Sample Medical Coding Report 1
PREOPERATIVE DIAGNOSIS:
Right trimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS:
Right ankle fracture in light of osteoporosis and
subacute presentation.
PROCEDURE:
Open reduction and internal fixation of right trimalleolar ankle fracture.
ANESTHESIA PERFORMED: General with 20 cc of 0.25% Marcaine
ANTIBIOTICS:
Cefazolin 2 g IV.
ESTIMATED BLOOD LOSS: Less than 50 cc.
TOURNIQUET: None.
COMPLICATIONS:
Significant osteopenia requiring quad cortical fixation.
IMPLANTS:
Arthrex locking and nonlocking plate through the lateral malleolus with 2.4 and 3.5 cortical screws and Arthrex 2.4 titanium T-plate and Arthrex 5th metatarsal hook with 3.0 titanium screws.Arthrex Amnion attach 3 x 8 cm.
HISTORY: The patient is a 90-year-old female, who had a mechanical fall sustaining a right trimalleolar ankle fracture dislocation.She was advised that she be treated non-operatively given that she was quite frail and old.However, she is a community ambulator and when she presented to me, given that her ankle is feeling dislocated, this may not be amenable for a community ambulator, we decided to proceed with surgical intervention.The risks and potential complications were described and the patient decided to proceed.
DESCRIPTION OF PROCEDURE:
The patient was met in the preoperative holding area, where consent performed by the patient.All questions were answered.Her extremity was marked for surgery.The patient was brought back to the operative suite, placed supine on the operative table.She was then placed in a sloppy lateral position with the bean bag.Her right lower extremity was then prepped and draped in the usual sterile manner.Prior to proceeding, a formal time-out was performed by all team members present.IV antibiotics were administered. Using a posterolateral incision measuring approximately 10 cm, the skin was incised as well as FHL tendon sheath.The interval was then developed and dissection was carried down to the posterior malleolus.Given the subacute
presentation of this fracture, the fracture fragments were not as mobile as fracture.I dissected off the posterior malleolus and tried to reduce, but she had extensive osteoporotic bone and is was difficult to obtain an adequate reduction .We thus contoured the titanium T-plate and contoured to the posterior malleolus and we used a contoured plate to reduce her posterior malleolus.We placed a 3.0 cortical screws that reduced her posterior malleolus.We then dissected anterior to our peroneal tendons onto the lateral malleolus.Given that he had any kind of malleolus, but again was not mobile.We tried to release the posterior malleolus with more dissection, her bones started to crumble.We decided then to place a lateral locking plate with 2.4 unicortical locking screws.We then reduced the fragment using quad cortical fixation with 3.5 screws from fibula to tibia.He had a perfect reduction, however, her length, alignment, and rotation were relatively achieved.Given her age, comorbidities and decided to accept the slight misalignment.We made a separate incision over the medial ankle and dissection was carried down to the medial malleolus.Again, we tried
to reduce it, however, nature of the bone is very difficult to reduced and keep the fixation intact.I initially cut two 4.0 titanium headless screws, but given the osteophyte of the bone it was still unstable.We then removed the two 4.0 titanium headless screws and base contoured to the medial malleolus and fixed it with 3.0 cortical screws.Stress images taken, fluoroscopic images confirmed
excellent length, alignment, and rotation.The mortise was intact.The subcutaneous tissue was just closed.We initially tried to do a layer closure, but again her skin was so frail, the sutures were tearing through the skin given her tenuous nature of her skin, we then decided to place amnion, followed by Arthrex jumpstart and sterile dressings were applied, followed by a short-leg splint.
At the end of the case, all counts were accounted for.The patient was awakened from general anesthesia and transferred to the PACU in stable condition.
POSTOPERATIVE PLAN:
The patient will be discharged back to her skilled nursing facility.She will be nonweightbearing to right lower extremity.DVT prophylaxis with Eliquis which should be restarted in 24 hours from the time of surgery.She will follow up in my clinic in 2 weeks for a wound check.0
27823-RT
Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip
ICD 10:
S82851A Displaced trimalleolar fracture of right lower leg, initial encounter for closed fracture
Sample Medical Coding Report 2
EXAM:
IR HEPATIC CHEMO EMBOLIZATION
REASON FOR STUDY:
Disease of liver
DIAGNOSIS:
Hepatocellular carcinoma recurrence
CONSENT:
The procedure and possible complications were explained to the patient and written informed consent obtained.Complications include, but are not limited to, bleeding, allergic reactions to injected medications, and infection.While these complications are unusual, they are possible.
MEDICATIONS:
Intravenous Fentanyl and Versed were given for analgesia and sedation.A nurse monitored the patient.
PROCEDURE/FINDINGS:
Medication reconciliation form reviewed and any changes related to this procedure resolved.Maximal Sterile Barrier Technique utilized.Area over the right groin was sterilely cleansed, draped, and anesthetized buffered 1% lidocaine.Using direct ultrasound guidance, access was gained to the right common femoral artery.Over a wire following dilatation a 5 French sheath was placed.Through the 5 French sheath over a wire a VS2 angiographic catheter was advanced and formed in the aorta.Catheter was then placed into the superior mesenteric artery with angiographic images obtained.Angiographic images demonstrate no collateral vasculature to the liver.
The VS2 catheter was then placed into the celiac artery with angiographic images obtained.Again demonstrated is a replaced left hepatic artery off the left gastric artery.In the segment 5 region there is an area of hypervascularity noted.In the segment 6/7 region a small area of hypervascularity is noted along the edge of the tumor necrotic mass.
Microcatheter was advanced over a microwire into the segment 7/8 branch vessel with angiographic images obtained.Angiographic images again demonstrate the spots of neovascularity seen on CT long the margin of the necrotic tumor.
Chemoembolization was conducted with 100-300 micron drug-eluting beads.
The catheter was then pulled back and placed into the segment 6/7 vessel with angiographic images obtained.Angiographic images demonstrate hypervascularity particularly in the segment 6 region.Chemoembolization was conducted with 100-300 micron drug-eluting beads.
Catheters were then pulled back.The VS2 catheter was then pulled back into the origin of the left gastric artery with angiographic images obtained. Angiographic images obtained demonstrate no significant areas of neovascularity.
Catheter was then removed without complication.Sheath was removed and pressure was held to hemostasis.There were no immediate complications.The patient tolerated the procedure well.Patient received a total of 30 mg of doxorubicin on drug-eluting beads.
Patient will stay overnight for pain and nausea control.
PERFORMED PROCEDURES:
First order catheterization superior mesenteric artery.Third order catheterization right hepatic artery with 4th order catheterization segment 7/8 branch and fourth order catheterization segment 5/6 branch. Chemoembolization with drug-eluting beads.Second order catheterization left gastric artery with angiographic imaging.Ultrasound guidance for vascular access.
Total fluoroscopy time is 22.1 min.
MODERATE SEDATION FACE-TO-FACE TIME:
Seventy-five min.
IMPRESSION/PLAN:
1.Successful chemoembolization with 30 mg of doxorubicin on 100-300 micron drug-eluting beads for areas of recurrent marginal enhancing tumor along the large necrotic mass in right hepatic lobe. 2.Patient will stay overnight for nausea and pain control.
3.Follow-up 4 phase CT in 6 weeks.
CPT code
37243
Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction
75774-59
Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation
75726-59
Angiography, visceral, selective or supraselective, radiological supervision and interpretation
36248-59
Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family
36245-59
Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
36247-59
Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
Sample Medical coding report 3
PREOPERATIVE DIAGNOSIS:
Left inguinal hernia.
POSTOPERATIVE DIAGNOSIS:
1.Reducible initial left inguinal hernia.
2.Reducible recurrent right inguinal hernia.
3.Reducible umbilical hernia
PROCEDURE:
1.Laparoscopic robot-assisted repair of reducible initial left inguinal hernia with mesh.
2.Laparoscopic robot-assisted repair of reducible recurrent right inguinal hernia with mesh.
3.Open repair of reducible umbilical hernia
ANESTHESIA:
General endotracheal anesthesia.
ANESTHESIOLOGIST:
ESTIMATED BLOOD LOSS:
Less than 25 mL.
DRAINS:
None.
SPECIMENS REMOVED: None.
COMPLICATIONS:
None.
DISPOSITION:
To recovery room.
CONDITION ON TRANSFER: Satisfactory.
INDICATIONS FOR SURGERY:
Michael is a 74-year-old man who developed intermittent left groin pain over the last year or so, and has also seen intermittent bulge.He went to see his PCP, Dr. Antonio Soler, of Santa Rosa
(fax #707-303-4377), who made the diagnosis and referred him to see me in consultation.
In the office, we discussed natural history of his condition and the different options available to him, which would include what would happen if nothing was done, laparoscopic, laparoscopic robot-assisted or open hernia repair with and without mesh.The goals, benefits, and risks of each of the options were reviewed in detail.The risks of surgery include injury to bowel, blood vessels, and surrounding organs such as the ureter, iliac vessels, blood supply to the testicle and vas deferens.Additionally, there is a risk of recurrent hernia, incisional hernia, and future episodes of bowel obstruction, and nonsurgical complications such as heart attack, stroke, pneumonia, and pulmonary embolism to name a few.All of his questions were answered and he verbalized understanding and wanted to proceed with surgery.
DESCRIPTIONS OF FINDINGS: In addition to the known indirect left inguinal hernia that was approximately 3 cm in diameter, there was a previously unrecognized recurrent right 1 cm indirect inguinal hernia.Both of these hernias were repaired using two separate pieces of mesh using the transabdominal preperitoneal mesh placement technique.A previously unrecognized umbilical hernia was repaired primarily with 0 Vicryl suture and no mesh was used due to its small size at approximately 0.6 cm.
DESCRIPTION OF THE OPERATION: The patient was taken to the operating room and placed supine on the operating room table.Sequential compression devices were placed and then general endotracheal anesthesia was induced.His legs were spread using the split leg table, both arms were tucked with care to pad the pressure points and a protective faceplate was placed.His abdomen was then prepped and draped in the usual sterile fashion and a time-out was done in order to confirm the patient, the procedure as well as the preop administration of IV antibiotics.Local anesthetic was injected into the umbilicus and a vertical incision was made.A previously unrecognized 8 mm umbilical hernia was found. The hernia sac was dissected free and transected.The hernia defect was extended to 12 mm in length and a finger was used to enter the peritoneal cavity without injury to bowel or blood vessels.A 12 mm trocar, with the obturator
removed, was then inserted through the hernia defect and the abdomen was insufflated with carbon dioxide and he was placed in Trendelenburg position. Laparoscopy then revealed the above findings.Two separate 8 mm robotic trocars were placed in the right and left lateral abdomen, at the level of the umbilicus.The robot was then brought in and docked to all 3 trocars. The robotic bipolar graspers and suture MegaCut were then inserted and docked, and I
transitioned to surgeon console to perform the operation.
The initial left inguinal hernia repair was performed by making a transverse incision from the midline over the left lateral side, midway between the level of the umbilicus and the hernia defect.The preperitoneal space was dissected all the way down to the hernia sac and the hernia sac was dissected free and reduced back into the peritoneal cavity.It was somewhat chronic in nature,
which made it moderately difficult, but it was able to be achieved.Further dissection was carried medial of the hernia sac towards the pubic rami, inferior of the hernia sac and laterally to the left anterior superior iliac spine, so as to create room for the mesh.A left-sided Covidien Parietex Anatomic ProGrip mesh was prepared on the back table by placing a 2-0 V-Loc suture in the center of it, rolling it up, hydrating, and inserting into the peritoneal cavity.It was then situated in the preperitoneal space and then unfurled so as to repair the indirect inguinal hernia defect but also covered the direct and femoral potential weak points.The ProGrip technology secured the mesh in place.The peritoneal opening was then closed using the 2-0 V-Loc suture in a continuous
running fashion and the needle was removed.
I then performed the repair of the previously unrecognized recurrent right inguinal hernia using a similar technique.In brief, a transverse incision was made in the peritoneum, the preperitoneal space was developed down to the hernia sac, which was easily reduced and further dissection was created medially, laterally and inferiorly, so as to create room for the mesh.The mesh was then
placed in a similar fashion and the ProGrip technology secured the mesh in place.The mesh covered not only the indirect hernia, but also the direct and femoral weak points.Similarly, the peritoneum was reapproximated by suturing it closed at the inferior to superior edge using a 2-0 V-Loc suture.This needle was then removed as well.I then returned to the surgical field and the
robotic instruments were removed and the robot was undocked.The abdomen was desufflated of carbon dioxide.
I then performed the repair of the umbilical hernia.Due to its small size, it was closed without mesh.Two separate 0 V-Loc suture was then placed through the fascia in a figure-of-eight fashion and this constituted the repair. Exparel was then injected to augment the previously injected 0.25% Marcaine with epinephrine.All the skin incisions were then closed using 4-0 Monocryl
followed by liquid adhesivedressing.The sponge and instrument count were correct and he tolerated the procedure well.He was then extubated and transferred to the recovery room for postoperative care.
CPT code:
49651-RT
Laparoscopy, surgical; repair recurrent inguinal hernia
49650-LT
Laparoscopy, surgical; repair initial inguinal hernia
49585
Repair umbilical hernia, age 5 years or older; reducible
ICD 10
K4090 Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
K4021 Bilateral inguinal hernia, without obstruction or gangrene, recurrent
Sample Medical Coding Report 4
PREOPERATIVE DIAGNOSIS:
SVT, tachycardia bradycardia
POSTOPERATIVE DIAGNOSIS:
same as above
PROCEDURE:
EP study, TEE, pacemaker implanation
This is a delightful 83-year-old gentleman with a tendency towards tachycardia- bradycardia syndrome, who had an SVT noted on a Zio patch as an outpatient.He was unable to tolerate higher doses of beta blockade due to his tendency of bradycardia.Given the symptomatic SVT and failure from appropriate medical therapy, he was deemed an appropriate candidate to consider for EP study and possible ablation.While in the preoperative area, the patient had different atrial arrhythmia and there was some question of an atrial tachycardia or atrial flutter for possible atrial fibrillation.We had an extensive discussion with the patient prior to the procedure about next steps in treatment, as the patient is not on anticoagulants and has not had a previous diagnosis of atrial flutter or fibrillation in the past.Therefore, we opted on the final strategy including doing a diagnostic EP study to understand the rhythm.If it was truly atrial flutter or atrial fibrillation requiring anticoagulants prior to the procedure, then we would do a TEE to see if there was a clot or not.If it was an overt easy right-sided atrial flutter, we would ablate it.If it is a left-sided flutter or fibrillation, then wait on further extensive left atrial ablation due to lack of preceding anticoagulation and his elevated CHADS score including age, hypertension, and diabetes.Subsequently, I discussed this in detail with the patient and with Dr. Singh, his outpatient cardiologist.If the patient did have some complex left-sided atrial arrhythmias, then we would opt to do a TEE to make sure there was no clot and then go ahead and implant a pacemaker, given his tachycardia-bradycardia syndrome, thus allowing for requirements of additional beta blockade or antiarrhythmic therapy for arrhythmia suppression in a safe manner without any subsequent life-threatening bradycardia.
The patient was thus brought back to the EP laboratory in a fasting, postabsorptive, nonsedated state.Time-out was completed.Informed consent was obtained, witnessed, and reviewed.Antibiotics were administered. Right femoral vein was accessed using the modified Seldinger technique after a mixture of lidocaine and bupivacaine was infiltrated in this area.One access point was obtained with a 7-French short sheath and one retained wire.Through the 7-French short sheath, we put in a CS diagnostic catheter, which showed the patient to be in a left-sided atrial flutter with a cycle length of 210 milliseconds.Given his lack of anticoagulation, his elevated CHADS2-VASc score has tendency towards tachycardia-bradycardia syndrome.We went ahead and did not tackle this particular atrial flutter and also knowing that he had a different one as an outpatient.Catheters and sheaths were removed, and hemostasis was obtained.There were no immediate complications.We then did a TEE to make sure there was no left atrial thrombus existing and none was seen.
Please see separate report for details.Finally, we went ahead and put in a right-sided pacemaker.The right side of the chest was prepped and draped in a sterile manner.Preprocedural pause was again done.The local anesthetic was applied to the right upper chest.A #10 blade was used to make an incision in this area.Blunt and Bovie dissection carried out to the pre-pectoralis fascia. Using the guidance of ultrasound, access was obtained into the right axillary vein.Wire was seen to course below the level of diaphragm confirming venous access.A retained wire mechanism was used, and the right atrial and right ventricular leads were placed in the appropriate locations in the cardiac chambers.Once adequate sensing impedance and threshold parameters were obtained, lead collars were affixed to the pectoralis muscle with 0 silk tie.
Tug testing was done on the collar, it was stable.Lead tips were cleaned and dried and plugged into the appropriate sockets of the device generator.Tug testing was done on the generator and it was stable.The pocket was flushed with copious amounts of antibiotic solution.A dry field was observed.An 0 silk header stitch was used to affix the device into the pocket.The pocket was closed with a 2-0 Vicryl, 3-0 Monocryl, 4-0 Monocryl, Dermabond, and Steri- Strips on top of it.
DEVICE INFORMATION: St. Jude PM.The right atrial lead is a St. Jude LPA, serial number CVA.Right ventricular lead is a LPA.The right atrial lead sensing is 3.6 mV, impedance 490 ohms,
threshold not obtained due to atrial flutter.Right ventricular lead is sensing 11.4 mV, impedance 740 ohms, threshold 0.75 V at 0.4 milliseconds pulse width. At the end of the case, there were no immediate complications.Sponges and needles were accounted for.The patient will undergo the usual postoperative care, bedrest, telemetry per protocol, right arm sling, serial antibiotics, chest x-ray, consider antiarrhythmic therapy, and start anticoagulants hopefully days and tomorrow night for his multiple arrhythmias.
33208-KX
Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular
I471 Supraventricular tachycardia
Sample Medical Coding Report 5
PROCEDURE:
Left heart catheterization, left ventriculography, selective coronary angiography, pressure wire assessment of the LAD.
PREOPERATIVE DIAGNOSIS:
Coronary artery disease.
POSTOPERATIVE DIAGNOSIS:
Coronary artery disease.
CLINICAL HISTORY:
The patient is a 63-year-old man with a history of several months of exertional bilateral arm discomfort.During stress testing, he developed ischemic EKG changes.He was brought to cardiac catheterization lab for further evaluation.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought to cardiac catheterization lab in a fasting state.The right wrist and the right groin were prepped and draped in a sterile fashion via a 6-French sheath in the right radial artery.A 6-French JR4 and JL3.5 diagnostic catheters were used to perform selective coronary angiography.Left heart catheterization and left ventriculography were performed with a 6-French angled pigtail catheter.IFR assessment of the LAD was performed (see details below). At the end the procedure, the catheter sheaths and wires were removed with adequate hemostasis using a HemoBand.There were no immediate complications and the patient left the cath lab in stable condition.
FINDINGS:
1.Hemodynamics.Aortic pressure 121/63, left ventricular pressure 121/18, heart rate 60 rhythm sinus.There is no pressure gradient across the aortic valve with catheter pullback.
2.Left ventriculography demonstrated hyperdynamic contractile function of all segments of left ventricle in the RAO projection with a visually estimated ejection fraction of greater than 70%.There is no evident mitral regurgitation.
3.Coronary anatomy.There was severe calcification in the LAD and circumflex seen on fluoroscopy.The left main was a large caliber vessel with no flow- limiting disease.The LAD was a large caliber vessel.There was a 20% to 30% ostial stenosis seen in the LAO caudal view.In the more distal segment of the LAD, there was a stenosis that began and extended across the origin of the first diagonal.The degree of stenosis appeared to be 50% to 70%.The mid LAD about halfway down the ventricle had smooth mild narrowing of approximately 30%.There was a single major diagonal branch, which was large and branching.There was disease beginning at the ostium
which was probably mild and a few millimeters later just before the bifurcation a 90% stenosis.The medial pole of the diagonal branch had 80% to 90% origin lesion.The remainder of the diagonal had no flow-limiting disease in this medial pole.The lateral pole had mild disease immediately after the bifurcation.There was normal flow into these vessels.The circumflex was codominant.There was no significant disease at the origin. The mid circumflex beyond the first obtuse marginal had a relatively focal 80% to 90% lesion.The distal circumflex before 2 small OM branches and then the large left posterior ventricular branch had a tubular 80% to 90% stenosis.The first obtuse marginal was a moderate-sized vessel and had a long segment of disease up to 95% in severity with normal flow into this vessel.The 2nd and 3rd obtuse marginals before the left posterior ventricular branch were very small with no flow-limiting disease.The left
posterior ventricular branch was moderate in size and had no flow-limiting disease.The right coronary artery was codominant.There was mild disease mid vessel at the bend approximately 20% to 30%, just beyond there was a tubular 30% stenosis.Beginning about 20 mm before the crux, there was diffuse disease up to 50% extending to the bifurcation.The origin of the posterior descending artery had 80% to 90% stenosis, which was relatively focal but then about 10 mm later was another focal stenosis of 80% to 90%. There was a very small posterolateral branch which had no flow-limiting disease.The PDA itself beyond the origin was a moderate size vessel with normal flow.
4.IFR assessment of the LAD: The Verrata wire was advanced to the tip of the EBU 3.5 guide and was normalized.The wire was then advanced after intracoronary nitroglycerin into the mid LAD beyond the bifurcation with the first diagonal, and the IFR was determined to be 0.83, repeat 0.81, and repeat 0.83.The wire was withdrawn to the tip of the guide and the pressures remained equal.Repeat angiography after IFR assessment showed no significant change in appearance of the left coronary system.
CONCLUSION:
1.Severe three-vessel coronary artery disease.
2.Normal left ventricular systolic function.
3.Mildly elevated left ventricular filling pressure.
4.IFR assessment into the mid LAD determined to be approximately 0.82.
93458
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed
93571
Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement during coronary angiography including pharmacologically induced stress; initial vessel
I2510 Atherosclerotic heart disease of native coronary artery without angina pectoris
