Sample Medical Coding Report 1

REASON FOR STUDY: cervical radiculopathy

CLINICAL HISTORY: Cervical radiculopathy

COMPARISON: None.

TECHNIQUE:
Medication reconciliation form reviewed and any changes related to this procedure resolved. Standard technical protocol was utilized.

Dosimetry: CTDI: 7 mGy; DLP: 246 mGy-cm (Note: These dose indicators do not reflect the effective patient dose, but are metrics based on standardized CT phantoms. The effective dose may vary widely depending on body size, shape, and other patient factors).

Dose reduction was performed with automated exposure control, iterative reconstruction technique and/or adjustment of the mA and/or kV for patient size.

Procedure:
Under sterile conditions, a 25-gauge needle was placed into the left C5-6 foramen and a left C6 selective nerve root injection was performed using 10 mg of dexamethasone and 2 mL of 1% Xylocaine. Patient tolerated the procedure well. The CT images show appropriate needle position within the left C5-6 foramen

Findings: The needle is seen appropriately positioned in the left C5-6 foramen posterior aspect

Performed procedures: Left C6 selective nerve root injection

IMPRESSION:
1. Successful left C6 selective nerve root injection as discussed above

CPT 64479  Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level

ICD 10: M54.12 Cervical Radiculopathy

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Sample Medical Coding Report 2

EXAM: US LIVER CORE BIOPSY

REASON FOR STUDY: liver mass

DIAGNOSIS:
Suspect hepatocellular carcinoma. Biopsy taken to confirm diagnosis prior to
initiating treatment.

CONSENT:
The procedure and possible complications were explained to the patient and
written informed consent obtained. Complications include, but are not limited
to, bleeding, allergic reactions to injected medications, and infection. While
these complications are unusual, they are possible.

PROCEDURE/FINDINGS:
Ultrasound guidance is utilized. Using sterile technique and 1% lidocaine for local anesthesia a 20-gauge core biopsy needle was introduced into the mass in the right lobe of the liver with 3 passes. Samples were placed in formalin for pathologic evaluation. There were no immediate complications. The patient tolerated the procedure well.

The patient was watched in recovery. Her hematocrits remained stable. She did have sinus tachycardia in the 110s which may be secondary to overall volume loss that she had not eaten earlier. The patient was completely stable. EKG was obtained confirming sinus tachycardia. Patient was discharged in stable condition to her retirement community which has special clinical beds to be watched overnight.

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

PERFORMED PROCEDURES: Ultrasound-guided core needle biopsy right hepatic lobe mass

IMPRESSION:
Successful ultrasound core needle biopsy right hepatic lobe mass.

CPT code : 47000 Biopsy of liver, needle; percutaneous

ICD 10 : K76.89 Other specified diseases of liver

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Sample Medical Coding Report 3

PREOPERATIVE DIAGNOSIS:   Residual fragments status post prior ureteroscopic

laser fragmentation.

POSTOPERATIVE DIAGNOSIS:   Residual fragments status post prior ureteroscopic

laser fragmentation.

PROCEDURE:   Right ureteropyeloscopy, laser fragmentation and basket extraction of stones from right kidney and ureter, removal of indwelling ureteral stent.

INDICATIONS FOR PROCEDURE:  

The patient is a 54-year-old woman with developmental delay, who has previously been managed for a urinary tract infection and obstructing large right renal stone. She initially underwent stent placement, followed 1 week later by right ureteroscopy and laser fragmentation of the stone. At the time of the procedure, I was unable to access all stone fragments in the lower pole of the kidney. The patient returns today for reassessment to see if any fragments remain in to deal with these.

The patient cannot undergo office procedure such as stent removal in the office on account of her severe developmental delay. Similarly, we were not able to obtain a urine culture prior to the procedure.

PROCEDURE IN DETAIL:  

The patient was brought to the operating room and she was given anesthetic. An IV was then placed. She was placed in lithotomy position, prepped with Betadine, draped in normal fashion. The cystoscope sheath was used to obtain a specimen of urine for a culture. The patient was then given 80 mg of gentamicin and 2 g of Ancef.

I now proceeded with the operation. I performed cystourethroscopy and grasped the stent at the ureteral orifice. I brought the tip of the stent out the urethral meatus and passed a wire up into the renal pelvis. I then introduced the cystoscope and passed a second wire alongside this. Over the second wire, I passed a cystoscope. I did not wish to place a ureteral access sheath on account of the larger diameter and the possibility that small stones in the ureter might be forced against the side of the ureter by the ureteral access sheath. I passed the scope all the way up into the renal pelvis, then removed the second wire. I then performed systematic evaluation of the calices. There were several small fragments measuring a few mm in size in a lateral mid pole calyx. There was a calcification that was apparently adherent to the wall of the lower pole calyx. The remaining calices appeared to be free of any stones. Contrast was used to delineate the architecture of the kidney. This allowed me to be sure that all calices were inspected. I then introduced the laser fiber and fragmented the mid pole stones all down to submillimeter sizes. The largest of these I removed with the 4 wire basket. In doing so, I inspected the ureter which had several additional fragments. I then proceeded to clear out the ureter using the semi rigid scope. I then completed ureteroscopic evaluation of the upper tracts, inspecting the lower pole calyx where there appeared to be a calcification adherent to the wall. The position of the stone was made it impossible to get a direct application of the laser or basket onto it. Angulation required to access the pole limited the further mobility of the scope and laser fiber. This fragment appeared to be very very small and in fact may be soft tissue as the visualization was inadequate to determine whether or not this was a stone with any certainty.

There was seen to be very little utility in trying further to manipulate this small fixed apparent calcification. I therefore elected to terminate the procedure at this time. I inspected the ureter one final time taking the scope out. There appeared to be edema but no significant fragments and no areas of obstruction. The safety wire was removed. I then performed cystoscopy. There was so much edema on the trigone that it was not possible to easily obtain a retrograde pyelogram. I was afraid of manipulating the orifice anymore and raising a false flap of mucosa, and I therefore emptied the bladder and observed some urine, irrigation, and contrast passing through the orifice into the bladder. I elected at this point to terminate the procedure and not to consider placing a new stent.

The patient was subsequently taken out of lithotomy position, awoken, transferred to a gurney and brought back to the recovery room. I spoke with the patient’s mother and emphasized importance of letting me know should the patient develop any fevers or chills or severe abdominal pain. I am confident that she will do well without the stent but in the event of any unexpected clinical changes, reassessment for sepsis syndrome and obstruction would be appropriate. The patient’s mother understands this.

CPT code – 52353 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)

ICD 10: N20.0 Renal stone