Sample coded Surgery Medical Coding Charts Part 9

Sample Medical coding chart 1

Pre-op Diagnosis: vitreous hemorrhage left eye

Post-op Diagnosis: vitreous hemorrhage left eye, multiple horseshoe tears left eye

Procedure: PPV/EL/FAx + gas left eye

Implants: none

Anesthesia Type: GETA

Estimated blood loss (mL): 0.1

Findings: see below       

Specimens: none

Complications: none

Indication and consent: The patient presented to the Retina Center with a complaint of decreased vision.  The patient was noted to have blurred vision due to vitreous hemorrhage left eye.  After discussion of risks, benefits, and alternatives the patient elected for surgery.  Informed consent was obtained in clinic after the patient was allowed to ask questions and all concerns were addressed.  A written consent form was then signed and placed in the patient’s chart.

Description of procedure: The patient was brought to the operating room.  The patient’s operative eye was inspected with indirect ophthalmoscopy to verify the diagnosis and to confirm this eye as the operative eye.  The patient’s eye was then prepped and draped in the usual sterile fashion for intraocular surgery, including 5% Betadine on the ocular surface. 

Westcott scissors were used to make a buttonhole peritomy in the inferonasal quadrant, dissecting down to bare sclera.  A subtenon’s cannula was used to inject approximately 3 mm of 0.75% bupivacaine into the subtenon space for anesthesia. 

A cannula loaded on a trocar was inserted 3.0 mm posterior to the limbus in the inferotemporal quadrant.  The infusion line was placed through the cannula.  The tip of the infusion line was directly visualized to be in the correct space prior to the start of the infusion.  Two additional cannulas loaded on trocars were inserted at the same distance posterior to the limbus at approximately the 2 and 10:00 a.m. positions.  Through the 2 superior cannulas, the endo illuminator and micro vitrector were used to perform a core vitrectomy under the recite wide-angle viewing system.  The peripheral vitreous skirt was carefully trimmed for 360 degrees using scleral depression.  An old tear was noted at 1:30 with good laser barricade.

The eye was examined 360 degrees using scleral depression, and 2 additional breaks were noted one at 12 (partially open HST) and one at 6 with significant traction and active bleeding from a nearby blood vessel.  Endolaser photocoagulation was performed 360 around these breaks after using the vitreous cutter to amputate the flaps and remove all traction.  Endodiathermy was used to stop the bleeding from the vessel at 6.

A Fluid exchange was performed with the soft tip cannula.  An additional 360 scleral depressed exam was performed once the eye was filled with air.  And no other holes tears or breaks noted.  The surgeon drop a concentration of 22% SF6 gas and then an air-gas exchange was performed.

The 3 cannulas were removed and the superotemporal and inferotemporal sclerotomies were sutured with 7-0 vicryl, the superonasal sclerotomy was noted to be water tight.  The intra-ocular pressure was palpated to be within normal limits.  Subconjunctival injections of Cleocin and dexamethasone were given in the inferior cul-de-sac. 

The patient’s face was cleaned and dried.  Polytrim or bacitracin ophthalmic ointment was instilled into the eye, which was then patched.  After being awoken from anesthesia by the Anesthesia Service the patient was taken to the PACU in stable condition.

CPT code: 67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulationICD:

H4312 Vitreous hemorrhage, left eye

Sample Medical coding chart 2

Pre-op Diagnosis: Right retinal detachment

Post-op Diagnosis: Right retinal detachment

Procedure: Right scleral buckle, cryopexy, drainage of subretinal fluid.

Implants: #510 scleral buckle

Anesthesia Type: GETA

Estimated blood loss (mL): 1.0

Findings: Retinal detachment right eye

Specimens: None

Complications: None

Indication and consent: This patient has reduced vision due to retinal detachment right eye.  I have explained the nature of this condition, the treatment options, and the risks and benefits of treatment.  Post-operative restrictions and requirements were also explained.  Possible complications include further loss of vision, loss of the eye, and complications from anesthesia.  All questions were answered. This patient expressed understanding and with informed consent asked to perform following operation.

Description of procedure: In the supine position under general anesthesia eyelids of the left eye were taped closed over lubricating gel.  A protective shield was placed over the left eye.  Povidone iodine was used to sterilize the right eye, eye lashes, and surrounding skin.  An IV dose of Ancef antibiotic was given.  Sterile drapes and an eyelid speculum were placed.  A time-out was conducted.  Conjunctiva was opened in the inferior temporal 180 degrees.  Each rectus muscle was isolated on a 2-0 silk ligature.  Sclera was normal.  The retinal detachment had not significantly changed compared with examination in the office.  This was an inferior and temporal detachment involving the macula.  The detachment was caused by a single retinal hole near the 630 meridian.  Cryopexy was applied to the hole.  A scleral buckle was placed consisting of a #510 soft silicone radial scleral buckle.  Indentation of the buckle was produced with 5 0 Ethilon sutures.  Two mattress sutures were used.  Partial subretinal fluid was drained through a needle perforation technique in the inferior temporal quadrant.  Fundus exam showed excellent buckle closure of the retinal hole, perfect perfusion of the central retinal artery, and no complications.  0.5% Marcaine was irrigated to the posterior globe surface in each open quadrant with a blunt 19 gauge cannula.  Two 0 silk ligatures were removed.  Conjunctiva was closed with 6 0 plain collagen suture.  Ancef antibiotic and Decadron steroid were injected beneath conjunctiva.  A temporary punctal plug was placed in the inferior canaliculus.  The superior punctum was stenotic and did not require occlusion.  The speculum and drapes were removed.  The cornea epithelium remained intact.  Brimonidine eye drops were instilled.  Polybac antibiotic ointment was instilled.  A sterile eye patch bandage dressing was placed over the right eye.  Throughout surgery the cornea was kept moist and the retina was protected as much as possible from the light sources.  The left eye was uncovered.  Additional lubricating gel was instilled in the left eye.  She was awakened from anesthesia and taken to recovery in excellent condition.  Everything went perfectly.

CPT code: 67101 Repair of retinal detachment, including drainage of subretinal fluid when performed; cryotherapy

ICD: H33011 Retinal detachment with single break, right eye

Sample Medical coding chart 3

Pre-op Diagnosis: Preop diagnosis painful contracted hammertoe 5th toe right foot

Post-op Diagnosis: Postop diagnosis painful contracted hammertoe 5th toe right foot there also appeared to be a neuroma of the lateral plantar digital nerve extending in the toe and back to the level of the  5th MPJ.  The neuroma was approximately 3 cm in length and 3 mm in witdth at its widest white pearly  nerve tissue.

Procedure: Procedure amputation 5th toe right foot

Estimated blood loss (mL): 0.5

Findings: Things.  Preoperatively the 5th toe right foot patient had a digital arthroplasty several years ago resulting in the toe being contracted dorsally and prominent the extensor tendon was contracted the toe would not plantar flexor come down at time of surgery the toe was contracted and elevated the extensor tendon was contracted upon excision of the digit plantarly the lateral plantar nerve to the digit was found to be hypertrophied possible neuroma approximately 3-4 mm in width and 3 cm in length was excised and sent to pathology for examination

Specimens: Specimens were the amputated 5th toe proximal middle and distal phalanx and a possible neuroma from the lateral plantar aspect of the 5th MPJ and toe

Complications: No complications

Description of procedure: The patient was brought to the operatory via gurney and assisted from the gurney onto the operating room table with the patient in the supine position satisfactory anesthesia LMA was provided by Dr. bur satisfactory local anesthesia was obtained in the right foot using 10 cc of 2% xylocaine plain in a posterior tibial block lateral sural block and midtarsal field block of the 3rd 4th and 5th metatarsals right foot.  The right foot was prepped in the usual aseptic manner using a 5 minutes Betadine scrub from toes to below the knee this was followed with Betadine paint body dry sterile draping was then applied using a sterile vapor barrier sterile under draped sterile stockinette to the right lower extremity in a sterile over draped. 

Team time-out was called the patient was identified he had been given 1 g Ancef within the hour prior to surgery the surgical area on the right foot was identified allergies medications were reviewed.

Satisfactory hemostasis was obtained during the procedure using a Martin’s bandage as a tourniquet applied in a 2 marked technique with the 2nd bandage just proximal to the right ankle.

Using a 15 blade a dorsal longitudinal incision was made over the extensor tendon to the 5th toe right foot from the level of the 5th MPJ distally onto the base of the proximal phalanx of the 5th toe.  The incision was then directed distally and medially and plantar across the plantar surface and then up the lateral side proximal to match the initial incision.  Through careful dissection the soft tissue was reflected from the base of the proximal phalanx the capsule of the 5th MPJ was incised the proximal phalanx was plantar flexed and carefully dissected so as to remove the entire digit.  The wound was examined and it was found that the plantar lateral nerve to the 5th toe appeared to be hypertrophied possible neuroma through careful dissection a 3 cm length of portion of this nerve was resected and sent to pathology for evaluation.  Also found was a suture material from the previous surgery possibly Ethibond this material was dissected from the capsule.  The extensor tendon to the 5th toe was then sutured to the flexor tendon of the 5th toe and the capsule was closed repaired using 4 0 Vicryl.  The wound was then further closed using 5091 to close the skin.  Postop 10 cc of 0.5% Marcaine plain were injected in a midtarsal field block of the 3rd 4th and 5th metatarsal right foot also 1 cc are 4 mg of Decadron were injected into the surgical area.  Sterile dressing was applied using Nu-Gauze drain is a non adherent dressing sterile 3 x 3 80s and Kling the tourniquet was released blood loss was minimal less than 5 cc by volume.  The dressing was completed using 1 in medical adhesive tape and an Ace bandage.

CPT code: 28820 Amputation, toe; metatarsophalangeal joint

ICD: M2041  Other hammer toe(s) (acquired), right foot

Sample Medical coding chart 4

Pre-op Diagnosis: Left breast cancer, post neoadjuvant chemotherapy

Post-op Diagnosis: same

Procedure: Bilateral skin sparing mastectomy, left sentinel lymph node biopsy, left axillary lymph node dissection; ICG green injection

Anesthesia Type: GETA

Estimated blood loss (mL): 40

Findings: Sentinel lymph node 1 negative, node 2 positive

Specimens: left breast, sentinel lymph nodes x2, right breast, level 1 and level 2 left axillary nodes

Complications: none

Indication and consent: 60F with locally advanced left breast cancer treated with neoadjuvant chemotherapy. Here for bilateral mastectomy and nodes.

Description of procedure: The patient was brought to the operating room the appropriate checklist were performed.  Antibiotics were given.  Patient was anesthetized.  Patient was prepped and draped the usual manner. Dr. marked out elliptical incisions on both sides pre operatively. I inject ICG green in 4 peri areolar dermal blebs in the left breast at the beginning of the case.

I started on the right breast and incised the skin with scalpel. Flaps were raised superiorly to clavicle, inferiorly to IMF, laterally to latissimus and medially to sternal border. Hemostasis was achieved throughout the case with cautery. The breast was removed off the pec muscle in a medial to lateral fashion including pec fascis. This was checked for lymph nodes, marked with a stitch and sent to pathology. Using the SPY machine, I did the sentinely lymph node biopsy through the same incision. Two sentinel lymph nodes were found. The both felt grossly abnormal. These were sent to pathology and #1 was negative but #2 was positive. There was no clip in either node.

I then took the left breast off next. The elliptical incision was incised with scalpel. Flaps were raised superior towards clavicle. I did not reach the port a cath. Flaps were also raised medially to sternal border, inferiorly to IMF and laterally to latissimus. Hemostasis was achieved with cautery. The breast was removed off the pec muscle (including fascia) in a medially to lateral fashion.  Local anesthetic was placed in the serrated us for a block.  Dr. Pitcher then came in and completed the breast reconstruction, which will be dictated separately. He started on the left and then completely the right side after I was done with the lymph node dissection.

The left axillary lymph node dissection was done through the same mastectomy incision.  I opened up clavipectoral fascia and identified the axillary vein, thoracodorsal neurovascular bundle, and long thoracic neurovascular bundle.  These were all preserved.  The tissue was taken from levels 1 and 2 within the boundaries of the axillary vein, so radius, latissimus, and lateral axillary skin.  I 1st took the tissue down from the axillary vein along the edge of serratus and the subcutaneous tissue to the axilla.  Some of the lymph nodes felt abnormal.  To intercostal nerves were able to be preserved.  I made a window above the long thoracic nerve and went up under Peck minor.  I divided the Y branch of the medial pectoral nerve and took out level to using combination blunt and sharp dissection with cautery and LigaSure.  Level 2 was sent as a separate specimen.  I continued the remainder of level 1 from the top down.  Hemostasis was achieved along the way with cautery, ligasure and clips on the smaller vessels branching off from the axillary vein and thoracodorsal nerovascular bundle.  The cavity was irrigated.  Local anesthetic was infused between Pec major and Pec minor and along the serratus fascia.

CPT code:

19303-50  Mastectomy, simple, complete

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

38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)

C50912 Malignant neoplasm of unspecified site of left female breast