Medical coding Sample Report 1
EXAM DESCRIPTION: IR cvc port removal
CLINICAL HISTORY: Port removal
CONSENT: The procedure, risks, benefits, and alternatives were discussed with thepatient, and all questions were answered. Informed consent was obtained verbally and in writing.
NURSING/MEDICATIONS: Continuous cardiorespiratory monitoring was provided throughout the examination. Local anesthesia only
PROCEDURE: The patient was positively identified, taken to the angiography suite, and positioned supineon the fluoroscopy table. Timeout was performed. The skin overlying the port was prepped and draped in usual sterile fashion using all elements of maximal sterile barrier technique including cap, mask, hand hygiene, sterile gloves, sterile gown, 2% chlorhexidine skin preparation, and large adhesive sterile drape. Local anesthesia was provided by administration of lidocaine 1% solution.
An incision was made along the previous incision. Indwelling catheter was mobilized and delivered completely from the vein. Hemostasis was obtained with manual compression at the venotomy.
Sutures anchoring the port within the pocket were cut and removed. The port was liberated from the pocket and removed. The pocket was irrigated with sterile saline. Inspection of the port and catheter revealed an intact system upon removal.
Incision was closed by multiple deep interrupted followed by running subcuticular Vicryl suture. Dermabond was applied to the closed incision. Sterile dressing was applied.
FINDINGS: Scout fluoroscopic image showed an intact port/catheter. Post removal image demonstrated no evidence of complication.
Complications: None immediate. The patient tolerated the procedure well, and was transferred in stable condition for further monitoring.
Estimated Blood Loss: Less than 4 cc
Fluoroscopy time: Time 0.1 minute
IMPRESSION:
- Successful port removal under fluoroscopy.
CPT & ICD 10 code:
36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion
Z452 Encounter for adjustment and management of vascular access device
C20 Malignant neoplasm of rectum
C211 Malignant neoplasm of anal canal
Medical coding Sample Report 2
Pre-op Diagnosis: End-stage OA left knee
Post-op Diagnosis: Same
Procedure: Total knee arthroplasty left with navigation
Implants: depuy attune femoral Porocoat cruciate retaining size 9 left cementless
Anesthesia Type: regional, local and spinal
Surgeon:
Anesthesiologist:
Estimated blood loss (mL): 35
Findings: Diffuse grade 4 changes patellofemoral compartment focal grade 4 changes medial compartment
Specimens: None
Complications: None
Tourniquet Time: 48 minutes
Indication and consent: Advanced arthritic change with pain and dysfunction refractory to conservative treatment
Description of procedure: Patient was brought to the operating room where spinal was placed followed by positioning in th e supine position. The left lower extremity is concerned alcohol ChloraPrep draped in the usual sterile fashion anterior skin incision outlined I dyne impregnated Vi-Drape placed. My initials left knee confirmed Ancef 2 g given. 1 g of TXA. A tourniquet was insufflated 250 mm after use of an Esmarch.
Anterior skin incision was made we irrigated immediately with Irrisept as well as fiber 6 times throughout the case in addition to 3 L of pulsatile lavage with normal saline. Standard medial parapatellar arthrotomy was performed we dressed the patella 1st which had grade 4 changes it measured 26 mm removed 9 mm in preparation for the 3 peg medialized patella and drilled cognizant of position and rotation.
We then placed Ortho align the distal femur set at 2.5 degrees of flexion neutral varus valgus and made our distal femoral cut followed by sizing. We placed a 4 1 sizing block in 3 degrees external rotation and made our cuts with Hohmann’s protecting the collaterals followed by the sulcus cut.
We then directed our attention to the tibia we use ortho line we said at 7 degrees of posterior slope 0.5 degree of varus and removed 8 mm off the lesser affected lateral side. We did so with the PCL retractor and Homans in place. We irrigated removed some osteophytes off the posterior femur very carefully. We then trialed we were content with our motion stability there is a solid endpoint with full extension no lift-off of the tibial base plate and stable throughout arc of motion we irrigated again drilled femur prep the tibia injected the capsule with 15 cc Gore% Marcaine with epinephrine morphine we then impacted the tibial component placed the polyethylene and impacted the femoral component while still extending the knee. We then cemented the patella and held the steadfast while cement matured well irrigating the knee and Aricept. We released the tourniquet hemostasis perfected letter cautery there was no undue bleeding 2nd g of TXA was given within close the capsule with 1. Stratafix 0 Vicryl 2-0 Vicryl 3-0 Stratafix will be placed in this soft tissues followed by Dermabond a silver impregnated occlusive dressing and Ace wrap he will be transferred to recovery with no known complications
CPT & ICD 10 code:
27447-LT Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
64447-LT Injection(s), anesthetic agent(s) and/or steroid; femoral nerve
M1712 Unilateral primary osteoarthritis, left knee
Z96652 Presence of left artificial knee joint
Medical coding Sample Report 3
Pre-op Diagnosis: Ruptured distal biceps tendon right
Post-op Diagnosis: Same
Procedure: Open repair right distal biceps tear
Implants: Arthrex biceps button
Anesthesia Type: GETA and local
Estimated blood loss (mL): 10
Findings: Complete rupture distal biceps
Specimens: None
Complications: None
Tourniquet Time: 47 minutes
Indication and consent: Pain positive put tests positive MRI for complete rupture right distal biceps. The patient did not want to live with any weakness if possible
Description of procedure: I updated the patient’s history and physical earlier today and prior to being taken back to the operating room he want to speak with me again. I had asked him to be careful with anti-inflammatories supplements and stay hydrated for his creatinine was slightly elevated his protein was high. I have asked him to follow-up with his primary care physician for this which she agrees to do. He informed me that several months ago he was in a bad spot light undergoing a divorce and use cocaine and quite possibly some other drugs but has been drug-free for weeks. He reassured me that he has not done any drugs in the recent past and that he will follow up with his primary care physician.
Following this conversation is doing back to the operating room general some do’s the right upper extremity is constant alcohol ChloraPrep draped in usual sterile fashion and a sterile tourniquet placed on the upper arm my initials right elbow confirmed and 2 g Ancef were given. After elevation tourniquet was insufflated 250 mmHg
Next we outlined curved incision beginning proximal medial extending over the distal elbow flexor crease and continuing distally and laterally. We made our incisions of the dermis only we were very careful hemostasis a electric cautery we but I dissected down to the fascia the biceps tendon was easily encountered a head some scarring post completely ruptured. We debrided the tendinotic and getting down to good healthy collagen fibers in place the baseball stitch with the FiberLoop extending 3 cm above the distal end I irrigated with Aricept and place the tendon a wet 4 x 4 well we developed the the interval where will follow palpably to the tract down to the radial tuberosity. We initially exposed this with Army-Navy is not placed a blunt wide small Hohmann over the lateral edge being very careful to stay on the bone in doing so only with maximum supination. I then placed a Z retractor medially exposing the radial tuberosity I did see wisp of tendon from where the biceps had been pulled away. We then used Arthrex pin I drilled the near cortex into the far cortex and then drilled a 7 mm hole consistent with the size of the tendon into the near cortex only we irrigated very thoroughly an effort to prevent heterotopic ossification we loaded the biceps button passed it and engaged appropriately we pulled the tendon down into the radial tuberosity he has a free needle and took 2 passes through the biceps tendon very carefully and tied this with alternating half hitches followed by alternating post. We irrigated released the tourniquet there was no undue bleeding minimal hemostasis with electrocautery as needed we were very meticulous again effort to prevent heterotopic calcification. We close subcutaneously after injecting 4-6 cc of 0.25% Marcaine with epinephrine in the dermis we used 3-0 Vicryl. We then placed interrupted nylon 3-0 in the dermis 0 form lightly applied fluffs Webril Ace wrap posterior splint in neutral pronation supination. Patient will be transferred recovery with no known complications.
CPT & ICD 10 code:
24341-RT Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff)
S46211A Strain of muscle, fascia and tendon of other parts of biceps, right arm, initial encounter