Sample Medical Coding Report 1
Pre-op Diagnosis: 1. Nasal septal fracture
Post-op Diagnosis: same as above
Procedure: 1. Closed reduction nasal septal fracture with internal and external fixation
Anesthesia Type: GETA
Surgeon:
Anesthesiologist:
Assistant 1:
Estimated blood loss (mL): 50
Complications: None apparent
Indication and consent: patient is a 35-year-old gentleman who suffered an nasal septal fracture. The mechanism injury was a fist to the face. He was seen in the Facial Plastic surgery Clinic where we discussed closed nasal bone reduction. After mild deliberation patient agreed undergo the procedure.
Description of procedure: the patient was identified in the preoperative holding area where surgical consent was obtained is taking operating room and induced general anesthesia. Oral endotracheal tube was then placed. Afrin pledgets were placed in the nasal passage. He did have a depressed nasal bone fracture on the right as well as a lateralize nasal bone fracture on the left, and expose septal cartilage noted as well. We reduced the fracture with the Goldman bar. We then readjusted the patient’s bony and cartilaginous septum. This was done with the large nasal speculum. Two Doyle splints were then placed hemostasis was achieved with the suction cautery the Doyle splints were sutured in place with a mattressed 2-0 Prolene suture. Steri-Strips were then placed on the nose an Aquaplast splint was placed for final fixation. Patient we can stable condition.
S022XXA
CPT code : 21337 Closed treatment septal & nose fracture
Sample Medical Coding Report 2
Pre-op diagnosis: Dysphagia
Post-op diagnosis: other (Mild Schatzki’s ring, dilated to 18 mm via Savary)
Procedure: The patient is referred for endoscopic evaluation of dysphagia. Her last dilation was 5 years ago. Once under sedation the Olympus upper endoscope was lubricated passed through the oral cavity with ease into the esophagus then into the stomach which is insufflated with air. This is passed through the pylorus to the 2nd portion of the duodenum. The duodenum is unremarkable. The endoscope was returned back to the stomach. The stomach is generally unremarkable. There may be a very small hiatal hernia seen on retroflexion. The endoscope was returned back to the esophagus. The esophagus is generally normal though there does appear to be a very subtle Schatzki’s ring near the GE junction. A wire was fed is the endoscope was removed and over this a 17 mm Savary was passed with mild resistance. The endoscope was passed back into the esophagus no significant trauma is seen, therefore an 18 mm Savary was passed. At this point the endoscope was removed the patient and the procedure ended. Patient tolerated the procedure well without immediate complication.
Impression: Mild Schatzki’s ring, dilated
Recommendation: If today’s dilation helps, it can certainly be repeated on an as-needed basis. Continuing her PPI for her reflux is also appropriate. If her dysphagia does not respond today’s procedure, I recommend a barium esophagram to rule out Zenker’s diverticulum and if that were to be negative a manometry might be appropriate.
Anesthesia: MAC
Surgeon:
Estimated blood loss (mL): 5
Pathology: none sent
Condition: stable
Disposition: same day
CPT code: 43248 Esophagogastroduodenoscopy, flexible, transoral; insertion of guide wire followed by passage of dilator(s) through esophagus over guide
R1310
Sample Medical Coding Report 3
Pre-op Diagnosis: right little finger metacarpal neck fracture with angulation and rotation
Post-op Diagnosis: same
Procedure: closed reduction and percutaneous pinning right little finger metacarpal neck fracture
Anesthesia Type: regional
Surgeon:
Anesthesiologist:
Estimated blood loss (mL): 2
Findings: Good reduction and alignment (including rotation) achieved
Complications: none
Indication and consent: 54 y/o female s/p fall hitting right hand on a wall. She presented with the angulated metacarpal neck fracture but had malrotation of almost 10 degrees crossing under the ring finger. She presents understanding the risks and benefits of surgery.
Description of procedure: Patient was brought in the operating room suite and placed supine on the operating room table. A blockage been placed preoperatively as she did not want have any chance of undergoing general anesthesia. When adequate anesthetic level been reached the right upper extremity was sterilely prepped and draped in usual fashion. A time-out was taken identifying correct patient, side, and procedure. A closed reduction was performed with longitudinal pressure dorsally with the MP joint flexed 90 degrees. Palpably the reduction was good. The finger was then externally rotated and a K-wire (0.62) was inserted between the little finger metacarpal head and the ring finger metacarpal head. Fluoro was then used to check angulation was felt to be very good in both planes. Rotation was felt to be anatomic. A 2nd K-wire was introduced. Final fluoro shots were then obtained and saved. The pins were bent outside the skin, transected, and a sterile lightly compressive dressing was applied. An ulnar gutter splint was placed holding the wrist in slight dorsiflexion in the fingers in intrinsic plus position including the middle ring and little fingers in the splint. She was then transferred to PACU in stable condition.
CPT code: 26608-RT Percutaneous skeletal fixation of metacarpal fracture, each bone
S62336A
