Sample coded Surgery charts for Medical coders Part 16

Medical Coding Sample Chart 1

Procedure: CERVICAL FACET INJECTION LEFT C5-6 and C6-7

Diagnosis: Cervical Spondylosis

The patient has been referred to the Pain Management Center for cervical facet injection treatment of chronic axial neck pain. The patient has had long standing cervical pain thought to be facet joint generated and which has been refractory to other therapies.

Risks and expected side effects as well as potential benefit of the procedure were reviewed with the patient, and their voiced concerns were addressed. The printed consent form was signed and witnessed. Standard time-out procedure was performed.
The patient was placed in the prone position on the fluoroscopy table and automated blood pressure cuff and pulse oximeter applied. The skin entry points for approaching the anatomic target points of the cervical facets of LEFT C5-6 and C6-7.were identified with a 10 degree from perpendicular medial oblique fluoroscopic view and marked. Following thorough Chlorhexidine preparation of the skin and draping and 1% lidocaine infiltration of the skin entry points and subcutaneous tissues, a 3inch 25gauge spinal needle was placed under fluoroscopic guidance at the anatomic course of each facet targeted. The needles were advanced in a plane that was coaxial with the axis of the xray path. The needles were adjusted to remain coaxial and advanced toward the C5-6 and C6-7 facets on the LEFT side using repeated images every 2 to 4 mm of needle advancement. Upon contact with the needle tip at the surface of the joint space, a lateral radiograph was then obtained and the needle was advanced just slightly to penetrate the posterior joint capsule at the C5-6 and C6-7 levels respectively. The needle tip was in excellent position both from an AP and lateral plane view. A solution containing 10mg of dexamethasone and 0.5% bupivacaine was injected using a 3ml syringe into each joint space after negative aspiration. The patient tolerated the procedure well and at no time was there any heme, csf, or air aspirated prior to injection.

CPT :64490-LT Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 ;second level (List separately in addition to code for primary procedure)
ICD-10: M47.812 Spondylosis without myelopathy or radiculopathy, cervical region

Medical Coding Sample Chart 2

COLONOSCOPY REPORT

COLONOSCOPY: With cold snare polypectomy

INDICATIONS: History of a large acing colon polyp that is been recurrent she is here to reevaluate the polypectomy site
MEDICATIONS: See anesthesia note
DESCRIPTION: The Colonoscopy was explained in detail to the patient prior to the procedure including risks such as bleeding and colonic perforation. The patient was informed that in the event of a complication, they may require surgery to treat the complication. The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. On external anal exam, there was no evidence of external hemorrhoids or fissures. On digital rectal exam there was no palpable masses. A standard Olympus colonoscope was inserted into the rectum and passed in the usual fashion to the level of the terminal ileum. The preparation of the colon was excellent with a Boston bowel prep score of 9. The scope was then slowly withdrawn and careful examination of the entire colon was performed.

FINDINGS / THERAPY:
Ileum -normal
Cecum -normal
Ascending colon -I do see a large scar from the previous polypectomy site that is well demarcated with tattoo ink. On the margin of the scar there is a small 3 mm area that may just be granulation tissue although I cannot completely exclude possibility of a small amount of adenomatous tissue in this area was removed with a cold snare. The remainder the scar was clearly free of adenomatous tissue
Hepatic flexure -normal
Transverse colon -normal
Splenic flexure -normal
Descending colon -normal
Sigmoid colon -diverticulosis
Rectum -normal
Anal canal -normal
***Withdrawal time 9 minutes

IMPRESSION:
1. Diverticulosis
2. Previous polypectomy site in the ascending colon free of neoplasia with just a small area of concern that was removed

CPT : 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
ICD-10 : K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding

Medical Coding Sample Chart 3

Preoperative Diagnosis: Biliary dyskinesia
Postoperative Diagnosis: Biliary dyskinesia
Procedure: Robotic single-site cholecystectomy
Anesthesia: GETA plus 0.25% Marcaine local
Estimated Blood Loss: Scant
Complication: None

Indications For Procedure: He is a 54-year-old gentleman with a several month history of postprandial fecal urgency and diarrhea. He denied any associated right upper quadrant or epigastric abdominal discomfort, nausea, vomiting, or any other associated complaints.
After continued symptoms a follow-up gallbladder ultrasound in december month was also unremarkable. Follow-up HIDA scan demonstrated a diminished gallbladder ejection fraction of 19%, suggestive of biliary dyskinesia.

Recommendation was made for an outpatient robotic single-site cholecystectomy. The procedure, benefits, risks, and alternatives to surgery were discussed in detail. The patient acknowledged understanding of these discussions and desired to proceed with surgery as soon as possible.

Procedure In Detail: The patient was brought to the OR, placed in supine position on the OR table. After the uneventful induction of general endotracheal anesthesia, abdomen was prepped and draped in a sterile fashion. After infiltration of skin site with 0.25% Marcaine, a 2.5 cm incision was made within the base of the umbilicus, carried down through the skin with skin knife through subcutaneous tissues with Bovie electrocautery. Careful dissection carried down to the umbilical fascia, which was carefully divided along the full length of the skin incision with Bovie electrocautery. A da Vinci single-site Gelport was then carefully introduced through the fascial defect. With the port in place, CO2 gas infused and adequate pneumoperitoneum was achieved. An 8.5 mm camera port was then placed through the Gelport. The da Vinci laparoscope was introduced and visual inspection of abdominal cavity was undertaken. Under direct visualization, the da Vinci robot was carefully brought in position over the patient’s right shoulder and docked to the camera port. Under direct visualization, two curved 5 mm cannulas were the placed through the Gelport and docked to the robot. A 5 mm accessory port was then placed through the Gelport. A 5 mm grasper was then used to carefully grasp and retract the gallbladder fundus providing good exposure of the infundibulum and area of Calot’s triangle.

At this point, I broke scrub and assumed control of the robot at the control console. Using a fundus grasper and hook cautery, careful dissection was undertaken beginning at the infundibulum and carried down to Calot’s triangle as the cystic duct and cystic artery were identified and delineated. The gallbladder infundibulum was then carefully mobilized both medially and laterally providing good critical view of safety to ensure both structures terminating within the gallbladder wall. Each structure was then triply ligated with medium large Weck clips and divided. The gallbladder was then carefully dissected free of the hepatic bed using the hook cautery. Once the gallbladder was fully freed and mobilized, careful inspection was made to confirm hemostasis and bowl integrity at the resection site. When this was confirmed, the site was irrigated and reinspected. When hemostasis and bowl integrity were again confirmed, the robotic instruments were removed and the robot was undocked and moved away from the patient table.

After scrubbing back into the procedure, the gallbladder was carefully removed en bloc with the Gelport. Photodocumentation of the specimen was obtained and the specimen was was sent for permanent section evaluation. Careful inspection made to confirm hemostasis and bowl integrity at the umbilical facial site. When this was confirmed, the site was irrigated and reinspected. The fascia was then carefully reapproximated using #1 Stratafix in a running fashion. Additional 0.25% Marcaine was then placed around the perimeter of the fascial closure. The subcutaneous tissues followed by 4-0 Monocryl in a running subcuticular fashion to approximate the skin. The wound site was clean and dried and Dermabond dressing was applied. The patient tolerated the procedure well. There were no complications. All laparotomy pads, sponge, needle, and instrument counts were correct x2 at the end of the case. The patient was extubated in the OR and taken to recovery room in stable condition.

CPT : 47562 Laparoscopy, surgical; cholecystectomy
ICD-10 : k82.8 Other specified diseases of gallbladder

Medical Coding Sample Chart 4

Preoperative Diagnosis: Osteoarthritis right hip, right hip pain, right lower extremity radiculopathy
Postoperative Diagnosis: Same
Procedure: Right intraarticular hip injections with fluoroscopy
Anesthesia: Local anesthesia with I.V. sedation per Department of Anesthesia due to complications associated with anxiety and low pain threshold due to complications associated with severe chronic pain.
Complications: None

Procedure Note: Upon explanation of the risks and benefits the patient was transitioned to the procedure table. After adequate sedation was obtained by the department of anesthesia, while the patient was in the supine position the right hip was prepped in standard fashion for an anterior approach for intraarticular hip injection with Betadine solution. Subsequently appropriate sterile drapes were placed.

The skin and deeper tissues were anesthetized with 0.25% neutralized Marcaine through which a 22-gauge spinal needle was advanced with aspiration until the tip of the needle came to lie at the ridge of the acetabular rim. At this point, ½]cc of Omnipaque 300 was injected. Adequate Contrast spread was noted around the acetabular rim, at which point 40 mg of Depo-Medrol, followed by 5 cc of 0.25% neutralized Marcaine was injected. Procedure was performed on the right. The needle was removed. Band-Aid was placed over the puncture site. Right hip was manipulated in multiple positions. The patient was taken to postanesthesia recovery and found to be in satisfactory condition with improvement of her right hip discomfort.

CPT : 20610-RT Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)

ICD-10 :M16.11 Unilateral primary osteoarthritis, right hip