Sample 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…

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Sample 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…

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Sample 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…

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Sample 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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Sample 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…

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Sample 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…

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Sample 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…

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Sample 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…

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Sample 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…

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When 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…

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