- Surgery Medical coding Sample Coded Chart for Coders
PREOPERATIVE DIAGNOSIS:
Extruded vaginal mesh.
POSTOPERATIVE DIAGNOSIS:
Extruded vaginal mesh.
PROCEDURE:
1.Excision of vaginal mesh.
2.Cystoscopy.
SURGEON:
ANESTHESIA:
General.
ANESTHESIOLOGIST:
BLOOD LOSS:
10 mL.
COMPLICATIONS:
None.
IMPLANTS PLACED: None.
SPECIMEN SENT: Extruded vaginal mesh as well as surrounding vaginal tissue were sent for pathology.
INDICATION FOR SURGERY: This is an 81-year-old female who had prior undergone robotic sacrocolpopexy.She had been doing well up until about a year ago when she began to have vaginal bleeding.She went and saw her gynecologist who diagnosed that she had extrusion of the mesh at the vaginal apex.I discussed with her that she would need excision of this area.The risks of this procedure including pain, infection, bleeding, damage to nerves, arteries, organs, further extrusion of the mesh, and damage to bowel were explained to her and she consented to procedure.
PROCEDURE IN DETAIL:
The patient identified in preop holding and escorted back to OR, placed supine table, given excellent anesthesia and LMA was placed. She was put in dorsal lithotomy position, prepped and draped in the usual standard sterile fashion.She received 300 mg of IV clindamycin prior to start procedure.I began by placing a 21-French cystoscope into her bladder.Her bladder was distended 300 mL and carefully inspected.No lesions, masses, or stents were identified in the bladder.No evidence of any mesh extrusion within the bladder.Bilateral ureteral orifices were in orthotopic position.I then performed a vaginoscopy and apex was easily identified as having several of the Gore-Tex sutures as well as the vaginal mesh extruding.
I placed a 16-French Foley catheter.I injected the vaginal apical area with 0.25% Marcaine.The exposed vaginal mesh was then removed using Bovie electrocautery at a low energy setting.After about a 2 x 1 cm area of mesh was removed, I then also removed 5 of the Gore-Tex sutures as well.Irrigation of the area was then obtained.The edges of the vagina that were no longer had mesh extrusion were then brought back together using a 0 Vicryl suture in an
interrupted fashion.Packing with KY jelly was then placed.The patient tolerated the procedure well.She was then extubated and brought to PACU in stable condition.
CPT code: 57295
Revision of prosthetic vaginal graft; vaginal approach
The physician revises or removes a previously placed prosthetic vaginal graft via a vaginal approach. The patient is placed in the lithotomy position and a speculum is inserted. The physician visualizes the vagina. The apex of the vagina is accessed with deep retractors. Dissection is carried out to reach the affected graft material. Depending upon the type of complication (i.e., stricture or infection), the vaginal graft may be completely or partially excised to remove eroding mesh or revisions may be made in the graft and surrounding tissue. The vaginal epithelial layers and pelvic fascia are rearranged or reapproximated and closed. Vaginal packing is put in place
52000-59
Cystourethroscopy (separate procedure)
ICD 10 : T83711A Erosion of implanted vaginal mesh to surrounding organ or tissue, initial encounter
2. Surgery Medical coding Sample Coded Chart
PREOPERATIVE DIAGNOSIS:
Large cheek defect status post melanoma excision.
POSTOPERATIVE DIAGNOSIS:
Large cheek defect status post melanoma excision.
PROCEDURE:
Right cervical facial rotation flap with debridement of existing
open wound of the right cheek.
SURGEON:
ANESTHESIA:
General endotracheal anesthesia provided by Dr.
INDICATIONS FOR SURGERY:
The patient is a 77-year-old woman who was seen by Dr. , a Mohs surgeon, for excision of a large lesion in her right cheek.
This turned out to be melanoma in situ.Final dimensions of the excision were 4.6 cm x 3.7 cm and the defect was in the right mid cheek near the nasolabial fold lateral to the oral commissure.After testing the laxity of the cheek and neck and assessing the location of the defect, I decided that a cervical facial rotation flap would be necessary to close the defect without causing significant distortion of the mouth.Benefits, risks, and alternatives were discussed in
detail with the patient and her daughter and consent was signed.
PROCEDURE IN DETAIL:
The patient was brought to the operating room on 08/02/2019 for the purpose of the above procedure.General endotracheal anesthesia was induced.The patient’s head was placed on a gel donut.The head of bed was elevated 30 degrees.The bed was rotated 90 degrees.The cervical facial flap was outlined based on the deep plane face-lift approach.Again, the defect was 4.6 x 3.7 cm. Approximately 30 mL of 1% lidocaine with 1:100,000 epinephrine was injected for hemostasis and hydrodissection.This was allowed to work for 10 minutes.The face was prepped and draped in the usual sterile fashion.Procedure began with incising of the outlined flap.This was elevated up to the deep plane entry point in a subcutaneous plane.At the deep plane entry point, a subcutaneous mass incision was made and a subcutaneous mass dissection was carried forward to approximately the level of the facial artery.
The flap was then tested for mobility and was rotated into place.This was inset with a deep layer of 3-0 Vicryl sutures in this mass, followed by a cutaneous closure with 3-0 Vicryl and 4-0 Vicryl in the dermis and the cuticular closure with 5-0 nylon sutures in running locking and mattress fashion.The face was then dressed with bacitracin, Xeroform, and a face-lift dressing.The patient was returned to anesthesia for awakening and extubation having tolerated
the procedure well.
ESTIMATED BLOOD LOSS:
Less than 10 mL.
SPECIMENS REMOVED: None.
DISPOSITION:
The patient will be discharged today in the care of her daughter. We will follow up in 1 week for sutures.She has been given prescriptions for pain management, nausea, and perioperative antibiotics.
CPT code: 14040
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
ICD 10: Z481 Encounter for planned postprocedural wound closure
3. Surgery Medical coding Sample Coded Charts
EXAM:
IR CHEST TUBE INSERTION
REASON FOR STUDY:
Pneumothorax, :
DIAGNOSIS:
Pneumothorax , spontaneous.
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.
MEDICATIONS:
Intravenous Fentanyl and Versed were given for analgesia and sedation.A nurse monitored the patient.
PROCEDURE/FINDINGS:
Medication reconciliation form reviewed and any changes related to this procedure resolved.Maximal Sterile Barrier Technique utilized.Area over the left chest was sterilely cleansed draped and anesthetized buffered 1% lidocaine.Yueh needle was introduced into the pleural space.Air wasaspirated.Wire was advanced into the pleural space under fluoroscopic guidance.Following dilatation a 10 French pigtail catheter was placed.
Catheter is positioned near the left lung apex.Catheter was secured in place with 2 0 silk suture and placed initially to Pleur-evac suction.The lung nearly completely expanded.The catheter was then placed to a Heimlich valve. The patient will return tomorrow for follow-up chest x-ray and again on Friday for possible chest tube removal. There were no immediate complications.The patient tolerated the procedure well.
PERFORMED PROCEDURES:
Fluoroscopic guided chest tube placement Total fluoroscopy time is 0.32 minutes.
MODERATE SEDATION FACE-TO-FACE TIME:
Twelve min.
IMPRESSION/PLAN:
1.Successful fluoroscopic guided left chest tube placement.Ten French chest tube at the left lung apex completely re-expanded the lung.
2.Patient will return tomorrow for follow-up chest x-ray.Patient will return Friday for possible chest tube removal.
CPT code: 32557
Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance
ICD 10: J9311 Primary spontaneous pneumothorax
4. Surgery Medical coding Sample Coded Chart
PREOPERATIVE DIAGNOSIS:
Nasal deformity.
POSTOPERATIVE DIAGNOSIS:
Nasal deformity.
PROCEDURE:
Open septorhinoplasty (cosmetic).
SURGEON:
ANESTHESIA:
General endotracheal anesthesia provided by Dr.
INDICATIONS FOR SURGERY:
The patient is an otherwise healthy 20-year-old woman, who has a dorsal hump as well as a wide nasal tip lacking in definition.She sought my consultation for a cosmetic improvement of this.Benefits, risks, and alternatives to open septorhinoplasty were discussed in detail with the patient and the consent was signed.
PROCEDURE IN DETAIL:
The patient was brought to the operating room on 08/16/2019, for the purpose of the above procedure.General endotracheal anesthesia was induced.The patient’s head was placed on a gel donut and the head of the bed was elevated 30 degrees.A 4% cocaine-soaked cottonoids were placed in the nasal passages bilaterally.A soft throat pack was placed in the throat.Approximately, 10 cc of 1% lidocaine with 1:100,000 epinephrine was injected into the septum for hemostasis and hydrodissection.An additional 5 cc was injected into the nasal soft tissue envelope again for hydrodissection and hemostasis.This was allowed to work for 10 minutes before proceeding.The face was prepped and draped in the usual sterile fashion.
Procedure began with a standard inverted V transcolumellar incision, followed by bilateral marginal incisions.An open rhinoplasty approach was executed with supraperichondrial dissection onto the nasal tip and bridge at the rhinion. Transition was made to a subperiosteal pocket using a Joseph elevator.Next, an interdomal approach to the anterior septum was performed.The left and then right septal mucosal flaps were then elevated in their entirety.The
nasopharynx was suctioned and attention was returned to the nasal bridge.The upper lateral cartilages were sharply divided off the dorsal septum.A small amount of dorsal septal cartilage was trimmed approximately 2.5 mm and left in place at the rhinion.A 10 mm Cinelli double-guarded osteotome was then placed and used to take off the bony excess above this.The nasal bone edges were then rasped sequentially with #5, #3, and diamond rasps until smooth.Osteotomies were then performed to close the open roof.This required short fading medial osteotomies and bilateral low to low to high lateral osteotomies.Once the nasal bones were adequately mobilized, the width of the bridge was decreased with digital pressure and symmetry was checked.Returning then to the mid vault region, auto-spreader technique was used to close the mid vault.The excess of the upper lateral cartilages cephalically was scored and folded inward.This was then repaired to the dorsal septum using 4-0 PDS suture in mattress fashion x2.Returning to the nasal tip, a cephalic trim of the lower lateral cartilages was performed to create symmetric 7 mm complete rim strips.Tip-defining sutures were then placed.A small amount of septal cartilage was harvested from the inferior mid portion of the quadrangular cartilage.This was used to carve a columellar strut.In order to make room for the columellar strut inferiorly, a minimal caudal septal trim was performed in the area of the maxillary crest. The floating strut was then placed and secured with 4-0 PDS in 3 places in mattress fashion.This created the tip position and height as desired.Infra-tip and supra-tip equalization sutures were then placed with 5-0 PDS suture.A small crushed cartilage grafts taken from the cephalic access were then placed along the lateral crura inferiorly and under the omes for softening of the edges.These were secured with 6-0 nylon in each place.The nasal soft tissue envelope was brought back down over the tip and the columellar incision was closed with 7 interrupted 6-0 nylon utures.Following his, the marginal incisions were closed with interrupted 5-0 chromic suture bilaterally and the septal flaps were quilted using a 4-0 plain gut suture.Finally, for symmetry and width, the nasal sill was reduced bilaterally.The patient had a webbed nasal sill more so on the right than on the left.I performed a diamond-shaped incision in the sill extending into the nasal vestibule, approximately 4 mm in width and tapering to the alar groove inferiorly and to the extent of the vestibule interiorly.Once the tissue was excised, this was gently cauterized and the wound was closed with a deep 5-0 PDS suture, followed by 6-0 nylon suture for the exterior portion and a 5-0 chromic suture on the interior portion of the vestibule.This was repeated on the left side.The nasopharynx was again suctioned.The throat pack was removed.The patient was returned to Anesthesia for awakening and extubation having tolerated the procedure well.
ESTIMATED BLOOD LOSS:
20 cc.
SPECIMENS REMOVED: None.
DISPOSITION:
The patient will be discharged today in the care of her mother and will follow up in 1 week for her casts, stents, and sutures.She has been given prescriptions for perioperative antibiotics, pain control, nausea, and swelling.
CPT code: 30420
Rhinoplasty, primary; including major septal repair
ICD 10:
Z411 Encounter for cosmetic surgery
M950 Acquired deformity of nose
5. Surgery Medical coding Sample coded Chart
PREOPERATIVE DIAGNOSIS:
Recurrent acute tonsillitis.
POSTOPERATIVE DIAGNOSIS:
Recurrent acute tonsillitis.
PROCEDURE PERFORMED:
Tonsillectomy.
SURGEON:
ANESTHESIA:
General.
ESTIMATED BLOOD LOSS:
10 mL.
FINDINGS:
2+ bilateral tonsils.
COMPLICATIONS:
None.
SPECIMENS:
Right and left tonsils sent separately to Pathology.
INDICATIONS FOR SURGERY:
The patient is a 19-year-old female with recurrent acute tonsillitis.She has averaged over 3 infections a year for over 5 years and she met criteria for tonsillectomy.Risks and benefits of procedure were discussed with the patient and her family and she consented to surgery.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was brought back to the operating room, placed supine on the operating room table. A time-out was performed to identify the patient, procedure, site of surgery, OR staff, and OR equipment.General anesthesia was induced.An orotracheal tube
was placed.A shoulder roll was placed.Head drape placed.She was then turned 90 degrees to the left.A McIvor mouth gag was inserted into her oral cavity, opened and brought into suspension upon the Mayo table.Her anterior pillars were injected with a total 4 mL of 0.25% bupivacaine.Next, the right tonsil was grasped with a curved Allis and an extracapsular tonsillectomy was performed with a Bovie at a setting of 15 and 15.Care was taken to preserve the anterior pillar, posterior pillar and superior constrictor muscle.Any areas of bleeding were cauterized with suction electrocautery.The tonsil was then completely removed and sent as a specimen.Next, the left tonsil was grasped with curved Allis and an extracapsular tonsillectomy was performed taking care to preserve the anterior and posterior pillar and superior constrictor muscle.Any areas of bleeding were cauterized with suction electrocautery.The tonsil was then completely removed and sent to Pathology. The oropharynx was thoroughly irrigated.Any additional areas of oozing were cauterized with suction electrocautery and OG tube was passed to suction of her gastric contents.Next, she was brought out of suspension and then resuspended.The tonsillar fossa was re-examined.There was no further bleeding.This marked the end of the procedure.The patient was then awakened from anesthesia and returned to the postoperative care unit in stable condition.
CPT code : 42826
Tonsillectomy, primary or secondary; age 12 or over
ICD 10
J0391 Acute recurrent tonsillitis, unspecified
6. Surgery Medical coding Sample coded Chart
PREOPERATIVE DIAGNOSIS:
1.Microperforate hymen.
2.Dysmenorrhea.
3.Inability to place tampons or have intercourse due to imperforate hymen.
POSTOPERATIVE DIAGNOSIS:
1.Microperforate hymen.
2.Dysmenorrhea.
3.Inability to place tampons or have intercourse due to imperforate hymen.
PROCEDURE:
Partial hymenectomy
SURGEON:
INDICATIONS:
The patient is a 19-year-old gravida 0 with a history of normal, but painful menses, who presented to clinic after physical exam concerning for imperforate hymen.The patient reports she has never been able to have penetrative intercourse or place a tampon, however, does have a monthly menses. She had inability to tolerate exam in clinic, therefore needed exam under anesthesia, however, brief clinical exam did show an imperforate hymen.
FINDINGS:
Exam under anesthesia revealed a micro perforate hymen with a small 2 mm central opening.The remainder of the hymen was still intact.Otherwise, normal external genitalia.After revision of the imperforate hymen, a speculum exam was performed that showed a normal vaginal cavity and normal cervix.The patient has undergone a pelvic MRI that shows a normal uterus and ovaries. Therefore, no mullerian anomaly identified.
PROCEDURE IN DETAIL:
The patient was taken to the operating room with IV running.She was placed in dorsal supine position.General anesthesia was obtained without difficulty.She was then placed in dorsal lithotomy position in Allen stirrups.A safety time-out was performed confirming the correct patient and procedure.Antibiotics were not given as not indicated.The patient was prepped and draped in usual sterile fashion.Exam under anesthesia revealed the above findings.An indwelling Foley catheter was placed to protect and identify the location of the urethra.The remaining remnant hymen was injected with 1% lidocaine for pain control.A 15 blade scalpel was used to make a U-shaped incision starting at the previous central opening to remove the redundant imperforate tissue.This was removed and sent for permanent pathology.The newly created hymenal opening was then made hemostatic with several interrupted sutures of 3-0 Vicryl.Hemostasis was confirmed visually. A pediatric long Peterson speculum was used to inspect the vagina noting no vaginal septum.The cervix was visualized as normal and solitary with normal ectocervical opening.There was no significant endometrial contents, blood or abnormal discharge in the vagina to be irrigated.Therefore, given normal distal vagina anatomy, no hysteroscopy procedure was performed.The speculum was removed from the vagina.Hemostasis was again confirmed of the hymenal remnant closure.Bacitracin ointment was applied to the suture line.The Foley catheter was then removed.The patient was then woken from anesthesia.Peripad and mesh panties were placed.The patient was then moved back to the gurney. She was taken to recovery room in stable condition.
ASSISTANT SURGEON:
None.
COMPLICATIONS:
None.
QUANTITATIVE BLOOD LOSS: 20 mL.
IV FLUIDS:
1 L crystalloid.
URINE OUTPUT:
30 mL clear.
DISPOSITION:
The patient will be discharged home once meeting PACU criteria and will follow up at Marin Community Clinic with myself in 2 weeks.
CPT code: 56700
Partial hymenectomy or revision of hymenal ring
ICD 10:
Q523 Imperforate hymen
N946 Dysmenorrhea, unspecified
7. Surgery Medical Coding Sample Coded Charts
EXAM:
IR LUMBAR PUNCTURE
REASON FOR STUDY:
Infectious disease, :
CLINICAL HISTORY:
Infectious disease
COMPARISON:
None.
TECHNIQUE:
The procedure of a lumbar puncture was explained to the patient including risks and complications.The risk of spinal headache was specifically discussed.The patient agrees to proceed.
The patient was placed prone on the fluoroscopy table.Fluoroscopic guidance was used to select the L3 level for access.The area over the lumbar spine was sterilely cleansed and anesthetized with 1% lidocaine.And 1% lidocaine.
A 22-gauge Whitaker needle was advanced under fluoroscopic guidance.After obtaining fluid the needle was removed.Sterile dressing was placed.There were no immediate complications.The patient tolerated the procedure well.
FINDINGS:
A total of 15 mL of clear CSF fluid was obtained and placed in vials for analysis.
Total fluoroscopy time is 0.3 minutes.
Performed procedures:
Fluoroscopic guided lumbar puncture
IMPRESSION:
1.Successful lumbar puncture using fluoroscopic guidance as above described.
CPT code:
62270
Spinal puncture, lumbar, diagnostic
77003
Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures
G35 Multiple sclerosis
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