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…
Read MoreSample Coded report Humerus Fracture CPT code
Pre-op Diagnosis: Closed fracture of distal left humerus Post-op Diagnosis: Same as Pre-op Procedure(s): Left – OPEN REDUCTION INTERNAL FIXATION DISTAL HUMERUS VIA OLECRANON OSTEOTOMY- Wound Class: Clean Proc. Description(s) & CPT Code(s): OPEN REDUCTION INTERNAL FIXATION DISTAL HUMERUS: Anesthesia: General Complications: none Findings: complex fx Technique: The patient was taken to the OR and given general anesthesia. A foley catheter was placed. A time out was done. Prophylactic IV antibiotics were given. He was placed in the lateral position on the beanbag with all bony prominences padded. The patient and site were identified. The left upper extremity was prepped and draped in the usual…
Read MoreCPT code 85730 (Partial thromboplastin time PTT) Coding Guide
Code Description of CPT code 85730 ((Partial thromboplastin time PTT) 85730 – Thromboplastin time, partial (PTT); plasma or whole blood This exam may be ordered as a partial thromboplastin time or PTT, or as an activated partial thromboplastin time or APTT. The specimen is plasma. The method is automated coagulation instrument. The partial thromboplastin time is prolonged when deficiencies of coagulation factors VIII, IX, XI, and XII are present. This test is used to monitor the effectiveness of the anticoagulant drug heparin, which is prescribed for patients who have had…
Read MoreSample Coded report for Closed Fracture CPT code
PREOPERATIVE DIAGNOSIS: 1. Closed Left Tibial Plateau Fracture POSTOPERATIVE DIAGNOSIS: 1. Same PROCEDURES PERFORMED: 1. Closed Reduction with placement of external fixator: Left tibial plateau ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Minimal COMPLICATIONS: None. DRAINS: None. SPECIMENS: None. TOURNIQUET: None. HPI & INDICATIONS FOR PROCEDURE: The patient is a who presented to the emergency department s/p motor vehicle collision. He was a restrained driver whose operatively in a vehicle that struck a pole at a high rate of speed. Presented to the ED with complaints of left knee pain. Imaging revealed a…
Read MoreSample Coded report for Knee Arthroplasty CPT code
Pre-op Diagnosis: Primary osteoarthritis of left knee [M17.12] Post-op Diagnosis: Same as Pre-op Procedure(s): Left – TOTAL KNEE REPLACEMENT ROBOTIC ASSISTED – Wound Class: Clean Proc. Description(s) & CPT Code(s): TOTAL KNEE REPLACEMENT ROBOTIC ASSISTED: Stryker components: Size 2 cemented tibia, size 2 Press-Fit femur, size 9 mm posterior cruciate retaining tibial polyethylene insert. Patella not resurfaced Anesthesia: General Complications: None Findings: The patient is a 67-year-old female with longstanding osteoarthritis of the left knee with bone-on-bone changes on x-rays unresponsive to nonoperative measures. She desired a total knee arthroplasty. She has a history of a contralateral…
Read MoreSample Coded Report for AV fistula Creation CPT code
Pre-op Diagnosis: End stage renal disease (CMS/HCC) [N18.6] Post-op Diagnosis: Same as Pre-op Procedure(s): Left – LEFT AV FISTULA CREATION (CEPHALIC ADEQUATE) – Wound Class: Clean Proc. Description(s) & CPT Code(s): LEFT AV FISTULA CREATION (CEPHALIC ADEQUATE): Anesthesia: General Complications: There were no complications Findings: There is a thrill in the graft and a thrill in the vein distal to the graft. There is a biphasic radial artery and ulnar artery signal at the wrist Technique: The consents were obtained. The patient was taken to the operating room and placed supine on operating table. General endotracheal anesthesia was…
Read MoreSample coded report for Laparoscopy CPT code
Pre-op Diagnosis: Pelvic pain syndrome [R10.2] Chronic salpingitis [N70.11] Post-op Diagnosis: Same as Pre-op Severe pelvic adhesions Procedure(s): LAPAROSCOPIC LYSIS OF ADHESIONS – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers CHROMOTUBATION TUBALPLASTY LAPAROSCOPIC – Wound Class: Clean Contaminated – Incision Closure: Deep and Superficial Layers Proc. Description(s) & CPT Code(s): LAPAROSCOPIC LYSIS OF ADHESIONS: CHROMOTUBATION TUBALPLASTY LAPAROSCOPIC Anesthesia: General Estimated Blood Loss: 20 mL Quantitative Blood Loss: No data recorded Total IV Fluids: 1000 mL Specimens: No specimens Implants: * No implants in log * Complications: None Findings: Severe pelvic adhesions, peritoneal pseudocyst adjacent to left ovary. Fallopian…
Read MoreWhen to use CPT code 64630, 64632 & 64640
Description of CPT code 64630, 64632 & 64640 This procedure (CPT code 64630) is performed to treat chronic pain of the external genitalia, pelvis, and anorectal region. The pudendal nerve is destroyed using chemical, thermal, electrical, or radiofrequency techniques, which may be used independently or in combination. This procedure is designed to destroy the specific site(s) in the nerve root that produces the pain while leaving sensation intact. Generally intravenous conscious sedation is used during the initial phase of the procedure so that the patient can assist the physician in…
Read MoreWhen to use CPT code 22526 and 22527
Description of CPT code 22526 and 22527 Percutaneous intradiscal annuloplasty is a minimally invasive technique performed under fluoroscopic guidance to treat small tears in the annulus without an associated disc protrusion. The most common technique is intradiscal electrothermal therapy (IDET). In IDET, the physician advances a needle into the disc using x-ray image guidance. The appropriate treatment catheter is selected and inserted through the needle. Once the catheter is in position, the temperature of the heating portion of the catheter is increased gradually, raising the temperature of the affected site.…
Read MoreCoding tips for CPT code 15771, 15772, 15773 & 15774
Description of CPT code 15771, 15772, 15773 and 15774 Autologous fat grafting may be utilized in many areas of soft tissue augmentation or reconstruction, including congenital defects, contouring of face or breasts, and scarring as a result of burns, radiation, surgical procedures, or trauma. The physician obtains an autologous fat graft by liposuction technique. After identifying the most suitable area of fat harvesting (commonly the abdomen, trochanteric region, or the insides of the thighs and/or knees), the physician makes small incisions in the skin overlying the harvest area. A liposuction…
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