Medical Coding Sample Chart 1
Preoperative Diagnosis: Umbilical hernia
Postoperative Diagnosis: Umbilical hernia
Procedure: Open umbilical hernia repair with mesh (Covidien Parietex mesh patch, 8.6 cm).
Anesthesia: GETA plus 0.25% Marcaine local
Estimated Blood Loss: Scant
Complication: None
Indication for Procedure: He is a 55-year-old gentleman seen by me in November 2018 with complaints of an umbilical hernia. We discussed options for repair at that time, but he could not find a convenient time frame for surgery.
He returns today with complaints of enlargement of the hernia over the past several months with occasional discomfort with his activities. He would now like to proceed with surgical repair.
Recommendation was made for an outpatient open umbilical hernia repair with mesh. The procedure, benefits, risks, and alternatives to surgery were discussed in detail. The patient acknowledged understanding of these discussions and desired to proceed with surgery as soon as possible.
Procedure In Detail: The patient was brought to the OR, placed in supine position on the OR table. After the uneventful induction of general endotracheal anesthesia, abdomen was prepped and draped in a sterile fashion. After infiltration of skin site with 0.25% Marcaine, a 3 cm incision was made within the base of the umbilicus, carried down through the skin with skin knife through subcutaneous tissues with Bovie electrocautery. Careful dissection carried down as the umbilical hernia sac was identified. Plane of dissection was created between the hernia sac and the subcutaneous tissues in all directions. The sac was carefully mobilized and dissected down to the fascial defect. The sac was carefully freed from the edges of the fascial defect and reduced back into the preperitoneal space. A plane of dissection was then created in the preperitoneal space to accept a Parietex patch. The 2.5 cm fascial defect was repaired using a 8.6 cm Bard Parietex patch. The patch was carefully mobilized in the preperitoneal space. The four triangular flaps of the mesh were then carefully secured to the anterior abdominal wall using #1 Prolene in an interrupted U-stitch fashion. Once the mesh was secured, the site was inspected to confirm hemostasis. When hemostasis was confirmed, the site was irrigated with bacitracin solution and reinspected. The fascia was then carefully reapproximated over the mesh using #1 Prolene in an interrupted figure-of-eight fashion with the knots buried. Once the fascial closure was completed, the site was again irrigated and inspected to confirm hemostasis. Additional 0.25% Marcaine was then placed around the perimeter of the fascial closure. An umbilicoplasty was then performed as the superficial subcutaneous tissues were reapproximated with 3-0 Vicryl in an interrupted fashion, followed by closure of skin with 4-0 Monocryl in a running subcuticular fashion. Wound site was clean and dried and Dermabond dressing was applied. The patient tolerated the procedure well. There were no complications. All laparotomy pads, sponge, needle, and instrument counts were correct x2 at the end of the case. The patient was extubated in the OR and taken to recovery room in stable condition.
ICD -10 : K429 Umbilical hernia without obstruction or gangrene
CPT code : 49585 Repair umbilical hernia, age 5 years or older; reducible
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Medical Coding Sample Chart 2
Laterality/Level of Procedure: Lumbar
Extremity(s) of Procedure: back
Procedure: Lumbar Epidural Steroid Injection
PRE-PROCEDURE: Lumbar radiculopathy (M54.16)
POST-PROCEDURE: Lumbar radiculopathy (M54.16)
PROCEDURE IN DETAIL: Patient was seen and examined prior to procedure. NPO status and allergies were verified. The risk, benefits, and alternatives were discussed with the patient. The patient was taken to the fluoroscopy suite where standard ASA monitors were placed.
The patient was positioned in a prone position on the procedure table. Sterile prep and drape were employed and landmarks were obtained under fluoroscopy. A “Time Out” was performed prior to the start of the procedure.
Skin was localized with 1% lidocaine. A 22 gauge 3.5” spinal needle was advanced into the caudal epidural space at under direct fluoroscopic guidance. 1 mL of contrast dye was injected into the epidural space with typical epidural spread on AP and lateral fluoroscopic views. A total of 10 mL solution containing 6 cc of preservative-free normal saline, 1 cc 80 mg Depo-Medrol and 3 mL of 0.5% bupivacaine was injected in increments after negative aspiration. The needle was removed and the injection site was cleaned and an adhesive dressing was applied.
There were no paresthesia, motor weakness, or other complications. The patient tolerated the procedure well. Patient was recovered and discharged home with a chaperone in stable condition.
Assessment
1. Lumbar radiculopathy (M54.16)
CPT code: 62323 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal);with imaging guidance (ie, fluoroscopy or CT)
ICD-10 : M5416 Radiculopathy, lumbar region
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Medical Coding Sample Chart 3
Indication for Surgery left breast carcinoma
Preoperative Diagnosis left breast ductal carcinoma
Postoperative Diagnosis Same
Surgical Procedure Performed left reexcision segmental mastectomy
Assistant none
Anesthesia Gen. endotracheal anesthesia
Estimated Blood Loss Less than 50 mL
Urine Output Not measured
Findings left breast tissue
Specimen(s)left breast tissue with new medial margin
Complications None
Procedure Details : The patient was taken to the operating room and placed in the supine position. After adequate general tracheal anesthesia was obtained, her left chest was prepped and draped in normal sterile surgical fashion. A circumareolar incision was made at the 2 o’clock position on the left breast using the previous segmental mastectomy scar. Subcutaneous tissue was divided. The medial tissue surrounding the underlying palpable indurated tissue was then grasped with an Allis clamp. It was excised in its entirety and sent for pathologic analysis. Attention was placed towards margins. All margins appeared to be free of tumor. The wound was then irrigated with sterile saline and adequate hemostasis assured. The wound was then closed using 3-0 deep dermal Vicryl sutures and a 4-0 running Monocryl stitch. Steri-Strips and sterile bandage placed on both wounds. The patient was then brought from the operating room to the recovery room extubated in stable condition.
ICD 10 : C50912 Malignant neoplasm of unspecified site of left female breast
CPT code: 19301-LT Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy)
