Medical coding Sample Chart 1

PREOPERATIVE DIAGNOSIS:

Left shoulder instability with labral tear.

POSTOPERATIVE DIAGNOSIS:

Left shoulder instability with labral tear.

PROCEDURE:

Left shoulder arthroscopic stabilization.

SURGEON:

INDICATIONS FOR SURGERY:

The patient is a 28-year-old who has had multiple dislocations of the left shoulder.He has been able to self reduce for the most part.However, he has had dislocations greater than 10 times without relief

from conservative care including extensive physical therapy.Risks, benefits, and alternatives were fully discussed with him.He verbalized understanding of the diagnosis, the plan, the options.His physical examination and MRI findings were consistent with preoperative diagnosis and the patient desired to proceed.

ANESTHESIOLOGIST:

ANESTHESIA:

LMA and interscalene block, left shoulder.

ESTIMATED BLOOD LOSS:

Minimal.

IV FLUIDS:   1800 mL.

IMPLANTS UTILIZED: Arthrex knotless FiberTak anchors x5, three anterior and two

posterior.

COMPLICATIONS:  None perceived.

PROCEDURE IN DETAIL:

The patient was met in the preoperative holding area.All questions were answered.His left operative shoulder was marked.The patient was brought to the operating suite.Interscalene block was placed by Dr. followed by LMA general.He was placed in the right lateral decubitus position, taking great care to pad his bony prominences.His left shoulder was examined under anesthesia.He had significant instability anterior and posterior with a positive sulcus sign.The left upper extremity was prepped and draped in usual sterile fashion.A time-out was performed confirming appropriate patient, appropriate side, appropriate procedure, and he had received 2 g of Ancef intravenously.Diagnostic arthroscopy was performed.Immediately noted was an intact biceps tendon, intact rotator cuff.The superior labrum was normal.The anterior labrum was torn going from approximately 9 o’clock anteriorly, inferiorly past 6 o’clock around to approximately 3 o’clock posteriorly, for 180- degree labrum tear.Posterior tear had a large SLAP.The anterior glenoid had a grade 4 region of chondral wear consistent with recurrent instability.There was a superficial Hill-Sachs present, but no significant depth to the Hill-Sachs lesion and the labrum was easily pulled superiorly, which restored tension on the inferior glenohumeral ligament.Two anterior cannulas were placed to facilitate both diagnostic arthroscopy and the repair and using Arthrex ReelPass hook, I was able to pass suture around the labrum for the repair and superior translation of the labrum and capsule to the anchors.Anchors were placed in successive fashion going from anterior inferior at 7 o’clock, 8 o’clock and 9 o’clock and then posterior at 5 o’clock and 4 o’clock to create a superior shift to the inferior labrum.The articular cartilage was covered somewhat with the 9 o’clock anterior anchor and prior to placing the anchors, the neck of the glenoid was prepared using a Linvatec elevator followed by Arthrex Torpedo sucker shaver to create a bleeding surface for the repair.The sucker shaver was utilized also for preparing the labrum prior to the repair.At the conclusion, the shoulder was balanced.The excess fluid was removed.Incisions were closed with 3-0 Monocryl.Of note, the posterior anchors were placed through a “7 o’clock” portal to facilitate the proper trajectory and I used a curved guide for the knotless FiberTak anchors.He tolerated the procedure well, was transferred to the Postanesthesia Care Unit in good condition.

CPT code:

29806-LT

Arthroscopy, shoulder, surgical; capsulorrhaphy

29807-LT -59

Arthroscopy, shoulder, surgical; repair of SLAP lesion

M25312                Other instability, left shoulder

S43432A               Superior glenoid labrum lesion of left shoulder, initial encounter

Medical coding Sample Chart 2

PREOPERATIVE DIAGNOSIS:

Left knee ACL tear.

POSTOPERATIVE DIAGNOSIS:

Left knee ACL tear.

PROCEDURE:  Left knee anterior cruciate ligament reconstruction.

SURGEON:

ASSISTANT:

None.

ANESTHESIA:  Dr.  Adductor canal block and general laryngeal mask.

ESTIMATED BLOOD LOSS:   Minimal.

DESCRIPTIONS OF FINDINGS: The patellofemoral joint was normal.Medial compartment normal.Lateral compartment normal.Intercondylar notch demonstrated a chronic proximal ACL tear with incompetent anterior cruciate ligament.The patient’s hamstrings were found to be narrow and too short to allow any semblance of an ACL reconstruction.However, a patellar tendon graft produced a nice solid reconstruction.

INDICATIONS FOR SURGERY:

The patient complained of recurrent instability due to a left ACL tear despite nonoperative treatment.

PROCEDURE IN DETAIL:

Informed consent was obtained.The patient was identified, the site was confirmed and marked in the preop area, and taken to operating room and placed supine.The anesthesia was induced as above.An exam under anesthesia revealed a grade 2 pivot shift with intact collaterals and negative dial test.A tourniquet was applied to the left lower extremity which was prepped and draped in the usual sterile fashion.Time-out was called. Antibiotics infused per protocol.The knee was instilled with 25 cc of 0.25% Marcaine with epinephrine.The limb was exsanguinated and tourniquet inflated. A 3 cm incision was made over the pes anserinus.Bleeders controlled with electrocautery and sartorius fascia incised.The lower margin of the semitendinosus was identified and separated from the above gracilis.It was detached distally.Upon harvesting, a full tendon was achieved, however, was found to be muscular very low resulting in a graft that was only approximately 120 mm long.The above gracilis was then checked, and although, it was unknown about length, it was far too narrow to be utilized for ACL reconstruction.The area was carefully explored for any accessory tendons.None were found.It was determined that this was inadequate tissue for an ACL reconstruction.Decision was made to change to patellar tendon graft.The decision was made against allograft based on the patient’s young age.A 6 cm incision was then made over the patellar tendon.Bleeders were controlled with electrocautery and the paratenon incised.The center one-third of the patellar tendon was harvested and a 15 mm proximally and 25 distally were then harvested with saw and osteotomes.It was then fashioned into a patellar tendon ACL graft, which measured 9 x 15 proximally and 10 x 25 distally with 90 mm total length.It was tensioned on the back table with 2 mm drill holes through the bone blocks using #2 FiberWire suture.Standard superomedial, inferomedial, and inferolateral arthroscopy portals were established with 11 blade and blunt obturators. Systematic inspection of the knee joint was carried out with findings as above. The remnants of the ACL were removed.In the native position of the ACL origin, a 6 mm over-the-top guide was positioned through the anteromedial portal with the knee deeply flexed and guide pin passed out.It was confirmed to be appropriately positioned and drilled to a depth of 20 using a standard tibial guide, and using the pes anserine incision, a tibial guide was placed in the center of the ACL footprint on the tibia and 10 mm tunnel made using the shuttle suture.The graft was placed into the femoral tunnel and secured with an Arthrex 7 x 20 metal interference screw, however, it was observed that the graft was pushed posteriorly.The screw was removed and graft withdrawn.It was observed that the back wall had fractured for a depth of about 5 mm, so the guide pin was reinserted and it was drilled up to 25 mm of depth and the graftreinserted beyond the area of blown out back wall and again secured with the same interference screw resulting in solid fixation.The graft was then maximally tensioned, taken through 15 cycles of range of motion and in slight flexion and secured distally with an Arthrex 8 x 25 metal interference screw. The graft was then tested for Lachman and pivot and found to be extremely stable.The scope was inserted and a graft found to be well positioned with no impingement.The area was irrigated with saline.Bone graft was used to bone graft the patella. The paratenon was closed with 2-0 Vicryl simple and the skin with 3-0 Vicryl inverted simples and skin staples.The knee was instilled with 25 cc of 0.25% Marcaine with epinephrine.A sterile dressing and Polar Care were applied.He was awoke from anesthesia and taken to recovery in satisfactory condition having tolerated the procedure well.

29888-LT Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

S83512A       Sprain of anterior cruciate ligament of left knee, initial encounter

Medical coding Sample Chart 3

PREOPERATIVE DIAGNOSIS:

1.Maxillary hypoplasia.

2.Obstructive sleep apnea.

3.Malposed mandibular 3rd molars

POSTOPERATIVE DIAGNOSIS:

1.Maxillary hypoplasia.

2.Obstructive sleep apnea.

3.Malposed mandibular 3rd molars

PROCEDURE:

LeFort 1 maxillary osteotomy.

SURGEON:

SERVICE: Oral and maxillofacial surgery.

SURGICAL ATTENDING: Dr.

ASSISTANT SURGEON:

INDICATIONS FOR SURGERY/HISTORY OF PRESENT ILLNESS: The patient is a 23-year-

old male who was referred to the Oral and Maxillofacial Surgery office of Dr.  and Dr.  as an outpatient for evaluation of his maxillary hypoplasia, obstructive sleep apnea, and associated skeletal abnormality.

CONTENT AND HISTORY AND PHYSICAL: The patient was evaluated and as an

outpatient both clinically and radiographically.He was deemed to have

maxillary hypoplasia, a resultant skeletal class 3 malocclusion, and

obstructive sleep apnea at the level of the nasopharynx.Additionally, we felt

the patient should have their malpositioned mandibular third molars removed due

to the high long-term risk of periodontal disease.

Three-dimensionalpreoperative radiographic films were obtained in order to

create a three-dimensional surgical guide to plan his surgical repositioning of

the maxilla.

DESCRITPTION OF PROCEDURE: The patient was identified in the preoperative

holding area.Consent was obtained and written in verbal fashion.The risks,

benefits, and alternatives of surgery were reviewed with the patient and his

family at the bedside.A written consent was obtained, and the patient was

transferred to operating room #7 at MarinHealth Medical Center.He was placed

in the supine position on the operating room table and transferred to the

Anesthesiology Service for induction of general anesthesia, where he was

nasally intubated.The patient was then turned back over to the Oral Surgery

service for securement of the nasal endotracheal tube.A total of 30 cc of

0.25% bupivacaine with 1:200,000 epinephrine was administered intraorally to

perform bilateral infraorbital blocks, posterior superior alveolar blocks, as

well as inferior alveolar, lingual, and long buccal nerve blocks.

After this, his oral cavity was prepped with chlorhexidine mouth rinse.His

face was prepared with Betadine.A 0.045 K-wire was placed at the radix as an

external positioning landmark.The patient was then prepped and draped in a

normal sterile fashion.The external landmark positioning was demarcated with

a long caliper with the central incisal and bracket measurements being

calculated preoperatively prior to any osteotomies.A moistened Raytek was

place d in the oropharynx to serve as a throat pack.The patient’s procedure

then commenced by elevating and extracting the mandibular third molars.Then, a

maxillary circumvestibular incision using Electro Bovie cautery from the left

maxillary 1st molar region up to the right maxillary 1st molar region was

created.

The mucosa, subcutaneous tissue, lamina propria down to the subperiosteal level

was continued, and then sharp dissection was used to create the subperiosteal

plane, which identified the bilateral pyriform rims and zygomaticomaxillary

buttresses bilaterally as well as the infraorbital nerve, neurovascular

bundles.After the pertinent anatomy was retracted and protected, the

pterygoid plates were approximated in the subperiosteal plane to the dissection

bilaterally.The nasal mucosa was dissected from the lateral nasal walls and

maxillary floor, and at this point, a LeFort 1 osteotomy was performed using a

702 bur on a surgical hand piece that extended from the pyriform rims down to

the zygomaticomaxillary buttresses bilaterally and then carried posteriorly as

far as I would allow, then followed with osteotomes to fracture the lateral and

medial pterygoid plates as well as the single-guarded and double-guarded

osteotome to perform continued osteotomies of the lateral nasal walls

bilaterally as well as to reduce and remove the nasal septum from the maxillary

spine.After all the osteotomies were prepared, the Anesthesiology team was

advised to perform hypotensive anesthesia with a MAP of around 60 to 70, which

was achieved in the patient’s maxilla, it was downfractured without any

complications.The descending palatine arteries were identified and preserved.

The lateral nasal walls were then had an osteoplasty performed in order to

reduce any sharp edges.The maxillary spine was also reduced with a surgical

hand piece and then the maxillary teeth were placed into the surgical guide

splint and secured with a 26-gauge and 24-gauge wire.After the maxilla had

been downfractured, we also verified complete mobilization of the maxilla

without any obvious damage to the peripheral mucosa.After full mobilization of

the maxilla was achieved and the splint was placed, we placed the patient into

maxillomandibular fixation using 24-gauge wire with the condylar head seated in

the bilateral fossa respectively.We then remeasured the patient’s maxillary

vertical dimension using the external landmarks as previously described, and

they were matched identically to the preoperative measurements, and the

patient’s maxillary advancement was stabilized using KLS 0.8 mm profile plate

and monocortical screw fixation with plate at the pyriform rims and

zygomaticomaxillary buttresses bilaterally.After the plates and screws were

fixated, the patient was removed from maxillomandibular fixation.The occlusion

was verified to be appropriate and without any interferences into the guided

splint.So, the wounds were irrigated with copious sterile saline and closed

with alar cinch suture using 4-0 PDS, and then the circum vestibular mucosal

incision was closed with 3-0 Vicryl suture in a running fashion.The patient

was hemostatic.The throat pack was removed.An orogastric tube was placed.

The mandibular 3rd molars, numbers 17 and 32 were elevated, luxated, and

extracted without any difficulty.Hemostasis was achieved at that area as well,

and the patient was then turned back over to the Anesthesiology Service for

emergence, where he was extubated without any complications and transferred to

the post anesthesia care unit in a stable postoperative state.

COMPLICATIONS:

None.

SURGICAL FINDINGS: Maxillary hypoplasia, status post maxillary advancement via

LeFort 1 osteotomy.

ESTIMATED BLOOD LOSS:

50 mL.

IV FLUIDS:

1500 of lactated Ringer’s.

CPT code : 21143    Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft

M2602  Maxillary hypoplasia

Medical coding Sample Chart 4

EXAM:

CT-guided lumbar puncture with CSF drainage and pressure measurements

REASON FOR STUDY:

Intracranial hypertension

CLINICAL HISTORY:

22-year-old with history of intracranial hypertension which had been adequately treated with VP shunt for some time, which subsequently became no longer effective.Recent VP shunt revision end of october with only temporary benefit.Now back with severely disabling symptoms.Plan for outpatient dural venous sinus workup for possible stenting vs LP shunt.

COMPARISON:

TECHNIQUE:

The study was performed in an ACR accredited facility.Medication reconciliation form reviewed and any changes related to this procedure resolved.After discussion of the indication, risks, benefits and alternatives of the procedure, verbal and written consent were obtained from the patient.

The patient was placed in the right lateral decubitus position on the CT table.The procedural site was appropriately identified.A preliminary CT was performed and the L2-3 level was localized.The patient was prepped and local anesthesia with 1% lidocaine was administered.Under CT fluoroscopy, an introducer needle was advanced into the lesion.Then, under CT fluoroscopy, 22-gauge spinal needle was used to obtain access to the intrathecal space. After demonstration of clear CSF returned, opening pressure was measured in a lateral decubitus, legs extended position, during quiet respiration.There were no complications.Afterwards, the site was cleaned and a Band-Aid

applied.

Dosimetry: CTDI: 1.5 MGy; DLP: 19 mGy-cm (Note: These dose indicators do not reflect the effective patient dose, but are metrics based on standardized CT phantoms.The effective dose may vary widely depending on body size, shape, and other patient factors). Dose reduction was performed with automated exposure control, iterative reconstruction technique and/or adjustment of the mA and/or kV for patient size.

Procedure performed:

CT fluoroscopic guided lumbar puncture with manometry.

FINDINGS:

Opening pressure was 16 cm of water.15 mL clear CSF was then removed.Closing

pressure was 8 cm of water.

IMPRESSION:

CT-guided lumbar puncture with removal of CSF.Opening pressure was 16 cm of H2O, 15 mL of CSF was removed, closing pressure was 8 cm of H2O.The patient’s symptoms immediately improved.

62272  Spinal puncture, therapeutic, for drainage of cerebrospinal fluid 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures

G932      Benign intracranial hypertension