Category: Can you code this

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…

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…

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…

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…