Sample Coded Medical coding Charts for Surgery Part 18

Sample coded Medical coding chart 1

Indication for Surgery
Partial tear left Achilles with retrocalcaneal bursitis

Preoperative Diagnosis
As above

Postoperative Diagnosis
As above

Operation
1. Left Achilles tendon debridement/repair
2. Excision of Haglund’s deformity and retrocalcaneal bursa
3. Intraoperative radiographs with immediate interpretation by surgeon

Surgeon(s)

Anesthesia
General anesthesia

Estimated Blood Loss
Minimal

Findings
Scarring of the distal Achilles with partial tear and retrocalcaneal bursitis

Specimen(s)
None

Complications
None

Technique
Implants:
Achilles speed bridge (Arthrex) 4.7 x 15 mm swivel locks ×4, proximal row loaded with #2 fiber tape

The patient was brought to the operating room on a stretcher. Following induction and administration of general anesthesia a tourniquet was placed on the left thigh and the patient was carefully rolled into a prone position with abdominal elevation. All pressure points were carefully padded and protected. The left foot and leg were prepped and draped in the usual sterile fashion. The limb was exsanguinated and the tourniquet inflated to 275 mmHg.

An incision was made over the posterior distal leg extending from the distal Achilles over the calcaneal tuberosity. This was carried down sharply through skin and subcutaneous tissue as a single flap. The Achilles tendon was divided in the midline and any calcific tendon exposed through subperiosteal dissection. Any abnormal tendon was debrided and all the calcium was removed from the tendon using a rongeur and an osteotome to remove calcification from the posterior calcaneus. The Haglund’s deformity could be visualized and this was removed with a curved osteotome. There was significant inflamation and bursitis. Following removal of all bony exostoses a power rasp was used to smooth down the bone edges. Under fluoroscopic control a lateral view was obtained confirming removal of all bony spurs and protuberances.

The Achilles speed bridge was then used for repair of the tendon back to the bony bed of the calcaneal tuberosity. Proximal and distal screw holes were drilled in the posterior tuberosity. Proximal 4.75 mm swivel locks loaded with #2 Fibertape were placed after tapping and the tapes were brought through the medial and lateral Achilles tendon holding the foot in a slightly plantarflexed position. One medial and one lateral fiber tape was then brought distally and placed into the calcaneus in a similar fashion with an additional 4.75 mm swivel lock. The other medial and lateral tapes were brought distally to the opposite side of the calcaneus and anchored into bone in a similar fashion. Additional 0-Vicryl suture was used to repair the split in the Achilles tendon.

The tourniquet was released and all bleeding controlled with Bovie electrocautery. The wound was irrigated and closed with 3-0 Vicryl in the Achilles tendon sheath and subcutaneous tissues, and interrupted 3-0 nylon mattress sutures in the skin. A sterile mildly compressive dressing with a posterior fiberglass splint was applied.

The patient tolerated the procedure well and there were no intraoperative complications sponge and needle counts were correct x2 and the patient was brought to recovery room awake and in stable condition.
It should be noted that an assistant was needed throughout the case for positioning of the patient, retraction to allow surgical exposure during debridement and repair, and during closure and splint application.

ICD 10 : M66372 Spontaneous rupture of flexor tendons, left ankle and foot
M7662 Achilles tendinitis, left leg

CPT code: 27650-LT Repair, primary, open or percutaneous, ruptured Achilles tendon;
28118-LT Ostectomy, calcaneus

Read also: Coding guide for coding Kissing Stents CPT codes

Sample coded Medical coding chart 2

Indication for Surgery;
Incontinence
Preoperative Diagnosis
Same
Postoperative Diagnosis;
Incontinence & dysfunctional voiding
Operation
Videourodynamics
Surgeon(s)

Anesthesia :Local
Estimated Blood Loss
None
Urine Output

Findings
No incontinence demonstrated. Dysfunctional voiding.
Specimen(s)

Complications
None
Technique
Uroflowmetry was performed. Videourodynamics were performed in the sitting position with leak point pressures also measured in the standing position. A catheter was placed in the bladder for measurement of intravesical pressures and one in the rectum for measurement of abdominal pressures. EMG electrodes were placed in the perirectal area. Please see the formal report located on the chart for details. Briefly, she had a stable bladder with normal compliance and no uninhibited contractions. No incontinence demonstrated with provocative maneuvers. She exhibited dysfunctional voiding with an intermittent flow pattern.

Details of study:
Filling study: 1st sensation, 1st desire, strong desire, and capacity were reached at 20 cc, 240 cc, 365 cc, 397 cc.
Voiding study: Max flow 21.7, average 8.4, volume 434, pressure at peak flow 18.3, postvoid residual 0
EMG: Sphincter activation with attempts to void

CPT code: 51728 – Complex cystometrogram (ie, calibrated electronic equipment);with voiding pressure studies (ie, bladder voiding pressure), any technique
74455 – Urethrocystography, voiding, radiological supervision and interpretation

ICD 10 : R32 – Unspecified urinary incontinence

N39.9 – Disorder of urinary system, unspecified

Read also: Coding guide for Nephrostogram procedures codes

Sample coded Medical coding chart 3

Indication for Surgery : Indwelling right ureteral stent

Preoperative Diagnosis : Same

Postoperative Diagnosis : Removal of right transplant ureteral stent

Operation : Cystoscopy and stent removal

Surgeon(s)

Anesthesia
Sedation

Findings
Right ureteral stent removal with good efflux from transplant kidney

Complications
None

Technique
This patient was given IV antibiotics and prepped and draped in a supine position. Appropriate timeout performed. A 16 French flexible scope was directed into the urethra and passed into the bladder. The stent was observed and was grasped and removed without difficulty. Normal efflux was noted from the ureteral meatus. Patient was transferred to recovery in stable condition.

ICD 10 code: Z466 – Encounter for fitting and adjustment of urinary device
CPT code: 52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple

Read also: Coding guide for cystourethroscopy CPT codes

Sample coded Medical coding chart 3

Preoperative Diagnosis :
Gross hematuria
Recurrent urinary tract infections
Nocturia
Frequency
Urgency

Postoperative Diagnosis :
Gross hematuria
Recurrent urinary tract infections
Nocturia
Frequency
Urgency

Operation :
Cystoscopy
Bladder biopsy
Fulguration of biopsy sites
Pelvic exam

Anesthesia : MAC

Estimated Blood Loss :30cc

Findings
Erythematous bladder mucosa predominantly involving the posterior wall extending up towards the dome

Specimen(s)
Bladder washing for urine cytology
Bladder biopsy x2

Complications : None

Technique : After informed consent was obtained the patient was brought to the operating room. She was placed on the table in supine position. Appropriate heart and lung monitoring devices were attached. IV anesthesia was then begun. She was repositioned into dorsal lithotomy. Genitals were prepped and draped in sterile fashion. She did receive preoperative antibiotics. Appropriate timeout protocol was followed.

Cystoscope was gently inserted into the urethra. Meatus and urethra were normal without stricture or lesion. Bladder neck was normal. The bladder was then entered and was systematically examined. Erythematous bladder mucosa predominantly involving the posterior wall extending up towards the dome. Bilateral ureteral orifices were seen in the normal anatomic position. Each had clear efflux of urine.

Bladder washing was performed. 30 cc of urine will be sent for cytology.

Decision was made to biopsy the abnormal bladder mucosa. Cold cup biopsy forceps were placed. 2 samples were obtained. Tissue was collected and will be sent to pathology for analysis. Biopsy sites were fulgurated using the Bugbee electrode. Hemostasis was adequate

Bladder was then drained and the cystoscope was removed.

Pelvic exam was then performed. Normal external female genitalia. Normal external urethral meatus. No urethral masses. No obvious cystocele, rectocele, or apical descent. Vaginal mucosa appeared normal.

Patient tolerated the procedure well without surgical complication. She was awakened from anesthesia and transported to the PACU for recovery in stable condition.

ICD 10 Codes:

R350- Frequency of micturition
R310 Gross hematuria

R3915 – Urgency of urination
N39.0- Urinary tract infection, site not specified

CPT code: 52224 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy