Sample coded Surgery chart 1

History: The patient is a 39-year-old male with a history of end-stage renal disease.  The patient has an indwelling left upper extremity brachiocephalic hemodialysis fistula with reports of increased venous pressures and suboptimal dialysis.

Comorbidities:

1. Hypertension.

2. End-stage renal disease

Services performed:

1. Diagnostic fistulagram

Date of service: 

Following explanation of risks and benefits informed consent was obtained Pre-procedure medications: 2 mg of Versed said and 50 mcg fentanyl Intra procedure medications: 10 cc 1% lidocaine Contrast agent: 80 cc of Optiray

Procedure:The patient was placed in the supine position on the fluoroscopy table.  The left upper extremity was treated to sterile technique and draped in a surgical fashion.  Utilizing ultrasound guidance the cephalic outflow tract was cannulated proximally to the arteriovenous anastomosis and oriented centrally.  Employing standard ventral techniques there was subsequent placement of a 7 French sheath.  A diagnostic fistulagram was performed. The arteriovenous anastomosis was widely patent.  The entire length of the cephalic outflow tract was dilated with multifocal areas of aneurysms.  There was no evidence of flow limiting stenosis from the arteriovenous anastomosis centrally into the right atrium.

Complications: None immediate

Impression: 1. Diagnostic fistulagram of the patient’s indwelling left upper extremity brachiocephalic hemodialysis fistula demonstrating the entire length of the cephalic outflow tract to be dilated with multiple focal areas of pseudoaneurysms over areas of frequent cannulization.  There was no evidence of flow limitations.  Please continue to use the hemodialysis fistula as clinically indicated.  In the future the hemodialysis fistula will most likely require surgical revision.

CPT code: 36901

ICD 10 : I12.0

N18.6

Sample coded Surgery Chart 2

Procedure(s): XR lumbar puncture LP (CPT: )

HISTORY:  THE PATIENT IS A 70-YEAR-OLD MALE WITH CLINICAL SUSPICION OF MENINGITIS.

Services performed: Fluoroscopic guided lumbar puncture.

Following explanation of risks and benefits informed consent was obtained

Pre-procedure medications: None

Intra procedure medications: 10 cc 1% lidocaine

Contrast agent: None

Procedure:The patient was placed in the prone position on the fluoroscopy table.  The skin over the lumbar spine was treated to sterile technique and draped in a surgical fashion.  The epidural space at the level of L4/L5 was selected as surgical site.  The skin and deep subcutaneous tissues were diffusely infiltrated with 1% lidocaine.  Utilizing fluoroscopic visualization a 20 gauge spinal needle was directed into the epidural space at the level of L4/L5 until there was aspiration of CSF fluid.  Opening pressures were approximately 5 mm of water.  The initial CSF fluid was blood tinged which cleared over time.  .  Approximately 6 cc of CSF fluid was aspirated and placed into 4 sequentially numbered sterile vials.  Following the procedure the needle was removed with an occlusive dressing placed.  The patient tolerated the procedure well with no immediate complications.

Complications: None immediate

Impression:

1. Successful fluoroscopic guided lumbar puncture obtaining 6 cc of CSF fluid. Specimens were sent to the laboratory according to the ordering physician’s request.

CPT code :62328

Sample Coded Surgery chart 3

Preoperative Diagnosis:  Multiple myeloma

Postoperative Diagnosis:  Same

Surgeon: 

Assistant: 

Procedure:  Infuse-A-Port placement, fluoroscopy guidance

Anesthesia:  Monitored anesthesia care with local

The patient was taken the operating room placed on table supine position.  Monitored anesthesia care was administered in standard fashion.  Right neck and chest areas prepped and draped in usual sterile fashion. Patient was then positioned in Trendelenburg position.  The right chest wall was then locally anesthetized with Marcaine with epinephrine.  Right subclavian vein was then cannulated.  Guidewire was passed.  Fluoroscopy assured correct passage of a guidewire into the right heart region.  Further local anesthesia was then injected adjacent to the needle guidewire system.  Transverse incision made. Needle was removed.  A pocket was created using blunt dissection and electrocautery surgery.   The dilator sheath mechanism was then inserted over the guidewire.  The guidewire and dilator were removed and the catheter was quickly inserted into the sheath.  Sheath was broken removed in a standard fashion. Fluoroscopy was then used to measure the catheter to appropriate length. Catheter was then cut, then snapped together to the port in standard fashion.  The port flushed easily.  It was positioned into the pocket.  The pocket was closed in layers using Vicryl suture.  Final fluoroscopy assured correct passage of the port catheter.  Skin was closed in layers using Vicryl suture. Steri-Strips, sterile dressings were applied. Patient tolerated the procedure. Final chest x-ray pending to decide disposition.

Date of Procedure:

Anesthesia Type: MAC

Surgeon:

Disposition: Same Day

CPT code : 36561, 77001

ICD : C90.00 Multiple myeloma