Pre-op Diagnosis: Prostate cancer (CMS/HCC) [C61] Post-op Diagnosis: Same as Pre-op Procedure(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION – Wound Class: Clean Contaminated Proc. Description(s) & CPT Code(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION: Anesthesia: General Estimated Blood Loss: less than 100 mL Quantitative Blood Loss: No data recorded Implants: * No implants in log * Complications: None Findings: Dictated Technique: RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION Technique: Drains: 1) 18 French Foley catheter, 2) 19 French JP drain Procedures: 1) robotic-assisted laparoscopic radical prostatectomy with bilateral nerve sparing…
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Sample coded report for Gastrectomy Robotic Assisted cpt code
Pre-op Diagnosis: Morbid obesity (CMS/HCC) [E66.01] Body mass index is 43.75 kg/m². Essential hypertension, OSA with cpap Post-op Diagnosis: Same as Pre-op Procedure(s): Procedure(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED Proc. Description(s) & CPT Code(s): SLEEVE GASTRECTOMY ROBOTIC ASSISTED: Anesthesia: General Estimated Blood Loss: None Quantitative Blood Loss: No data recorded Drain: None Complications: none Findings: Liver appeared fatty Technique: Tonie Williams is electively admitted for robotic sleeve gastrectomy today for obesity and health problems directly related to obesity. The patient has been extensively informed of the risks, benefits, limitations, and alternatives to surgery as a means of aggressive weight control through discussions in the…
Read MoreSample Coded report for Spinal Cord Stimulator Battery Replacement Exam
Pre-op Diagnosis: Chronic pain syndrome [G89.4] Mechanical breakdown of implanted electronic neurostimulator of spinal cord, initial encounter (CMS/HCC) [T85.112A] Post-op Diagnosis: Same as Pre-op Procedure(s): Spinal Cord Stimulator Battery Replacement – Wound Class: Clean Anesthesia: Monitor Anesthesia Care Estimated Blood Loss: None Drain: None Total IV Fluids: Per anesthesia record Specimens: No specimens Complications: None Findings: None Disposition: aroused from sedation, and taken to the recovery room in a stable condition Condition: doing well without problems Technique: The patient was placed prone on the operating room table, with monitored anesthesia care. Lumbar region sterilely prepared and draped in usual fashion. Local…
Read MoreSample Coded report for Shoulder Arthroplasty CPT code
Pre-op Diagnosis: Arthritis of left shoulder region [M19.012] Left shoulder rotator cuff tear arthropathy and severe degenerative changes at the level of the glenohumeral joint with inferior humeral head osteophyte formation. Post-op Diagnosis: Same as Pre-op Procedure(s): Left – LEFT REVERSE TOTAL SHOULDER ARTHROPLASTY Anesthesia: General and interscalene regional nerve block. Estimated Blood Loss: 200 mL Specimens: Standard arthroplasty specimens. Implants: DJO reverse total shoulder arthroplasty – glenoid base plate with 30 mm screw length. Circumferential screw x3-22 mm, 14 mm, 22 mm. Glenoid head with retaining screw size 32 mm -4 mm. Humeral stem, small shell, 6 mm x 108 mm.…
Read MoreSample Coded report for CYSTOSCOPY LITHOTRIPSY CPT code
Pre-op Diagnosis: Uric acid nephrolithiasis [N20.0] Post-op Diagnosis: Left nephrolithiasis Procedure(s): Left – URETEROSCOPY – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA Left – CYSTOSCOPY LITHOTRIPSY URETERAL and renal STONEs – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA Left – CYSTOSCOPY, URETERAL STENT EXCHANGE – Wound Class: Clean Contaminated – Incision Closure: No Incision / NA Proc. Description(s) & CPT Code(s): URETEROSCOPY: CYSTOSCOPY LITHOTRIPSY URETERAL STONE: CYSTOSCOPY, URETERAL STENT EXCHANGE: Anesthesia: General Complications: None Findings: The patient had a large stone burden in the left kidney. Another calyx was obstructed by a…
Read MoreSample Coded report for skin Excision CPT code
Pre-op Diagnosis: Excess skin [L98.7] Post-op Diagnosis: excess skin of upper arms ( bat wing deformity) bilateral Excess skin of chest wall right and left lateral chest35x10 cm, 38×12 cm right chest Painful scar abdomen 21 cm horizontal scar and 19 cm vertical component Procedure(s): Bilateral – BRACHIOPLASTY excision bilateral excess soft tissue lateral chest Right 38×12 cm Left 35×10 cm Painful scar abdomen excision and closure 21 cm horizontal component and 19 cm vertical component or 40 cm total length Anesthesia: General Findings:excess skin with poor skin elasticity secondary to massive weight loss…
Read MoreSample coded report for Ovary cystectomy CPT code
Pre-op Diagnosis: Bilateral ovarian cysts [N83.201, N83.202] Post-op Diagnosis: Same as Pre-op s/p procedure performed Procedure(s): OVARIAN CYSTECTOMY ROBOTIC ASSISTED/ ROBOTIC ASSISTED UNILATERAL OVARIAN CYSTECTOMY, POSSIBLE UNILATERAL SALPINGOOOPHORECTOMY SALPINGOOPHORECTOMY BILATERAL ROBOTIC ASSISTED/ POSSIBLE UNILATERAL Anesthesia: General Complications: none Findings: Normal appearing female external genitalia On laparoscopic entry, uterus and right ovary normal appearing. Left ovary with an approximately 3 cm hardened cyst on the superior portion. Tiny paratubal cysts bilaterally. Hemostasis noted at the end of case. Read also : Sample Coded report for Ureterosopy CPT code Sample Coded report for Rotator Cuff repair CPT code…
Read MoreSample Coded report for Shoulder Arthroscopy CPT code
PREOPERATIVE DIAGNOSIS: 1. Left shoulder Rotator cuff tear. 2. Subacromial bursitis. 3. Subacromial impingement. 4. Acromioclavicular arthritis. 5. Biceps tendon tear. POSTOPERATIVE DIAGNOSIS: 1. Same PROCEDURE: 1. Left shoulder arthroscopic rotator cuff repair.with soft tissue augmentation. 2. Subacromial decompression/acromioplasty. 3. Arthroscopic debridement of subacromial space and glenohumeral joint. 4. Arthroscopic distal clavicle excision/Mumford procedure. 5. Mini-open subpectoral biceps tenodesis. ANESTHESIA GIVEN: General with interscalene block PREOPERATIVE ANTIBIOTICS: Ancef 2 gm IV ESTIMATED BLOOD LOSS: minimal INDICATIONS FOR PROCEDURE: The patient has a history of shoulder pain that has been unresponsive to conservative measures. I have recommended a shoulder arthroscopy with possible…
Read MoreSample Coded report of URETEROSCOPY CPT code
Pre-op Diagnosis: Renal stones, Recurrent UTI, solitary Left Kidney Post-op Diagnosis: Same, Bladder lesion overlying bladder neck and LEFT Ureteral orfice Proc. Description(s) & CPT Code(s): LEFT URETEROSCOPIC LITHO, STONE EXTRACTION: BLADDER BIOPSY; URETEROSCOPY CYSTOSCOPY WITH STENT PLACEMENT: Anesthesia: General Complications: none Findings: 1. Stones mostly matrix material with small pebble like consistency. Removed with prolonged basketing and irrigation. Papillary lesion overlying left bladder neck and LEFT UO. Cold cup biopsy obtained. Lesion is 2.5 cm left bladder neck, overlying left trigone and ureteral orifice small satellite lesion noted. Unsure of malignancy or inflammatory. Sig…
Read MoreSample Coded report for Rotator Cuff repair CPT code
PREOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. POSTOPERATIVE DIAGNOSIS: Right shoulder rotator cuff tear. Right shoulder SLAP tear. Right shoulder impingement. Right shoulder AC DJD. Right shoulder biceps tear INDICATION FOR PROCEDURE: Brief History: A 76 y.o. -year-old male has had persistent shoulder pain and functional limitation despite conservative management. MRI showed above-mentioned findings. Operative and non-operative options were discussed and time was allowed for questions. Risks of surgery were discussed. Signed consent was obtained, and patient was scheduled for above-mentioned procedure. PROCEDURE PERFORMED: Right shoulder arthroscopic rotator cuff repair. Right shoulder arthroscopic…
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