Medical coding Sample Chart 1
PREOPERATIVE DIAGNOSIS: Recurrent streptococcal adenotonsillitis
POSTOPERATIVE DIAGNOSIS: Same
ANESTHESIA: General by endotracheal tube.
COMPLICATIONS: None.
OPERATION/PROCEDURE:
Traditional tonsillectomy and adenoidectomy.
FINDINGS:Tonsils: 3+, significant scar to superior constrictor muscle Adenoids: 1+
INDICATION: Recurrent streptococcal adenotonsillitis
DESCRIPTION OF PROCEDURE: After informed consent was obtained in the preoperative holding area, the patient was brought to the operating room and properly identified using the patient’s date of birth and medical record number. With the patient supine following general anesthesia via endotracheal tube, the patient was placed in the Rose position. Mouth gag was inserted without difficulty. The palate was palpated and noted to be intact. Traditional tonsillectomy was performed using traditional guard tip Bovie and hemostasis was obtained with electrocautery. The palate was retracted. An adenoidectomy was performed using the suction Bovie and hemostasis was achieved with electrocautery. The tonsillar fossae were injected using 1% lidocaine with epinephrine 1:100,000 3 cc total. There was no active bleeding at the termination of the procedure. The child was lightened from anesthesia, extubated, and taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS: 10 cc.
PATHOLOGY SPECIMENS: Right and left tonsils for gross only.
CPT code :42821 Tonsillectomy and adenoidectomy; age 12 or over
ICD 10: J03.01 Acute recurrent streptococcal tonsillitis
Medical coding Sample Chart 2
Procedure: 1. Left hemithyroidectomy
- Direct laryngoscopy
Anesthesia Type: GETA
Estimated blood loss (mL): 20
Specimens: Left hemithyroidectomy to pathology
Complications: None apparent
Indication and consent: The patient is a 57yo F with longstanding (>8 years) history of left thyroid nodule. She underwent a CT neck following a fall in 1/2021 which demonstrated calcified thyroid nodule. She underwent thyroid U/S and FNA with pathology suspicious for follicular neoplasm. She presented to ENT clinic for further evaluation. On repeat ultrasound in clinic, was found to have dominant left thyroid lobe nodule that is hypoechoic, harbors microcalcifications, does not demonstrate evidence of extrathyroidal extension, is somewhat ill defined at the border measuring 2.94 x 1.43 x 2.33 cm. The right thyroid lobe harbored anechoic colloid cysts that were subcentimeter. Screening neck ultrasound was without further significant findings. We discussed options of repeat FNA with afirma testing vs. hemithyroidectomy vs. total thyroidectomy. Discussed that pending final pathology, might need completion thyroidectomy. Discussed risks of surgery including bleeding, damage to recurrent laryngeal nerve, hypothyoidism, hypocalcemia, need for further procedure. She would like to proceed with surgery. Given prior right neck surgery, benign appearing right thyroid lobe, and FNA results, recommend LEFT hemithyroidectomy. Patient in agreement of plan and acknowledges risk of possible need for completion surgery.She has a small lesion on left upper eyelid she would like excised at same time.
Description of procedure: Patient was identified in the preoperative holding area where surgical consent was reviewed with patient and her daughter. She was taken to the operating room and general endotrachea anesthesia was induced in the supine position. A surgical time out was performed. Patient’s left eye was prepped and draped for excision of eyelid lesion. Please see Dr. Baker’s note for further details. The table was rotated 180 degrees and a shoulder roll was placed. To confirm correct placement of the endotracheal Nims tube I did insert the glide scope into the oral cavity. Placed the tip of the scope into the on vallecula. The larynx was visualized with the marker on the NIMs tube just above the true vocal cords and twisted from midline. I rotated and advanced the tube to correct position.
The patient was prepped and draped in the usual sterile fashion. A 4 cm incision was designed 1 fingerbreadth beneath the cricoid cartilage. This was placed in the same rhytid as her prior right acdf scar. The subcutaneous dissection was carried through with the Bovie. We then raised Sub platysmal flaps again with the Bovie. We divided the straps along the midline raphae. We dissected the strap musculature from the anterior surface of the left thyroid. Attention was turned to the superior pole. A medial and lateral tunnel were dissected. Clips and harmonic were utilized for hemostasis. We took down the superior thyroid artery with harmonic. We then dissected the superior pole free from the trachea. At this point we took down the lateral soft tissue adjacent to the thyroid. We then turned attention to dissected the inferior pole. This was somewhat tethered, so attention was then turned to identification of the recurrent laryngeal nerve. We did skeletonize a portion of the nerve to allow us to remove berry’s ligament. This was taken down with bipolar cautery and sharp dissection. We then moved inferiorly to free up the inferior aspect of the gland. Again this was done with sharp dissection and the bipolar. We then of dissected the gland from the trachea until we reached the mid line. We divided the isthmus along the midline. Hemostasis was then achieved. We did stimulate the nerve to confirm that there was no at in inverted injury to it. Fibrillar was placed in the wound bed. A valsalva was performed to ensure hemostasis. We then closed the straps with 3 0 running locking Vicryl sutures. The subcutaneous tissue was closed with interrupted 5 0 Monocryl sutures. The skin was closed with a running vertical mattress nylon and dressed with silicone scar sheet. The patient was returned to anesthesia for extubation and wake up in stable condition. This concluded the procedure.
CPT code : 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy
ICD 10: E041 Nontoxic single thyroid nodule
Medical coding Sample Chart 3
Pre-op Diagnosis: Right shoulder rotator cuff tear of the supraspinatus and superior labral anterior to posterior tear subacromial impingement syndrome
Post-op Diagnosis: Same plus upper rolled border subscapularis tear
Procedure: Arthroscopy of the right shoulder with extensive intra-articular debridement 2. Arthroscopic rotator cuff repair of the subscapularis 3. Rotator cuff repair of the supraspinatus 4. subacromial decompression 5. Open subpectoral biceps tenodesis
Implants: Arthrex anchors
Anesthesia Type: GETA and regional (Interscalene nerve block)
Estimated blood loss (mL): 10
Findings: Upper rolled border tear of the subscapularis with a complete supraspinatus tear. Subacromial impingement syndrome and superior labral anterior-posterior tear
Specimens: None
Complications: None
Tourniquet Time: None
Indication and consent: Debra is a 65-year-old female with significant pain and dysfunction to her right shoulder she had failed conservative measures and desired a shoulder arthroscopy and she consented for that knowing risks benefits possible complications associated with the procedure and we proceeded at her request.
Description of procedure: Patient was seen evaluated in the preop holding area where she identified the right shoulder as the operative extremity was marked and she was administered interscalene nerve block and taken back to the OR suite she was anesthetized and then placed in the beach chair position. There are right shoulder was sterilely prepped draped usual fashion after which a formal time-out indicating correct side antibiotics have been administered. We then commenced by making a posterior portal and the scope was placed into the glenohumeral joint where we noted no significant chondromalacia and otherwise normal appearing cartilage. Subscapularis had a upper rolled border tear of the subscap and the rest the attachment looked okay. The supraspinatus had no retraction however a full-thickness rotator cuff tear was noted. I then evaluated the labrum which showed normal labral tissue inferiorly and posteriorly however the superior labrum and biceps attachment was completely torn and there is significant frayed tissue there. I came in through the anterior interval portal and cut the biceps tendon did and debridement of the labrum and some of the rotator cuff and also debrided and decorticated some of the bone on the lesser tuberosity for which to repair my subscapularis to. I created a anterior superior lateral portal and passed suture through the upper rolled border of the subscapularis and pulled over into a SwiveLock anchor in anatomic fashion on the lesser tuberosity to reattached that upper rolled border. Prior to doing this I did resect the middle glenohumeral ligament. After that intra-articular extensive debridement and the rotator cuff repair was done from the inside the joint I went into the subacromial space and spent quite a bit of time doing a thorough subacromial decompression as she had abundant bursal tissue over the rotator cuff. Once that was resected we had a good rotator cuff tissue laying over the attachment on the greater tuberosity with no retraction noted so we cleaned up the greater tuberosity and prepared the bone for repair. I then placed a 4 0.75 mm anchor on the at the articular margin. I then passed each limb of the suture in a horizontal mattress configuration and tied them and I placed a cinch stitch posteriorly to incorporate and pull that lateral tissue into the lateral anchor. I then placed 2 anchors laterally that were SwiveLock anchors and they had good purchase and fixation and at that point we were satisfied with the double row construct of the rotator cuff repair and we removed our instruments from the subacromial space and to the abducted externally rotated position for the biceps tenodesis. We made an incision in the axillary crease of approximately 1 in and bluntly dissected down until I identified the lateral border of the humerus and placed a Hohmann there elevating the Peck and then we could easily identified and pull out the biceps tendon from the groove we whipstitched it and cut the remaining tendon and drilled the 6.5 mm hole into the intertubercular groove and tenodesed it into the bone. We then noted it had excellent purchase and fixation we irrigated grossly and then closed all incisions and portals in standard fashion and sterile dressings were applied the patient was awakened and taken to PACU in stable condition.
CPT code :29827 Arthroscopy, shoulder, surgical; with rotator cuff repair
29826 Arthroscopy, shoulder, surgical;decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure)
23430 Tenodesis of long tendon of biceps
29823 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
64415 Injection(s), anesthetic agent(s) and/or steroid; brachial plexus
ICD 10:
M75101 Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic
S43431A Superior glenoid labrum lesion of right shoulder, initial encounter