transported in stable condition to the recovery room. Sponge and needle counts were correct.

CPT code:

37220-LT :Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

76937 :Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting

ICD 10 – I73.9 Peripheral vascular disease, unspecified