medicalcodingexamples - Medical Coding Guide

Sample Coded Surgery Reports for Medical Coders

July 27, 2022October 22, 2023 Jitendra M.Sc CPC

Sample Medical Report 1 PREOPERATIVE DIAGNOSIS: Right laryngeal lesion. POSTOPERATIVE DIAGNOSIS: Right laryngeal lesion. PROCEDURE: Microsuspension laryngoscopy with excision of right laryngeal lesion. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. SPECIMENS REMOVED: Right laryngeal lesions. COMPLICATIONS: None. INDICATIONS FOR SURGERY: The patient is an 84-year-old man with a history of dysphonia. He was found by an outside ENT to have a lesion overlying his right arytenoid surface. This was followed by both the outside ENT and myself and the lesion was concerning for an area of leukoplakia and therefore, intraoperative…

Medical Coding Examples Part 1

November 22, 2018October 22, 2023 Jitendra M.Sc CPC

Medical Coding Example 1 EXAM: NM GASTRIC EMPTYING STUDY REASON FOR STUDY: Nausea and vomiting CLINICAL HISTORY: Nausea and vomiting TECHNIQUE: A standard meal consisting of Eggbeater 4 oz, toast, jam and water was labeled with the radiopharmaceutical and administered orally to the patient. Subsequent static images were obtained at approximately 60 minutes, 120 minutes, 180 and 240 minutes. The images were subsequently used to compute the gastric half emptying time. Allergies: The patient has no known medication allergies. Radiopharmaceutical: Tc-99m sulphur colloid 760 mCi PO. FINDINGS: There is prompt radiopharmaceutical accumulation…

Learn and Earn Medical coding Examples for Coders

November 10, 2017December 30, 2017 Jitendra M.Sc CPC

Medical Coding Example Report 1 PREOPERATIVE DIAGNOSIS: Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic. POSTOPERATIVE DIAGNOSIS: Left small saphenous vein insufficiency with left lower extremity varicose veins that are symptomatic. PROCEDURE: Left small saphenous vein radiofrequency ablation. Phlebectomy of left lower extremity varicose veins with 6 incisions. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. OPERATIVE FINDINGS: The patient had a patent left popliteal vein upon completion of the procedure with good compression. She had multiple friable varicosities in the subcutaneous tissues of the…

Sample Surgery Medical report for Medical coders

November 2, 2017December 30, 2017 Jitendra M.Sc CPC

Sample Interventional Vascular Coding Practice charts

PREOPERATIVE DIAGNOSES: Rule out rotator cuff tear of the right shoulder. POSTOPERATIVE DIAGNOSES: 1. Partial thickness tear of supraspinatus, right shoulder. Type II superior labral tear, right shoulder. Degenerative joint disease with chondral injury and multiple loose bodies intraarticularly, right shoulder. OPERATIVE PROCEDURES: ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Minimal. DESCRIPTION OF PROCEDURE: