Medical Coding Guide

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…

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…

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.…

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…

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…

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…

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…

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…