Medical coding Sample Coded Report 1
Pre-op Diagnosis: Nodular sclerosis Hodgkin lymphoma of lymph nodes of multiple regions (CMS/HCC) [C81.18]
Post-op Diagnosis: Same as Pre-op
Procedure(s): Right – VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT – Wound Class: Clean
Proc. Description(s) & CPT Code(s): VASCULAR ACCESS – IMPLANTABLE PORT PLACEMENT:
Anesthesia: General
Estimated Blood Loss: Minimal
Quantitative Blood Loss: No data recorded
Drain: None
Total IV Fluids: 100 mL
Specimens: No specimens
Complications: none
Findings: tip of catheter at atriocaval junction
Technique: Patient was brought to the operating room and placed supine. A time out was conducted and the patient identifiers, procedure, and plan was reviewed. General anesthesia was induced, endotracheal intubation was performed, he was positioned with a shoulder roll, and the patient was prepped with ChloraPrep and draped in the usual sterile fashion. All pressure points were appropriately padded.
Using ultrasound , the right internal jugular vein was visualized and identified. With the patient in slight Trendelenberg, the vein was canalized with a needle under ultrasound. There was return of venous blood. The wire was passed through and c-arm fluoroscopy was used to confirm its passage into the inferior vena cava. A small pocket was made on the right chest wall for the 6 Fr port and 3-0 Prolene suture was used to fix the port in the pocket at 3 points. The catheter was tunneled to the neck, and modified Seldinger technique was used to introduce the sheath and pass the catheter, cut to an appropriate length, into the superior vena cava at the atrial junction under fluoroscopy. Care was taken to avoid introducing an air embolus.
The port was flushed with injectable saline. Blood was easily drawn back. We accessed the port and locked it with 2mL of heparin lock. Hemostasis was assured and the wound was closed with 3-0 Vicryl and 4-0 Monocryl. The skin incision at the neck was closed with Monocryl. Both incisions were covered with Exfin and a sterile dressing was applied to the accessed port.
Patient tolerated the procedure well, was extubated in the operating room and taken to recovery in stable condition. All sponge and needle counts were correct x2. I was present and scrubbed for the duration of the case from opening to closing of the sterile field. A chest x-ray in PACU confirmed good positioning of the catheter and no hemo/pneumothorax.
Disposition: awakened from anesthesia, extubated and taken to the recovery room in a stable condition, having suffered no apparent untoward event.
Condition: doing well without problems
CPT 36571 Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older
Medical coding Sample Coded Report 2
Pre-op Diagnosis: Pneumonia and influenza, persistent pneumothorax
Post-op Diagnosis: Same as Pre-op
Procedure(s): CHEST TUBE PLACEMENT – Wound Class: Clean
Proc. Description(s) & CPT Code(s): CHEST TUBE PLACEMENT:
Anesthesia: Sedation provided by PICU
Estimated Blood Loss: Minimal
Quantitative Blood Loss: No data recorded
Drain: 12 Fr pigtail chest tube
Specimens: No specimens
Implants: * No implants in log *
Complications: none
Findings: large amount of air removed, chest tube in good position on follow up x-ray with resolution of ptx
Technique:
After consent was obtained, the patient was placed under sedation by the NICU team. We removed the right chest tube dressing. Her right chest was then prepped and draped in sterile fashion. A site was chosen inferomedial from the current tube for the new chest tube. Local anesthesia was applied to the site. A small incision was made to accommodate the tube. The Finder ball was inserted into the chest just over the rib and we entered the chest cavity. A large volume of air was pulled back into the syringe. The wire was then threaded through the needle. The needle was removed and the dilator was passed. The catheter was then threaded over the wire. The wire was removed and air and serosanguineous fluid were drained. The catheter was then connected to a new Pleur-Evac. The tube was secured with a silk suture. A Sorbaview was applied. A chest x-ray confirmed placement and resolution of the pneumothorax. Overall she tolerated the procedure very well and remains in the PICU in stable condition.
Disposition: continue PICU care
Condition: doing well without problems
CPT 32557 Chest tube placement
Medical coding Sample Coded Report 3
OPERATIVE NOTE
Pre-op Diagnosis:
Complete heart block s/p ASO, VSD and arch repair
Post-op Diagnosis:
Same
Procedure: Implantation of DDD epicardial pacemaker system via re-sternotomy
Assistant(s): Patrick Nelson, PA
Due to the complexity of this heart lesion, Mr. Nelson assisted me during the entire operation
Anesthesia: General
Brief Clinical History: This is a 2-week-old patient born with D-TGA, VSD and coarctation with hypoplasia of the arch who underwent complete repair. Unfortunately he had developed complete heart block for which he is now brought to surgery for placement of a dual-chamber pacemaker. He was having what appeared to be an accelerated junctional rhythm and I was hopeful that his conduction would return however it did not.
Procedure in Detail: After informed consent the patient was brought to the operating room and placed in the supine position. After satisfactory induction of general tracheal anesthesia the patient’s right atrial line was removed because I felt it was in way of the future pacemaker pocket. The near infrared spectroscopy was monitored over the cerebrum and flank. Antibiotics were administered preoperatively. The chest and upper abdomen was prepped and draped in the usual sterile fashion. I 1st attempted to open the lower aspect of the sternotomy however was not able to reach the atrium. Therefore and upper reopening the entire sternotomy on. I then attached bifurcating 25 cm steroid eluting pacemaker electrodes on the LV apex and right atrium. Both septal leads yielded good amplitudes, thresholds and impedances. A right upper quadrant subcutaneous pocket was then fashioned to which these electrodes were tunneled and connected to the pacemaker device. Interrogation of the pacemaker demonstrated that it was functioning well. A 12 French chest tube was left draining the mediastinum. The patient already had bilateral 8.5 French pleural pigtails in place. The sternum was reapproximated with 0 Ethibond and the soft tissues closed in multiple layers in standard fashion. Patient tolerated the procedure well. There were no complications. Sponge instrument counts were correct at completion of case. Patient was transported to the cardiac intensive care unit in satisfactory condition.
CPT 33208 Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular