Medical coding Sample Chart 1

PROCEDURE PERFORMED:  

1. Left and right heart cardiac catheterization.
2. Selective coronary angiography.
3. Left ventriculography.
4. Performed from right radial artery and right brachial vein without

complication.

PREOPERATIVE DIAGNOSES:  

1. Severe tricuspid regurgitation.
2. Rheumatic mitral valve disease with mitral regurgitation.
3. Preoperative workup for tricuspid valve replacement.

POSTOPERATIVE DIAGNOSES:  

1. Mildly elevated left heart filling pressure.
2. Low normal cardiac output and index.
3. Normal systolic function.
4. Moderate to severe mitral regurgitation.
5. Severe tricuspid regurgitation.
6. No evidence of significant mitral stenosis by hemodynamic data.
7. Normal coronary arteries.

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 and right arm were prepped and draped in sterile fashion. Allen’s test was normal. Xylocaine 1% used for local anesthesia. A tourniquet was applied to the upper arm and under ultrasound guidance the right brachial vein was easily entered and a 6-French introducer sheath placed percutaneously. The right radial artery was also accessed in a similar fashion. A 5-French introducer sheath placed percutaneously. Intra-arterial heparin, verapamil, and lidocaine were administered. Diagnostic right and left heart cardiac catheterization, left ventriculography, and selective coronary angiography and left ventriculography were then performed using a standard balloon tipped PA catheter as well as a 5-French JR4, JL3.5, and 5-French angled pigtail catheter in multiple views using hand injection and power injection for left ventriculography. At the end of the procedure, all catheters were removed over a wire. Sheaths were pulled and manual pressure applied to the brachial vein and a vascular band placed to the radial artery site for hemostasis.

FINDINGS:  

Hemodynamics;

1. Left ventricular end-diastolic pressure is 18, left ventricular systolic pressure 109, aortic pressure 109/60.

2. Pulmonary catheter wedge pressure mean of 16, PA pressure 31/14 with mean  of 21, RV 33/7, RVEDP of 14, RA mean of 19 with V-waves to 27. Pulmonary  capillary wedge pressure with a mean of 16 and V-waves to 22.

3. PA saturation 72%.

Left ventriculography: Hyperdynamic left ventricle. Ejection fraction estimated 65% with no regional wall motion abnormality. There is at least moderate or moderate to severe mitral regurgitation.

Coronary angiogram.

1. Left main: Normal caliber vessel, no stenosis.
2. Left anterior descending: Moderate caliber vessel with no significant angiographic stenosis.

3. Left circumflex: Small nondominant vessel, no significant angiographic stenosis.

4. Right coronary artery : Large caliber dominant vessel with no significant angiographic stenosis.

CONCLUSION:  

1. Mildly elevated left heart filling pressure.
2. Normal systolic function.
3. Severely elevated right atrial pressure secondary to severe tricuspid regurgitation.
4. No significant mitral stenosis by hemodynamic data. Probable moderate mitral regurgitation by ventriculography.

5. Low normal cardiac output and index.
6. No significant angiographic coronary artery disease.

CPT code:

93460

Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

93005-XU

Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report

ICD 10:

I081 Rheumatic disorders of both mitral and tricuspid valves

I509 Heart failure, unspecified

I4891 Unspecified atrial fibrillation

Medical coding Sample chart 2

PREOPERATIVE DIAGNOSIS:  

1. Left breast hematoma, status post reconstruction.
2. Bilateral amastia.

POSTOPERATIVE DIAGNOSIS:  

1. Left breast hematoma, status post reconstruction.
2. Bilateral amastia.

PROCEDURE:  

1. Left breast hematoma evacuation.
2. Implant exchange with placement of new Mentor MemoryGel XTRA smooth high- profile silicone implant for reconstruction, reference number SHPX-560,

ANESTHESIA:   General anesthesia.

INDICATIONS:  

This is a 42-year-old woman who is about postop day 10 from her second-stage reconstruction with placement of implants. She appeared for her 1st postoperative appointment yesterday and clearly had a left breast hematoma which she states started 2 days prior to that. Due to the high risk of capsular contracture, long-term complications and discomfort of the left breast, we decided to go back to surgery to wash out this old blood and do an implant exchange.

PROCEDURE IN DETAIL:  

The patient was marked, taken to the operating room where general anesthesia was induced. A 2 g IV Ancef were given. Her left breast was prepped and draped with ChloraPrep in usual sterile fashion. A 7 cc of 1% lidocaine with epinephrine was infiltrated. Her previous inframammary fold incision was opened. The capsule was released and some old clotted blood was evacuated. The implant was removed. It appeared to be about 50 mL of clotted blood in the capsule. The area was then irrigated 1st with 1 L of normal saline. Hemostasis was checked and no active bleeding was noted. Long-lasting Marcaine was infiltrated. The pocket was then irrigated with another liter of

antibiotic irrigation. A JP drain was placed. The gloves were exchanged and the new implant opened. It was soaked in antibiotic irrigation and placed in no-touch technique with an implant sleeve. The capsule was closed with interrupted 3-0 Vicryl sutures. The skin was closed with 3-0 and 4-0 Monocryl. Steri-Strips, soft dressings and a postop garment was placed and the patient was

extubated and taken to PACU in stable condition.

CPT code:

19020-LT

Mastotomy with exploration or drainage of abscess, deep

19340-LT

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19328-LT

Removal of intact mammary implant

ICD 10:

L7632 Postprocedural hematoma of skin and subcutaneous tissue following other procedure

N6489 Other specified disorders of breast

Y834 Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure

Medical coding Sample Chart 3

PREOPERATIVE DIAGNOSIS:   Subcutaneous neoplasm of the left anterior thigh.

POSTOPERATIVE DIAGNOSIS:   Subcutaneous neoplasm of the left anterior thigh x4.

PROCEDURE:   Excision of subcutaneous neoplasm of the left anterior thigh x4.

COMPLICATIONS:   None.

SPECIMENS:   Subcutaneous neoplasm x4 measuring approximately 1 cm each.

ESTIMATED BLOOD LOSS:   Minimal.

HISTORY OF PRESENT ILLNESS:  

The patient is a 40-year-old female who presented my office with complaints of the lump that she had noticed a few weeks prior on her left anterior thigh. She was concerned about the etiology of these lumps. Originally, she did notice 5, but in the waiting area, she had only identified 4. She denies it is getting any larger and not having any significant discomfort, just concerned, anxiety over their source. She was consented for excision of subcutaneous neoplasm. Risks, benefits, and alternatives of the procedure were explained to the patient including but limited to, bleeding, infection, injury to adjacent structures, possibly recurrence. She agreed to proceed.

PROCEDURE IN DETAIL:  

After informed consent was obtained, the patient was taken back to the surgical suite, placed in supine position and MAC was administered. Left anterior thigh was prepped and draped in the usual sterile fashion. Universal time-out was performed. Preoperative antibiotics were given. Each mass was previously identified in the waiting area. Local was injected directly over the masses. A 1 cm incision was made directly over the previously marked mass. Bovie cautery was used through the soft tissue to the capsule of the mass. The mass was circumferentially dissected out with blunt dissection and was expressed through the incision. Capsule was ensured to be fully excised with Bovie cautery. This was performed on all 4 masses. Hemostasis was assured with Bovie cautery. The wound was again injected with additional local. Hemostasis was ensured. A 3-0 Vicryl stitch placed in deep dermal space, the two lateral incisions to approximate skin edges _____ subcuticular 4-0 Monocryl followed by Dermabond. Anesthesia was reversed. The patient was taken to the recovery room in stable condition.

CPT code:

27327-LT

Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm

27327-LT -XU

Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm

27327-LT -XU

Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm

27327-LT -XU

Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm

ICD 10:

D1724 Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg

Medical coding Sample Chart 4

POSTOPERATIVE DIAGNOSIS:   Acute appendicitis.

PROCEDURE:   Laparoscopic appendectomy.

COMPLICATIONS:   None.

SPECIMEN:   Appendix and mesoappendix.

INTRAOPERATIVE FINDINGS:   The patient had a retroperitoneal appendix _____

ESTIMATED BLOOD LOSS:   Minimal.

HISTORY OF PRESENT ILLNESS:  

The patient is a 48-year-old female, who presented to Marin General Hospital with 1-day history of acute abdominal pain in the right lower quadrant. CT confirmed acute appendicitis. She was consented for laparoscopic appendectomy. Risks, benefits, and alternatives of procedures were explained to the patient including, but not limited to, infection, injury to adjacent structures, possibly of open. She agreed to proceed. 

PROCEDURE IN DETAIL:  

After informed consent was obtained, the patient was taken back to surgical suite, placed in supine position. General anesthesia administered. Abdomen was prepped and draped in the usual sterile fashion. A universal time-out was performed. Preoperative antibiotics were given. Local was injected to the periumbilical region. Small incision made through the base of the umbilicus. Veress needle inserted. Abdomen insufflated with 15 mmHg followed by a 5 mm Versaport, followed by a 30-degree laparoscope. No underlying structures were noted to be injured. Under direct vision, a 5 mm Versaport was placed in the left lower quadrant and a 12 mm XCel port was placed in the left flank after local was injected under direct vision.

Attention then paid to the right lower quadrant. There was a large amount of thick fatty omentum adhesed to the cecum. Cecum was traced down and I could not identify the appendix, it was in the retroperitoneal space. Adhesions of the omentum were taken down off the _____ took down the lateral peritoneal attachments to the cecum. The cecum was rotated medially with blunt dissection. After full mobilization of the cecum, the appendix was in the retroperitoneal space. I was able to mobilize the appendix from the retroperitoneal structures. Small window was made through the base of the appendix and mesoappendix. White load Echelon stapler was fired across the mesial appendix and then able to identify the base of the appendix and the cecum. A blue load Echelon stapler was fired across the base of the appendix of the cecum. Additional White load across the

remainder of the mesentery placed in the EndoCatch bag and removed from the 12 XCel port with no fascia dilatation. Inspection noted the staple line noted to be intact.

Hemostasis was assured. Small amount of irrigation was performed at the right lower quadrant. The 12 XCel port was then closed with single interrupted 0 Vicryl suture and Carter-Thomason suture

passer. Pneumoperitoneum was reversed. Trocars removed. Skin was approximated with 4-0 Monocryl subcuticular stitch followed by Dermabond the patient extubated and taken to recovery room stable condition.

CPT code:

44970 : Laparoscopy, surgical; appendectomy

ICD 10:

K3580 Unspecified acute appendicitis