Sample Coded Surgery Charts for Coders

Medical coding Sample Chart 1

Procedure: Port-A-Cath removal

Preoperative diagnosis: no longer needs port a cath

Postoperative diagnosis: same.

Indications: The patient is a 62 year old woman who no longer needs a port a cath due to completion of treatment. . I had a conversation with the patinet about the risks and benefits of operative intervention. Specific risks were discussed including bleeding, infection, damage to surrounding structures, need for reoperation or reintervention. We discussed the risks of sedation and anesthesia. Consent was signed and placed in the chart

Procedure Details

The patient was brought to the operating room a preoperative time-out was performed confirming patient position and procedure. Sedation was induced without difficulty and the patient was placed supine on the operating room table with arms out and all pressure points padded. SCDs and a Bair Hugger were placed. Antibiotics were given within 30 minutes of incision. The patient was prepped and draped in the usual sterile fashion. Local anesthetic was infiltrated into the skin and soft tissue surrounding the Port-A-Cath. Once he had adequate analgesia I sharply incised the prior incision I dissected the Port-A-Cath free of its surrounding structures. The Port-A-Cath was removed in its entirety. The catheter tip was intact. The wound was irrigated hemostasis was assured. skin was closed with 4 O Monocryl. Dressings were applied. Patient tolerated the procedure well.

Findings:

Intact Port-A-Cath

Estimated Blood Loss: Minimal

Drains: none

Specimens: None

Complications: none

Disposition: ASD

Condition: stable

CPT : 36589  Removal of tunneled central venous catheter, without subcutaneous port or pump

ICD 10: Z45.2 

Z85.3

Medical coding Sample Chart 2

PREOPERATIVE DIAGNOSIS: Left knee severe degenerative joint disease refractory to conservative treatment.

POSTOPERATIVE DIAGNOSIS: Left knee severe degenerative joint disease refractory to conservative treatment.

PROCEDURE: Left Total Knee Arthroplasty

ANESTHESIA: General

ESTIMATED BLOOD LOSS: Per Anesthesia

OPERATIVE PROCEDURE: The patient has undergone conservative treatment. This has failed to give her any relief. At this point, the patient would like to proceed with left total knee arthroplasty. I have therefore explained to her the details of this condition, as well as treatment alternatives, details of the procedure, the needs, benefits, risks, potential complications and the fact there is no guarantee for success. We have discussed that the risks and potential complications include but are not limited to infection, bleeding, damage to blood vessel or nerve, wound healing problems, blood clots, blood transfusion, need for further surgery, serious medical or anesthetic complication, risk of loss of life or limb, etc. The patient fully understands and wishes to proceed with left total knee arthroplasty at this time.

The patient was brought to the operating room and placed on the operating table in the supine position. Appropriate anesthesia was performed. The patient was then secured to the operating table and all bony prominences were well padded. The leg was prepped and draped in the usual sterile fashion and placed in the DeMayo leg holder.

The knife was then used to make the incision in the midline anteriorly. The extensor mechanism was identified and fully exposed. The medial parapatellar arthrotomy was then created using electrocautery and the patella was everted. The fat pads were resected. The Bovie was used to obtain and maintain hemostasis throughout. The deep MCL was reflected off the proximal and medial tibial plateau. The osteophytes were removed. The ACL was resected. The anterior aspects of the menisci were resected. The exposure was complete.

The patella was then resected using the cutting guide and the patella was sized and drilled.

Attention was then directed towards preparation of the tibia. The extramedullary tibial guide was placed and the tibial plateau was fully exposed. The retractors were placed. The PCL was reflected off the posterior aspect of the tibial plateau. The extramedullary tibial guide was placed and adjusted for the appropriate varus-valgus, slope, and rotation. 1 mm of bone was resected off the deficient side. The tibial cut was complete. . The PCL was resected as well.

The femur was then prepared. The drill was drilled up the distal femoral canal. The cutting block was then placed. The appropriate cut was taken off the distal femur. The 5-degree valgus cut angle was used. All debris was removed. The distal femur was sized to the appropriate size. Soft tissue balancing instruments were used to set external rotation and the appropriate sized 4-in-1 cutting block was then placed. We ensured there was no notching of the femur. The block was then pinned in position and the cuts were made. A box cutting jig was used to cut the box. All bony debris was removed. The posterior osteophytes were removed and the posterior

capsule was injected with the local anesthetic. The femoral trial was placed and I then drilled for the femoral lugs.

The tibia was then subluxed forward. The tibial block was applied after rotation was determined. A reamer and keel hole punch then finished the tibia.

The trial components were placed. The knee was taken through full range of motion. Flexion and extension stability was assessed and felt to be well balanced and stable. The patella tracked appropriately. All trial components were then removed. At this point, the knee was copiously irrigated with pulsatile lavage.

The cement was mixed on the back table by the assistant simultaneously. The bone and components were all pre-coated with cement. The components were all placed and excess cement was removed. The leg was held in place with extension and axial load. The patella was held with the patella clamp. The cement was allowed to fully harden. Once the cement had fully hardened, the knee was flexed up and any excess cement removed. The knee was again examined and balance and tracking were good. The knee was irrigated with dilute betadine solution. The knee was again copiously irrigated with pulse lavage.

The medial parapatellar arthrotomy was then closed with #1 Stratafix sutures. The subcutaneous tissues were closed with 2.0-Stratafix buried fashion. Skin edges were approximated with Monocryl and skin glue. The knee was then cleansed and dried and a sterile dressing was applied. The patient was then awakened from anesthesia, transferred back to the transport bed and to the recovery room in stable condition. Anesthesia stated that the patient did well throughout the entire procedure.

CPT : 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

Medical coding Sample Chart 3

PROCEDURE: Laparoscopic bilateral salpingo-oophorectomy

SURGEON:

ASSISTANT:

ANESTHESIOLOGIST:

ANESTHESIA: GENERAL ANESTHETIC WITH ENDOTRACHEAL INTUBATION.

PREOPERATIVE DIAGNOSIS: Complex left ovarian cyst.

POSTOPERATIVE DIAGNOSIS: Left ovarian cyst.

INDICATIONS FOR OPERATION: The patient is a 64-year-old who was found on imaging studies done for right lower quadrant pain to have a complex left ovarian cyst. She is now brought in for laparoscopic bilateral salpingo-oophorectomies

FINDINGS: 2 cm x 3 cm simple appearing cyst on the surface of the left ovary. Right ovary and tube were normal. Filmy adhesions from the right ovary to the right posterior broad ligament.

DESCRIPTION OF PROCEDURE:

Patient was placed in the supine position on the operating table and put under a general anesthetic with endotracheal intubation. She was then moved to the dorsal dorsal lithotomy position with low stirrups and the abdomen, perineum and vagina were prepped and draped in a sterile fashion. A Foley catheter was placed. Exam under anesthesia revealed uterus to be anteverted, anteflexed, normal size and mobile. There were no adnexal masses palpable. The cervix was visualized with a speculum and grasped on the anterior lip with a single-tooth tenaculum. The uterus sounded to 7 cm. A Hulka tool was placed in the uterus for manipulation and the tenaculum and speculum were removed.

0.25% Marcaine with epinephrine was injected in the subumbilical area and a 12 mm transverse incision made at that site. A Veress needle was placed through the incision into the peritoneal cavity and pneumoperitoneum was established. The Veress needle was removed and replaced with a 12 mm trocar and sleeve. Entry into the peritoneum was confirmed with the scope. 0.25% Marcaine with epinephrine was then injected in both lower quadrants and 5 mm transverse incisions made at those sites. Secondary 5 mm trocar and sleeves were placed through those incisions under direct visualization.

The pelvis was then inspected. The uterus was normal size, small and mobile without any surface abnormalities. The right tube and ovary were normal with the exception of some filmy adhesions from the right ovary to the posterior broad ligament. On the left ovary, there was a 2 cm x 3 cm simple appearing cyst on the top of the ovary not really within its substance. Left fallopian tube was normal. Anterior and posterior cul-de-sacs were normal as was the the upper abdomen grossly.

The left adnexa was elevated and a LigaSure instrument used to cauterize across the infundibulopelvic ligament which was then transected. The LigaSure instrument was used to cauterize and transect the mesosalpinx from the fimbriated end to the cornua. The left utero-ovarian ligament and the base of the left fallopian tube were then cauterized and transected removing the adnexa. The right ovary was then elevated and the LigaSure instrument used to cauterize across the infundibulopelvic ligament which was then transected. The LigaSure instrument was used to cauterize across the mesosalpinx from the fimbria to the cornua which was then transected. LigaSure instrument was used to cauterize across the right utero-ovarian and tje base of the right fallopian tube and then transecting those structures removing the adnexa.

A 5 mm scope was placed in the right lower quadrant port and an extract bag placed through the umbilical port. Both tubes and ovaries were placed in the extract bag which was then brought up to the umbilicus. The specimen was removed through the umbilicus draining the cyst of clear fluid.

The umbilical port was replaced in umbilicus. Inspection of all the ligation sites revealed no bleeding. Pelvis was irrigated with saline which was suctioned out. The instruments were then removed from the abdomen and the pneumoperitoneum allowed to escape. In the umbilical incision, the fascia was closed using a figure-of-eight suture of 0 Vicryl. The remainder of that incision and the lateral incisions were closed using subcutaneous and subcuticular sutures of 4-0 chromic. Sterile dressings were placed over the incisions. The Hulka tool and Foley catheter were removed. The patient was then brought out of her anesthesia and taken recovery in stable condition.

ESTIMATED BLOOD LOSS: 10 cc.

FLUIDS: 1000 cc crystalloid.

SPECIMENS: Bilateral tubes and ovaries.

CPT: 58661  Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

ICD 10: N83.292 Complex cyst of left ovary

Medical coding Sample Chart 4

Preop diagnosis: recurrent nephrolithiasis, left ureterolithiasis, urinary tract infection, bilateral nephrolithiasis

Postop diagnosis: left ureteral and renal calculus

Procedure: Cystoscopy, removal left double-J stent, left ureteroscopy, laser lithotripsy of left ureteral and renal calculus. Basket extraction of calculi fragments, placement of left double-J stent 6 x 26

Surgeon:

Anesthesia: General

drains: 6 x 26 double-J stent

specimen: Urine culture and calculi fragments

Indications: 34-year-old female with a history of recurrent nephrolithiasis. Patient had developed symptoms of left flank and was seen in the emergency room. CT scan scan demonstrated left UPJ stone 11 mm, and multiple right renal calculi no hydronephrosis. Patient did have evidence of active urinary tract infection. She was transferred to Saint Mary’s Hospital where she underwent cystoscopy and stent placement. Patient was discharged home on a course of Ceftinidir. She underwent a follow-up urine culture 48 hours ago which demonstrated no bacterial growth. She is now here for planned cystoscopy, removal of left double-J stent, ureteroscopy laser lithotripsy of ureteral/ renal calculi, basket extracted calculi fragments and placement of double-J stent. Preoperatively, we did review the risks benefits and possible complications specific to this procedure. This includes but is not limited to bleeding, infection, urethral injury, bladder injury, ureteral injury, ureteral stricture, retained stone fragments, anesthetic risks even possible death. Patient understood these risks does wish to proceed.

Findings:

The patient was was brought to the operating room and placed in the Supine position. She was given general mask anesthesia which she tolerated well. After an adequate level of anesthesia was achieved she was positioned in a dorsal lithotomy position. She was prepped and draped under the usual sterile technique. A protocol time-out was obtained.

A 22 French cystoscope was then used to evaluate the patient. The anterior urethra was normal appearance without any evidence of stricture. Upon entry the bladder both ureteral orifices were identified appeared to be in orthotopic position. A double-J stent was seen emanating from the left ureteral orifice. Systematic evaluation of the bladder With a 30 and 70 degree angle lens was notable for evidence of cystitis adjacent to the left ureteral orifice from the double-J stent. There was no other gross intravesical pathology. Specifically, no gross tumor or calculi.

The distal end of the left double-J stent was grasped and brought out through the urethra. A 0.035 wire was then placed into the left renal pelvis in a retrograde fashion under fluoroscopic guidance. A dual-lumen catheter was then advanced an additional safety wire was placed. An 11/13/36 ureteral access sheath was then advanced over the wire up to the mid ureter. I was unable to advance it any further.

A flexible digital ureteral scope was then used to evaluate the patient. Patient was noted to have a stone in the mid ureter At the distal end of the ureteral access sheath. Using the holmium laser the stone was then broken up into 3 fragments which were then removed using the 0 tip Nitinol basket. Ureteral scope was then advanced up into the kidney. Systematic evaluation of the calices was notable for the large stone in the lower pole calyx. Using the holmium laser the stone was then dusted. The largest of the fragments were removed with a Zero tip Nitinol basket. Systematic evaluation of remainder of the calices demonstrated no residual calculi.

Ureteral scope was then slowly withdrawn. The ureter was examined from the UPJ all the way down to the UVJ. There was no additional calculi seen. There is no evidence of any injury to the ureter.

A 6 x 26 double-J stent was then placed into left renal pelvis in a retrograde fashion under fluoroscopic guidance. The bladder was drained and the cystoscope was withdrawn. Patient tolerated procedure well was taken recovery room postoperative

CPT: 52356  Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type)

Medical coding Sample Chart 5

PREOPERATIVE DIAGNOSIS: Chronic Calculous Cholecystitis

POSTOPERATIVE DIAGNOSIS: Chronic Calculous Cholecystitis

PROCEDURE PERFORMED: Laparoscopic Cholecystectomy

SURGEON:

ASSIST:

ANESTHESIA: General

INDICATIONS: Patient is a 66 y.o. male with symptomatic chronic calculous cholecystitis

FINDINGS: Large Stones, significant scarring of the neck of the gallbladder.

DESCRIPTION OF THE PROCEDURE: The patient was brought to the operating room. A preoperative time out was performed confirming patient, position, and procedure. The patient was prepped and draped in the usual sterile fashion. 0.25% marcaine was used for anesthetic purposes prior to incisions throughout the case. A cut down at the belly button to gain access to the peritoneal cavity. A figure of 8 of 0-vicryl was placed in the fascia and this was used to attach the hasson port. The abdomen was insufflated and the camera was inserted. A subxiphoid and 2 subcostal 5mm ports were placed. The gallbladder was grasped and elevated over the liver. The peritoneum on either side of the gallbladder was released to aid in retraction. We then dissected identifying in the cystic triangle until we had clearly identified the cystic duct and the cystic artery. A picture of the critical view of safety was taken. We then placed clips on the cystic duct with 3 on the staying side and 1 on the gallbladder side. The artery was taken in the same fashion. We then released the gallbladder from the liver bed. The gallbladder was placed in the endocatch bag. We then achieved hemostasis of the liver bed. We suctioned any excess fluid. The gallbladder was removed from the abdomen but the skin and fascia had to be opened bigger. We used the suture passer to ensure closure of the incision in addition to the figure of eight stitch. We then allowed the gas to escape from the 12mm hasson port. The figure of 8 suture was then tied. We confirmed that the fascia was adequately closed. We then closed the skin with 4-0 monocryl. Glue was applied as a dressing. The patient was awoken from anesthesia and transferred to PACU in stable condition.

SPECIMENS: Gallbaldder

COMPLICATIONS: none

CPT : 47562  Laparoscopy, surgical; cholecystectomy