New Sample Coded Surgery Charts for Coders

Medical Coding Sample Report 1

PREOPERATIVE DIAGNOSIS:  

Left perineal lipoma.

POSTOPERATIVE DIAGNOSIS:  

Left perineal lipoma.

PROCEDURE:  

Excision of 5 x 7 left perineal lipoma.

SURGEON:  

INDICATIONS FOR SURGERY:  

This is a 70-year-old female who had a left perineal lipoma excised 10 years ago in Iran.Since then, it has been growing and is very uncomfortable.It bulges out of her clothing and between her legs.It was measured to be 4 cm in 10/2018, but when I saw her again, it had already grown to 7 cm. Risks and benefits of the procedure were explained to the patient in detail and include, but are not limited to the following: Bleeding; infection; the patient noncompliance; scarring; unsatisfactory results; wound disruption; hematoma; seroma; inability to completely remove the lipoma; injury to vessels, nerves, and adjacent soft tissue; numbness; pain; asymmetry; delayed healing;

recurrence; and need for further surgery.The patient understands and wishes to proceed.

PROCEDURE IN DETAIL:  

The patient was marked preoperatively in the preop holding area, marking the side that it was on.Next, the patient was taken to the operating room, laid supine on the operating table.SCDs were placed and Ancef was given and then the laryngeal mask anesthesia was obtained.She was placed in lithotomy position and then she was prepped and draped in a standard sterile fashion.

A time out was done.Next, the mass was marked out, which was bulging from her perineal.It was then anesthetized with 1% lidocaine with epinephrine and 0.25% Marcaine plain.A longitudinal incision was made with a #15 blade through the skin and subcutaneous tissue.The mass was identified, but the margins of it were not very distinct.This was all dissected free and measured 5 x 7 cm. Next, the wound was irrigated copiously with normal saline.A 7-French round drain was placed.The area was injected with Exparel which had been diluted with 10 cc of Marcaine.A total of 30 cc was used.Next, deep sutures were placed to decrease the dead space with 3-0 Vicryl sutures.The deep dermal layer was then closed with deep 3-0 Vicryl and then in the deep dermal layer interrupted 3-0 Vicryl and then a running 4-0 chromic was placed.The drain was secured with a 3-0 nylon.It was attached to bulb suction.

The patient tolerated the procedure well, was dressed with Aquacel and Biopatch and Tegaderms.She was then awakened from anesthesia, extubated, went to the recovery room in awake and in good condition.The sponge and needle count was correct at the end of the case.There were no complications.

CPT code: 27043 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater

13101-59 Repair, complex, trunk; 2.6 cm to 7.5 cm

ICD 10: D1772 Benign lipomatous neoplasm of other genitourinary organ

Medical Coding Sample Report 2

PREOPERATIVE DIAGNOSIS:  

Enlarged left groin lymph nodes, history of B-cell lymphoma.

POSTOPERATIVE DIAGNOSIS:  

Enlarged left groin lymph nodes, history of B-cell lymphoma.

PROCEDURE:  Excision of baseball size left inguinal and groin lymph nodes

cluster.

ANESTHESIA: General tracheal

COMPLICATIONS:   None.

ESTIMATED BLOOD LOSS:    25 mL.

SPECIMEN:   Lymph node cluster.

DRAINS:   #19 round Blake drain.

INDICATIONS FOR SURGERY:  

This 58-year-old gentleman has a diagnosis of B-cell lymphoma.He has a very large left inguinal mass which is a lymph node cluster. 

The oncologist requested excision of his mass for further studies of his B-cell lymphoma.I discussed with the patient risks and benefits of surgery includingrisk of infection, risk of bleeding, the risk of damage to surrounding

structures including nerves or arteries.I also discussed that he would have a large defect in the area after surgery.The patient seemed to understand and asked appropriate questions.

DESCRIPTION OF PROCEDURE:  

The patient was taken to the operating room in stable condition.After satisfactory general anesthesia was obtained, his left groin area was prepped and draped sterilely.The cluster was predominantly below the inguinal crease, although it appeared to originate above the inguinal crease. 

We performed a time-out.I then made an incision directly over the mass and carried this down through the subcutaneous tissue.I encountered a large cluster of lymph nodes, which was predominantly below the inguinal crease, although there appeared to be some extension that appeared to be going just underneath the inguinal crease.I carefully dissected this out using electrocautery.I encountered several large draining veins which I ligated with 3-0 silk ties.Due to the base of the mass, there was a cluster that was very near a nerve which I elected to leave in place rather than sacrifice the nerve. After excision of the mass, I then irrigated with saline.I brought a #19 round Blake drain out through a separate inferior based stab incision.I used 3-0 nylon to close with a mattress type suture and then reinforced the skin with staples.The patient was awakened, extubated, and taken to PACU in stable

condition.The mass was sent to pathology fresh for further characterization.

CPT code: 38500-LT Biopsy or excision of lymph node(s); open, superficial

ICD 10: C8335 Diffuse large B-cell lymphoma, lymph nodes of inguinal region and lower limb

Medical Coding Sample Report 3

PREOPERATIVE DIAGNOSIS:  

Dense mature cataract, right eye.

PROCEDURE:  Complex phacoemulsification cataract extraction with intra-ocular lens implant, mechanical pupillary dilation, right eye.

SECONDARY DIAGNOSIS: Floppy iris syndrome, small pupil.

INDICATION FOR SURGERY: This is a 92-year-old male with longstanding history of very dense cataract.Also, the patient is on Flomax and understands to stop the Flomax at least to 10 days prior to surgery.However, he could not stop the Flomax due to his prostatic hypertrophy and difficulty with urination.The patient understands due to having Flomax, there is increased risk associated with surgery and increasing the complexity of surgery, iris floppy syndrome increases risk of hyphema, iris sphincter tears, iris transillumination defect, and difficulty with surgery.

ANESTHESIA:  Local with IV sedation.

COMPLICATIONS:  None.

SUTURES: One 10-0 nylon suture was used.

PROCEDURE IN DETAIL:  After informed consent was obtained, the patient was identified by attending surgeon, brought into the operating room, and was placed in a supine position.Proper cuffs and monitors were placed and the patient was found to be in a stable condition.The right eye was prepped and draped in the usual sterile fashion.The rest of the operation was performed under the operating microscope.Lid speculum was placed to open the eyelid.Super sharp blade was used to create a paracentesis track incision.Viscoat was injected into the anterior chamber.A 3.0 keratome used to create a temporal clear corneal incision and additional viscoelastic injected to dilate the pupil further.Prebent cystotome was used to create an anterior capsular flap. Utrata was used to create an anterior curvilinear capsulorrhexis.BSS injected for hydrodissection and delineation.Phacoemulsification cataract extraction was performed.The cataract was very dense.All of the cortical material was removed using irrigation and aspiration.Floppy iris was noted and therefore, Healon 5 was used to place the iris back with assistance of a spatula. All of cortical material was removed and then Provisc was injected into the capsular bag and intraoperative aberrometry was used.A 22.5 diopter SN6AT6 lens was placed into the capsular bag and positioned according to intraoperative berrometry at axis 6.Viscoelastic was then removed and Miochol was injected again to constrict the pupil.One 10-0 nylon suture was placed through the corneal wound.Wound hydration was also performed.There was no evidence of any wound leak.Subconjunctival injection of Ancef and dexamethasone was given. The patient tolerated the procedure well and was taken to the recovery room in good condition.Please note that throughout surgery when direct visualization of the anterior chamber was not necessary, an opaque corneal cap was placed over the eye.Followup is tomorrow at 1000 hours in my office.

CPT code:66982-RT

Extracapsular cataract removal with insertion of intraocular lens prosthesis, manual or mechanical technique, complex, requiring devices or techniques not generally used in routine cataract surgery or performed on patients in the amblyogenic developmental stage

ICD 10: H2511 Age-related nuclear cataract, right eye

Medical Coding Sample Report 4

PREOPERATIVE DIAGNOSIS:  Left breast carcinoma clinical stage I to II.

POSTOPERATIVE DIAGNOSIS: Left breast carcinoma clinical stage I to II.

PROCEDURE: 1.Left breast seed localized segmental mastectomy.

2.Left sentinel node biopsy.

SURGEON:  

ASSISTANT SURGEON:  

ANESTHESIA:  

1.Dr. administered general anesthesia.

2.Local anesthetic with 40 mL of a 1:1 combination of 1% lidocaine with  epinephrine and 0.5% Marcaine plain.

ESTIMATED BLOOD LOSS: Minimal.

FINDINGS:  

1.Left sentinel lymph node #1, ex-vivo count 112564, sent for permanent  section.

2.Low gamma counts in the axilla after removal of 1 large sentinel node.

3.Left 6 o’clock specimen radiograph with a centrally located mass, biopsy  clip, and radar localization system.A 2nd radial localization system,  which missed deployed at the time of localization, was noted at the lateral  margin.The specimen was removed intact.

CLINICAL INDICATIONS:  

The patient is a 66-year-old woman with a clinical stage 1-2 left breast cancer.She presents for definitive surgical management.

PROCEDURE IN DETAIL:  Prior to surgery, the planned operation, risks, benefits, and alternatives were reviewed with the patient.Her questions were answered. Consents were reviewed and she agreed to proceed.She was brought to the operating room where general anesthesia was induced and found to be adequate. The post localization mammograms were reviewed in the room.The area of greatest gamma emission from the left axilla was noted and marked.The area of radar detection in 2 locations on the left breast was noted and marked.She was

then prepped and draped in the normal sterile fashion in the dorsal supine position.Axillary and periareolar incisions were marked and injected with local anesthetic.The incision in the axilla was made with a scalpel and carried through the underlying dermis with the Bovie.Subcutaneous fat was divided and the clavipectoral fascia was identified and incised.One sentinel node was identified and dissected away from the surrounding tissue with clips and cautery.Low gamma counts were noted throughout the axilla after removal of the sentinel node.The cavity was copiously irrigated.Hemostasis was meticulously achieved.The axillary incision was closed with 3-0 Vicryl deep dermals and 4-0 subcuticular Monocryl.

Attention was turned to the left breast.An inferior and lateral periareolar incision was made with a scalpel and carried through the underlying dermis with the Bovie.Subcutaneous skin flap was raised over the area of interest.The subcutaneous fat was divided and spared.The more medial area of radar detection was carefully excised with care taken to include the entire area of interest.The mass was not clearly palpable during dissection, because of surrounding dense breast tissue.The specimen was oriented and passed off for specimen radiograph with the findings as noted above.During the excision, the missed deployed radar localization device was found at the lateral aspect of the lumpectomy site and was sent separately.It was noted to be intact at removal. The cavity was then copiously irrigated.Hemostasis was meticulously achieved. A radiation localization device was placed and secured to the tissue with 3-0 PDS.Additional margins were taken circumferentially and passed off separately. The 2nd excision was taken all the way to the pectoralis fascia.The soft tissue was reapproximated over the BioZorb radiation localization device.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 received 2 g of Ancef prior to incision.She was placed in a chest binder at the conclusion of procedure.

 SPECIMENS:  

1.Left sentinel lymph node #1.

2.Left 6 o’clock.

3.Left 6 o’clock margins.

COMPLICATIONS:  

one apparent.

DISPOSITION:  

The patient was stable and awake when she was transferred to the postanesthesia unit.

CPT code:19285 Placement of breast localization device(s), percutaneous; first lesion, including ultrasound guidance

38792 Injection procedure; radioactive tracer for identification of sentinel node

19301-LT Mastectomy, partial;

38525 Biopsy or excision of lymph node(s); open, deep axillary node(s)

ICD 10: C50512 Malignant neoplasm of lower-outer quadrant of left female breast