sample charts - Medical Coding Guide

Sample Nephroureteral Catheter Placement Report for Medical coders

September 18, 2023October 28, 2023 Jitendra M.Sc CPC

Report 1 BILATERAL NEPHROSTOGRAMS PLACEMENT OF NEPHROURETERAL CATHETERS MODERATE CONSCIOUS SEDATION, FLUOROSCOPY CAN ULTRASOUND GUIDANCE AND UTILIZATION OF A STERILE SURGICAL TRAY.: INDICATION: Bilateral nephrolithiasis TECHNIQUE: Ultrasound and fluoroscopy guidance, fluoroscopy time is 14.7 minutes COMPARISON: None. FINDINGS: Having obtained informed consent prepping and draping the flanks in the usual aseptic fashion 1% lidocaine was utilized for local infiltration. Access to the lower pole collecting system of the left kidney is obtained utilizing ultrasound guidance an AccuStick system. Wire and catheter advanced into the collecting system of the left kidney…

Medical coding Examples or Sample Charts for Coders

June 25, 2023October 25, 2023 Jitendra M.Sc CPC

Since, we are here to learn about medical coding, we have to go through the charts as well. The medical coding charts are little difficult to understand in the beginning but once you become in reading the report then their won’t be any problem. Some of the medical coding examples or sample charts i am going to share with you in the article. Just go through the articles and check the CPT and ICD 10 codes assigned to them. If you able to understand these medical coding examples or scenario…

Sample Operative Report for Medical coders

June 2, 2018August 26, 2018 Jitendra M.Sc CPC

PREOPERATIVE DIAGNOSIS: Torn right medial and lateral menisci. POSTOPERATIVE DIAGNOSES: Torn right medial and lateral menisci, degenerative arthritis of medial femoral condyle, and chondromalacia patella. PROCEDURES PERFORMED: DISPOSITION: The patient tolerated the procedure very well. OPERATIVE PROCEDURE: The patient was brought to the operating room. He was properly identified and correct extremity was marked. The permit was checked. The patient received 600 mg of IV Cleocin as prophylaxis due to penicillin allergy. General anesthesia was administered and the right knee and right lower extremity were prepped and draped in 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: