Sample coded surgery Medical coding charts Part 14

Medical coding Sample report 1

Pre-op Diagnosis:

Left hip recurrent acetabular labral tear

Post-op Diagnosis: Same

Procedure: Left hip acetabular labral reconstruction using semi tendinosis allograft 6 mm in diameter.  Revision cam resection or femoral osteoplasty

Implants:  Five cinch lock anchors and 1 NanoTack anchor from Stryker

Anesthesia Type: GETA and regional (Fascia iliacus block)

Estimated blood loss (mL): 20

Findings:  Recurrent tear of the superior labrum.  Normal articular cartilage and no significant wave sign or bubble in the articular cartilage of the acetabulum.  Small amount of wear on the superior aspect of the femoral head where there was some recurrent impingement from the acetabulum.

Specimens: None

Complications:  None

Tourniquet Time: Traction time was 2:00 a.m. and 10 minutes

Indication and consent: Jamie is a 41-year-old female with significant pain and dysfunction to her left hip she had failed conservative measures and initially did quite well after her labral repair but that was over 5 years ago and recently over the last year to it has been bothering her more.  She had a another MRI which revealed a recurrent labral tear and so we discussed surgical intervention and she wanted to proceed we did so her request knowing full well risks benefits possible complications associated with the surgery.  We proceeded her request and the plan was possible revision repair versus reconstruction.

Description of procedure: Patient was seen and evaluated in the preop holding area where she identified the left hip as the operative extremity was marked and then she was taken back to the OR suite after the fascia iliacus block was administered.  She was then anesthetized on the hana table and her feet were placed in well-padded boots.  Gentle traction was administered just to affirm that we could adequately distract and get good visualization.  Once that was visualized under C-arm we then sterilely prepped and draped the left leg in standard fashion after which formal time-out indicated the correct side antibiotics been administered.  We then commenced the formal traction and anterior lateral portal was created and then a mid anterior portal was then created.  An interportal capsulotomy was done and our evaluation revealed a normal-appearing anterior and anterior superior labrum however posterior or the superior aspect of the labrum was torn again and very small and diminutive.  I contemplated for quite some time whether not a revision repair would be in order.  There was some irregularity on the acetabulum so as I trimmed some of that irregularity while I tried to decide what to do I noted that the labrum in that region was very small and therefore I decided that reconstruction would be in her best interest.  We decided at approximately 40 minutes of traction time and so we opened up the graft and Camryn Watson Pac worked on that diligently on the back table.  I did removed the labrum from the 10-2 o’clock region and prepared the rim with acetabular rim trimming.  Once everything was nice and smooth and the transitions were appropriate I then drilled 5 holes with the cinch lock drill bit mostly from the mid anterior portal but had to do 1 from the lateral portal as well as the NanoTack anchor which was drilled from the anterior lateral portal.  Once that was done the graft was finished preparing on the back table so we passed it through from posterior to anterior and we used the then a tack anchor to pull it into position and tightened down.  The transition there was acceptable so we left that transition and we went ahead and placed the rest of the cinch lock anchors all the way around to tell we got to the anterior-most anchor and that tightened it down very nicely and we amputated the graft after that.  Once that was done we cleaned up that transition as well with the the ablator Wand and cleaned up the graft and then took final pictures and at that point we noted some irregularity on her prior femoral osteoplasty that needed some revision so did a slight revision of the femoral osteoplasty until no further impingement sites were noted.  At that point we did a capsular closure with for interportal capsular stitches.  Of note the capsule was healed and prior capsular stitches were noted to be intact in the capsule was completely intact.  There was some adhesions on the far anterior and posterior aspect but superiorly there were no significant adhesions of the capsule on the labral tissue.  These were trimmed and cleaned prior to the labral reconstruction.  After the capsule was closed we closed the portal sites with interrupted nylon sutures and the patient was awakened and taken to PACU in stable condition with sterile dressings in place.

CPT codes:

29914 Arthroscopy, hip, surgical;with femoroplasty (ie, treatment of cam lesion)

29915 Arthroscopy, hip, surgical;with acetabuloplasty (ie, treatment of pincer lesion)

64450 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

Medical coding Sample report 2

Pre-op Diagnosis: Complex ovarian cyst.

Post-op Diagnosis: Right fallopian tube cyst, endometriosis.

Procedure: Diagnostic laparoscopy, right tubal cystectomy, fulguration of endometriosis.

Anesthesia Type: GETA

Estimated blood loss (mL): 5

Findings: Normal-appearing uterus, left tube, and ovary. Normal right ovary. Right tube contains 3cm cyst. Endometriosis noted in posterior cul-du-sac (implants and scarring distorting left uterosacral ligament). Normal appearing appendix. Normal appearing liver.

Specimens: None.

Complications: None.

Indication and consent:

INDICATION: 25yo G1P0 with infertility. TVUS (8/10/21): demonstrates hemorrhagic ovarian cyst on the left, possible endometrioma. On the right, either a complex ovarian cyst with internal projection vs paratubal cyst with free fluid surrounding the fimbria. Uterus appeared to be bicornuate vs. arcuate.

SURGICAL RISKS:  The patient was informed for the risks and benefits of the procedure.  Risks included, but were not limited to, bleeding, infection, injury to internal organs.  Patient expressed understanding of the risks involved and indicated desire to proceed.

Description of procedure: The patient was taken to the operating room where a time-out was performed to confirm correct patient, correct procedure.  General anesthesia was established. Patient was then positioned on the operating table in the dorsal lithotomy position with the legs supported in stirrups.  All pressure points were padded and a warm blanket was used to control of core body temperature.  The patient was then prepped and draped in the usual sterile fashion. Patient was straight cathed and clear urine was obtained.

OPERATIVE TECHNIQUE:  Attention was turned to the abdomen where a 5 mm vertical incision was made infraumbilically.  The 5 mm trocar was introduced under direct visualization using the laparoscope within the obturator of the trocar.  After intra-abdominal placement was confirmed, the obturator was removed from the trocar.  The camera was introduced and pneumoperitoneum was established using carbon dioxide.  Inspection of the abdominal cavity showed no evidence of injury to bowel, bladder, or vasculature. A 5 mm incision was then made 2 fingerbreadths above and medial to the anterior superior iliac spine.  A 5 mm trocar was introduced through this incision under direct visualization. A 3rd 5mm incision was made 1 handbreadth from umbilicus on the left.  Attention was turned to the pelvis. Patient was placed in Trendelenburg position.  Blunt graspers were used to displace the omentum and bowel cephalad. Blunt graspers were used to evaluate pelvic organs. Findings: Normal-appearing uterus, left tube, and ovary. Normal right ovary. Right tube contains 3cm cyst. Endometriosis noted in posterior cul-du-sac (implants and scarring distorting left uterosacral ligament). Normal appearing appendix. Normal appearing liver. The right tube was grasped and elevated. Cold scissors were used to incise mesosalpinx, cyst was grasped and shelled out from the tube with blunt dissection. Hot scissors were used to amputate the cyst from the small remaining stalk. Cyst was removed and sent to Pathology. Attention was turned to the posterior cul-du-sac. Hot scissors were used to fulgurate the endometrial implants and lysis the scarring. The procedure was then concluded at that time.  Pneumoperitoneum was evacuated.  Laparoscope was removed and the trocars were removed from the abdomen.  Skin incisions were closed with 4-0 Monocryl and Dermabond.  Hemostasis was noted at the incision sites.  All needle, sponge, and instrument counts were noted to be correct x2 at the end of the procedure. Patient tolerated the procedure well, and was transferred to recovery room in stable condition.

CPT codes:

58662  Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method

N83.8 Other noninflammatory disorders of ovary, fallopian tube and broad ligament

Medical coding Sample report 3

Pre-op Diagnosis: Right breast cancer

Post-op Diagnosis: same

Procedure: Bilateral mastectomy, right sentinel lymph node biopsy, ICG injection, port removal

Implants: none

Estimated blood loss (mL): 150

Findings: Sentinel lymph nodes x 8, including one with the clip in it. All negative on frozen.

Specimens: Right breast, sentinel lymph nodes1-8, left breast

Complications: none

Indication and consent: 43F with right locally advanced breast cancer treated with neoadjuvant chemotherapy.  She is here today for bilateral mastectomy, sentinel lymph node biopsy, and possible axillary lymph node dissection and port removal.

Description of procedure: The patient was brought to the operating room the appropriate checklist were performed.  Antibiotics given.  Patient was anesthetized.  Patient is prepped and draped in the usual manner.  Elliptical incisions were marked out on each breast including the nipple.  Her right nipple was slightly lower and the breast more contracted compared to the left but all attempts were made to ensure symmetry of the incisions.  I started on the right side by incising the skin and raising flaps superiorly to clavicle, medially to the sternal border, laterally towards the latissimus and inferiorly to the IMF.  Cautery and clips were used for hemostasis.  The breast was then removed in a medial to lateral fashion off of the pec muscle including pec fascia.  The patient was quite oozy throughout the case.  Once the breast was removed it was checked for lymph nodes marked with stitch and sent for pathology.  The patient had radionucleotide injected in four periareolar dermal blebs prior to the case.  I injected ICG green of the start of the case on the right breast in four periareolar dermal blebs.  Using the gamma probe in the spy machine the following lymph nodes were found:

1. hot and green, 671 + clip
2. hot and green, 188
3. hot and green, 130
4. green only

These were sent on frozen section and lymph node 1 had the clip in it and some atypical cells which could be dead tumor but did not look like it had active cancer in it.  The other 3 were negative.  I then sent lymph nodes 5 through 8 which were all green but not hot to be tested to make sure there were no other foci of cancer.  These were all negative on frozen.  There were no other hot, green, or palpable lymph nodes in the axilla.

The left breast mastectomy was then done next.  The scalp was used to incise skin and flaps were raised superiorly to clavicle medially to the sternal border inferiorly to the IMF and laterally to latissimus.  Breast was then removed in a medial to lateral fashion off of the Pec muscle including the Pec fascia.  This was marked with a stitch and sent to pathology.

The port was removed through the old skin incision.  One stitch was cut along the fascia.  A figure-of-eight 3-0 Vicryl was placed around the catheter entry site and once the port was removed this suture was tightened and pressure was placed on the subclavian vein for 5 minutes.  Hemostasis was achieved with cautery.  Skin was then closed with a running 4-0 Monocryl subcuticular.

For both breasts the cavities were irrigated, hemostasis was achieved with cautery.  A 15 French round JP drain was placed on each side and sutured to the skin with a separate silk stitch and exited the breast through a separate stab incision.  Surgiflow (thrombin clotting factor) was placed in each mastectomy cavity due to how oozy the patient was throughout the case.  Piece of Surgicel was placed in the right axilla for the same reason.

The mastectomy incisions were then closed with 3-0 deep dermal Vicryl interrupted every 1 cm and a running 4-0 Monocryl subcuticular.  Dressing was Mastisol, Steri is, ABD pads and Medipore tape.  The drains were covered with a Biopatch, gauze, Tegaderm.  The sponge and instrument counts were correct.  The patient went to recovery room in stable condition.

CPT code:

19303-50  Mastectomy, simple, complete

36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion

38525 Biopsy or excision of lymph node(s); open, deep axillary node(s)

38792 Injection procedure; radioactive tracer for identification of sentinel node

+38900 Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non-radioactive dye, when performed (List separately in addition to code for primary procedure)