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Medical Coding Guide
Learn How to Code
SAMPLE CODED SURGERY CHARTS FOR MEDICAL CODERS PART 16
Jitendra M.Sc CPC February 17, 2022 Sample coded Surgery charts for Medical
coders Part 162022-02-17T13:45:31+00:00 Can you code this, IR procedure, Medical
coding 1 Comment
Buck's Coding Exam Review 2022: The Physician and Facility Certification Step,
1st Edition
Medical Coding Sample Chart 1
Procedure: CERVICAL FACET INJECTION LEFT C5-6 and C6-7
Diagnosis: Cervical Spondylosis
The patient has been referred to the Pain Management Center for cervical facet
injection treatment of chronic axial neck pain. The patient has had long
standing cervical pain thought to be facet joint generated and which has been
refractory to other therapies.
Risks and expected side effects as well as potential benefit of the procedure
were reviewed with the patient, and their voiced concerns were addressed. The
printed consent form was signed and witnessed. Standard time-out procedure was
performed.
The patient was placed in the prone position on the fluoroscopy table and
automated blood pressure cuff and pulse oximeter applied. The skin entry points
for approaching the anatomic target points of the cervical facets of LEFT C5-6
and C6-7.were identified with a 10 degree from perpendicular medial oblique
fluoroscopic view and marked. Following thorough Chlorhexidine preparation of
the skin and draping and 1% lidocaine infiltration of the skin entry points and
subcutaneous tissues, a 3inch 25gauge spinal needle was placed under
fluoroscopic guidance at the anatomic course of each facet targeted. The needles
were advanced in a plane that was coaxial with the axis of the xray path. The
needles were adjusted to remain coaxial and advanced toward the C5-6 and C6-7
facets on the LEFT side using repeated images every 2 to 4 mm of needle
advancement. Upon contact with the needle tip at the surface of the joint space,
a lateral radiograph was then obtained and the needle was advanced just slightly
to penetrate the posterior joint capsule at the C5-6 and C6-7 levels
respectively. The needle tip was in excellent position both from an AP and
lateral plane view. A solution containing 10mg of dexamethasone and 0.5%
bupivacaine was injected using a 3ml syringe into each joint space after
negative aspiration. The patient tolerated the procedure well and at no time was
there any heme, csf, or air aspirated prior to injection.
CPT :64490-LT Injection(s), diagnostic or therapeutic agent, paravertebral facet
(zygapophyseal) joint (or nerves innervating that joint) with image guidance
(fluoroscopy or CT), cervical or thoracic; single level
64491 ;second level (List separately in addition to code for primary procedure)
ICD-10: M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
Read also: Coding guide for Epidural injection CPT codes for coders
Medical Coding Sample Chart 2
COLONOSCOPY REPORT
COLONOSCOPY: With cold snare polypectomy
INDICATIONS: History of a large acing colon polyp that is been recurrent she is
here to reevaluate the polypectomy site
MEDICATIONS: See anesthesia note
DESCRIPTION: The Colonoscopy was explained in detail to the patient prior to the
procedure including risks such as bleeding and colonic perforation. The patient
was informed that in the event of a complication, they may require surgery to
treat the complication. The patient was brought to the endoscopy suite and
placed in the left lateral decubitus position. On external anal exam, there was
no evidence of external hemorrhoids or fissures. On digital rectal exam there
was no palpable masses. A standard Olympus colonoscope was inserted into the
rectum and passed in the usual fashion to the level of the terminal ileum. The
preparation of the colon was excellent with a Boston bowel prep score of 9. The
scope was then slowly withdrawn and careful examination of the entire colon was
performed.
FINDINGS / THERAPY:
Ileum -normal
Cecum -normal
Ascending colon -I do see a large scar from the previous polypectomy site that
is well demarcated with tattoo ink. On the margin of the scar there is a small 3
mm area that may just be granulation tissue although I cannot completely exclude
possibility of a small amount of adenomatous tissue in this area was removed
with a cold snare. The remainder the scar was clearly free of adenomatous tissue
Hepatic flexure -normal
Transverse colon -normal
Splenic flexure -normal
Descending colon -normal
Sigmoid colon -diverticulosis
Rectum -normal
Anal canal -normal
***Withdrawal time 9 minutes
IMPRESSION:
1. Diverticulosis
2. Previous polypectomy site in the ascending colon free of neoplasia with just
a small area of concern that was removed
CPT : 45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
ICD-10 : K57.30 Diverticulosis of large intestine without perforation or abscess
without bleeding
Read also: Coding guide for Ultrasound Guidance CPT codes
Medical Coding Sample Chart 3
Preoperative Diagnosis: Biliary dyskinesia
Postoperative Diagnosis: Biliary dyskinesia
Procedure: Robotic single-site cholecystectomy
Anesthesia: GETA plus 0.25% Marcaine local
Estimated Blood Loss: Scant
Complication: None
Indications For Procedure: He is a 54-year-old gentleman with a several month
history of postprandial fecal urgency and diarrhea. He denied any associated
right upper quadrant or epigastric abdominal discomfort, nausea, vomiting, or
any other associated complaints.
After continued symptoms a follow-up gallbladder ultrasound in december month
was also unremarkable. Follow-up HIDA scan demonstrated a diminished gallbladder
ejection fraction of 19%, suggestive of biliary dyskinesia.
Recommendation was made for an outpatient robotic single-site cholecystectomy.
The procedure, benefits, risks, and alternatives to surgery were discussed in
detail. The patient acknowledged understanding of these discussions and desired
to proceed with surgery as soon as possible.
Procedure In Detail: The patient was brought to the OR, placed in supine
position on the OR table. After the uneventful induction of general endotracheal
anesthesia, abdomen was prepped and draped in a sterile fashion. After
infiltration of skin site with 0.25% Marcaine, a 2.5 cm incision was made within
the base of the umbilicus, carried down through the skin with skin knife through
subcutaneous tissues with Bovie electrocautery. Careful dissection carried down
to the umbilical fascia, which was carefully divided along the full length of
the skin incision with Bovie electrocautery. A da Vinci single-site Gelport was
then carefully introduced through the fascial defect. With the port in place,
CO2 gas infused and adequate pneumoperitoneum was achieved. An 8.5 mm camera
port was then placed through the Gelport. The da Vinci laparoscope was
introduced and visual inspection of abdominal cavity was undertaken. Under
direct visualization, the da Vinci robot was carefully brought in position over
the patient’s right shoulder and docked to the camera port. Under direct
visualization, two curved 5 mm cannulas were the placed through the Gelport and
docked to the robot. A 5 mm accessory port was then placed through the Gelport.
A 5 mm grasper was then used to carefully grasp and retract the gallbladder
fundus providing good exposure of the infundibulum and area of Calot’s triangle.
At this point, I broke scrub and assumed control of the robot at the control
console. Using a fundus grasper and hook cautery, careful dissection was
undertaken beginning at the infundibulum and carried down to Calot’s triangle as
the cystic duct and cystic artery were identified and delineated. The
gallbladder infundibulum was then carefully mobilized both medially and
laterally providing good critical view of safety to ensure both structures
terminating within the gallbladder wall. Each structure was then triply ligated
with medium large Weck clips and divided. The gallbladder was then carefully
dissected free of the hepatic bed using the hook cautery. Once the gallbladder
was fully freed and mobilized, careful inspection was made to confirm hemostasis
and bowl integrity at the resection site. When this was confirmed, the site was
irrigated and reinspected. When hemostasis and bowl integrity were again
confirmed, the robotic instruments were removed and the robot was undocked and
moved away from the patient table.
After scrubbing back into the procedure, the gallbladder was carefully removed
en bloc with the Gelport. Photodocumentation of the specimen was obtained and
the specimen was was sent for permanent section evaluation. Careful inspection
made to confirm hemostasis and bowl integrity at the umbilical facial site. When
this was confirmed, the site was irrigated and reinspected. The fascia was then
carefully reapproximated using #1 Stratafix in a running fashion. Additional
0.25% Marcaine was then placed around the perimeter of the fascial closure. The
subcutaneous tissues followed by 4-0 Monocryl in a running subcuticular fashion
to approximate the skin. The wound site was clean and dried and Dermabond
dressing was applied. The patient tolerated the procedure well. There were no
complications. All laparotomy pads, sponge, needle, and instrument counts were
correct x2 at the end of the case. The patient was extubated in the OR and taken
to recovery room in stable condition.
CPT : 47562 Laparoscopy, surgical; cholecystectomy
ICD-10 : k82.8 Other specified diseases of gallbladder
Read also: Coding Guide for Arthrogram CPT codes for coders
Medical Coding Sample Chart 4
Preoperative Diagnosis: Osteoarthritis right hip, right hip pain, right lower
extremity radiculopathy
Postoperative Diagnosis: Same
Procedure: Right intraarticular hip injections with fluoroscopy
Anesthesia: Local anesthesia with I.V. sedation per Department of Anesthesia due
to complications associated with anxiety and low pain threshold due to
complications associated with severe chronic pain.
Complications: None
Procedure Note: Upon explanation of the risks and benefits the patient was
transitioned to the procedure table. After adequate sedation was obtained by the
department of anesthesia, while the patient was in the supine position the right
hip was prepped in standard fashion for an anterior approach for intraarticular
hip injection with Betadine solution. Subsequently appropriate sterile drapes
were placed.
The skin and deeper tissues were anesthetized with 0.25% neutralized Marcaine
through which a 22-gauge spinal needle was advanced with aspiration until the
tip of the needle came to lie at the ridge of the acetabular rim. At this point,
½]cc of Omnipaque 300 was injected. Adequate Contrast spread was noted around
the acetabular rim, at which point 40 mg of Depo-Medrol, followed by 5 cc of
0.25% neutralized Marcaine was injected. Procedure was performed on the right.
The needle was removed. Band-Aid was placed over the puncture site. Right hip
was manipulated in multiple positions. The patient was taken to postanesthesia
recovery and found to be in satisfactory condition with improvement of her right
hip discomfort.
CPT : 20610-RT Arthrocentesis, aspiration and/or injection, major joint or bursa
(eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration,
injection, localization device) (List separately in addition to code for primary
procedure)
ICD-10 :M16.11 Unilateral primary osteoarthritis, right hip
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ABOUT JITENDRA M.SC CPC
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