Sample Coded Surgery Reports for Medical Coders

Sample Coded Surgery Reports for Medical Coders

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…

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