Sample report for Inpatient Coding Training


Sample Report 1- Inpatient Coding Training


PROCEDURE: Esophagogastroduodenoscopy with esophageal dilation.

INDICATIONS:  Dysphagia history of esophageal stricture weight loss nausea.

INSTRUMENTS: Olympus video upper endoscope.

MEDICATIONS: Versed 2  mg IV and Demerol 25 mg IV.

PHYSICAL EXAMINATION: GENERAL: The patient was in no distress. VITAL SIGNS: Stable.
CHEST: Clear  CARDIAC: Regular rate and rhythm. ABDOMEN: [Nondistended,
nontender]. NEUROLOGIC: The patient was alert and oriented.

DESCRIPTION OF PROCEDURE: Mr. Goodwin was placed in a left lateral position and IV sedation
was given in small incremental doses for the patient's comfort for moderate sedation. The throat was anesthetized with
Cetacaine spray.The endoscope was advanced without difficulty into the duodenum.

ESOPHAGUS: Esophagus the GE junction was  well distended. The
distal esophagus was not inflamed.  The esophagus was slightly tortuous..

STOMACH: [Stomach had minimal scattered erythema present hiatal hernia was present

DUODENUM: The duodenum was normal.

The endoscope was removed and Mr. Goodwin was placed in a sitting position.  A 50 and 52 French Maloney dilator was passed in the stomach with no resistance.  There was no blood on withdrawal of the dilators.
The patient tolerated the procedure well.

IMPRESSION:
1.  Empiric esophageal dilation to 50 French
2.  Gastritis
3. Slightly tortuous esophagus

ICD 10 PCS code0D758ZZ (dilation of Esophagus)
Dilation of Esophagus, Via Natural or Artificial Opening Endoscopic


Sample report for Inpatient Coding Training



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Sample Report 2 - Inpatient Coding training 


Knee Replacement

PREOPERATIVE DIAGNOSIS:  Right knee degenerative arthritis.

POSTOPERATIVE DIAGNOSIS:  Right knee degenerative arthritis.

PROCEDURE PERFORMED:  Right total knee replacement.


ANESTHESIA: General endotracheal anesthesia.

TOURNIQUET TIME:  61 minutes.

IV FLUIDS: Crystalloids

ESTIMATED BLOOD LOSS:  100 ml.

SPECIMENS: None.

COMPLICATIONS: None.

IMPLANTS:
1. Titanium Stryker total knee replacement system size 6 femoral component, CR.
2. CR tibial base plate with a titanium stem size 7.
3. A 32-mm asymmetric polyethylene insert patella.
4. 11 mm polyethylene insert


BRIEF HISTORY: JAMES HUBERT HARRIS JR is a 65 year-old M patient.  Patient had complaints of right knee  pain.  X-rays showed evidence of advanced right knee tricompartmental osteoarthritis.  Patient had prior of sleep tried activity modification, physical therapy, oral anti-inflammatory medication as well as intra-articular cortisone steroid injection.  The patient understood that the risks involved in surgery include, but are not limited to risk of infection, damage to the nerve, blood vessel, need for further surgery, continued pain, DVT, pulmonary embolism, stroke, and even death. The patient volunteered an informed consent. The patient was seen on the day of surgery in preop holding area.  Surgical site was marked. The patient was then wheeled back into the operating room.

DESCRIPTION OF THE PROCEDURE: The patient was placed supine on the operating table. General endotracheal anesthesia was administered. Proper time-out was performed. 2 g of IV Ancef were given.  Right lower extremity tourniquet above the knee was applied.  Right lower extremity was scrubbed with Betadine brush followed by prep with ChloraPrep. We started with a midline approach. Skin and deep fascia were incised. Medial and lateral flaps were created. We then performed a medial parapatellar arthrotomy. The patella was everted.  Examination of the knee showed advanced tricompartmental osteoarthritis. We then proceeded with the preparation of the distal femur. Intramedullary femoral cutting guide was used. This was set at 5 degrees of valgus. After making the distal femoral cut, the distal femur was sized at size 6. We then used a size 6 cutting block and made the anterior femur, posterior femur, anterior chamfer, and posterior chamfer cuts.  We then proceeded with the preparation of the proximal tibia. The medial and lateral menisci as well as anterior cruciate ligaments were taken down. We performed recess of the posterior cruciate ligaments. The proximal tibial cut was made using the extramedullary tibial cutting guide. We then used a spacer to see our flexion and extension gaps, and these were symmetric.  We then sized the proximal tibia at size 7. We used a size 7 tibial preparation guide and prepared the proximal tibia. We then trailed with size 6 femur, size 7 tibia and found adequate stability.  We then proceeded with the preparation of the patella. Patella was sized down to size 14 mm remaining patella. We then used an eccentric patellar trial. We used a 11-mm poly insert trial.  The knee was carried through range of motion, and the knee was stable with good mechanical axis. We then proceeded with removal of the trial components. The bone cut area was irrigated with normal saline. We then used bone cement to fix the tibial component with the stem. This was followed by placement of the femoral component and the patellar component. The cement was allowed to settle.  Excess cement was removed. The 11-mm tibial polyethylene insert was used. The tourniquet was released. Hemostasis was achieved. The wound was closed in layers. A 1/8-inch Hemovac drain was used. The patient tolerated procedure very well and was taken to the recovery room in a stable condition.

DISPOSITION: The patient would be admitted to the Orthopedic Service. The patient would be starting on continuous passive motion machine in the recovery room. The patient would then start physical therapy this afternoon. The patient would be started on [Aspirin 325mg Bid]  starting tomorrow.

ICD 10 PCS code – 
0SRC0J9 Replacement of Right Knee Joint with Synthetic Substitute, Cemented, Open Approach


Sample Report 3 - Inpatient Coding Training 


PREOPERATIVE DIAGNOSIS:  Left knee end-stage degenerative joint disease.

POSTOPERATIVE DIAGNOSIS:  Left knee end-stage degenerative joint disease.

PROCEDURE:  Left total knee arthroplasty.

FINDINGS:  End-stage tricompartmental osteoarthritis.

SPECIMENS REMOVED: Portions of the distal femur, proximal tibia, and posterior patella.

EBL:  50 mL.

ANESTHESIA: General.

COMPLICATIONS: None.

TOURNIQUET TIME:  46 minutes at 250 mmHg.

IMPLANTS: Stryker Triathlon total knee system, metal size 3. Tibial base plate; metallic size 2 cruciate retaining femur; size 3 x 13 mm deep dish polyethylene insert; 29 x 9 mm asymmetric patella button.

SIGNIFICANT HISTORY, INDICATIONS, AND CONSENT:  Rhonda is a 58-year-old female with longstanding history of left knee pain recalcitrant to conservative treatment secondary to osteoarthritis. After discussing risks, benefits, and alternatives of non-operative treatment and operative intervention, the patient wished to proceed with surgical intervention and consent was obtained with potential benefits of improved knee pain and improved function.

OPERATION IN DETAIL: The patient was seen in the preop holding area. The left lower extremity was signed. Consent was reviewed, questions were answered, H and P updated. SCD was placed on the right lower extremity. The patient was taken to the operative room, placed in supine position on the operative table, anesthesia placed monitoring devices and performed intubation. Tourniquet was placed high on the left lower extremity with the left lower extremity being sterilely prepped and draped in the usual orthopedic fashion. Time-out was performed. The patient received prophylactic
antibiotics. Consensus was reached amongst participants in the OR suite.

Esmarch was used to exsanguinate the limb. Tourniquet raised to 250 mmHg. Standard anterior approach to the knee was performed incising sharply through skin and then performed a medial parapatellar arthrotomy. The superficial MCL was carefully released  subperiosteally of the proximal tibia medially. We then released anterior soft tissue structures, everted the patella and gently flexed the knee, being careful to avoid injury to the patellar tendon distally. Next, intramedullary guide was placed within the femur intramedullary canal. We then performed a distal femoral cut removing 8 mm, 5 degrees valgus.

After a distal cut was made, this was sized using a posterior condyle referencing system to be a size 2 femur, size to cutting block was placed and distal femoral cuts were made in standard fashion. ACL was removed and PCL gently retracted.  End-stage tricompartmental osteoarthritis with severe medial arthrosis and varus malalignment was noted.

Extramedullary guide was placed for a tibial cut, which was perpendicular to the tibia and in line with the tibial crest. Once this was placed, we removed 7 from the high side with 2 mm removed from the more worn plateau. After tibial cut was made, we checked our alignment and found this to be quite appropriate. We then performed flexion-extension gap measuring, and again addressed our soft tissue balancing to appropriately balance the knee.  The knee had laxity laterally and so the deep MCL was trephinated and a larger polyethylene insert sized.  Our tibial baseplate was sized and rotated in line with the medial 1/3 of the tibial tubercle. This was provisionally pinned and attention turned to our patella cut. Our patella was then sized, removing approximately 7 mm of bone after measuring 21 mm. 14 remained, this was sized to a 29 mm patella and the patella was drilled.  Components were placed and provisional implants were found to be acceptable in regards to range of motion and ligamentous stability  throughout the motion arc.  We then performed our fin cut and drilled our femoral implant. Provisional implants were then removed.  The cut surfaces were then thoroughly irrigated and dried for cementation.

Cementation was being mixed on the back table while we injected Exparel within the deep structures of the knee being careful to aspirate prior to injection. 0.25% Marcaine was also injected at this time in standard fashion. We then began cementation of our tibial, femoral, and patellar components in standard fashion. After these were cemented and held until cement had hardened, excess cement was removed.  Range of motion and stability were found to be appropriate. We then allowed tourniquet to be released and immaculate hemostasis was performed with Bovie cautery.  Medial parapatellar arthrotomy was closed at the superomedial border of the patella with #1 Ethibond in an interrupted fashion. The remainder of the arthrotomy closed with #1 Vicryl in a watertight closure. We used 2-0 Vicryl for subcutaneous closure and staples for skin. Sterile soft tissue dressing was placed. The patient was placed in the TED hose aroused by Anesthesia and taken to postanesthesia care in stable condition.

PLAN: The patient will be admitted to Orthopedic Service. Begin CPM in the PACU. Radiographs will be taken in the PACU. 24 hours perioperative antibiotics will be given with 14 days of DVT chemoprophylaxis, and physical therapy beginning this evening

ICD 10 PCS code: 
0SRD0J9 Replacement of Left Knee Joint with Synthetic Substitute, Cemented, Open Approach


 Sample Report 4 - Inpatient Coding training


PREOPERATIVE DIAGNOSIS: term IUP, failure to progress
POSTOPERATIVE DIAGNOSIS: term IUP, failure to progress
PROCEDURE: primary low transverse cesarean section

ANESTHESIA: spinal
ESTIMATED BLOOD LOSS:600 ml
COMPLICATIONS:none
DRAINS:foley to gravity
SPECIMENS:placenta to path
FINDING: viable female infant
INDICATIONS FOR PROCEDURE: lack of cervical change, inability to rupture membranes
DESCRIPTION OF PROCEDURE:


PREOPERATIVE DIAGNOSIS: A [39.6]-week gestation

POSTOPERATIVE DIAGNOSIS: A [39.6]-week gestation

PROCEDURE: Primary low-transverse cesarean section.


ANESTHESIA: [spinal]

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: 600 mL.

FINDINGS: Live-born [female] infant, Apgars [8] at 1, [9] at 5, [7] pounds [3] ounces.  Clear fluid and intact placenta. Normal uterus, ovaries, and fallopian tubes bilaterally.

PROCEDURE IN DETAIL: The patient was taken to the operating room and after adequate spinal anesthesia was achieved, she was prepped and draped as a sterile field. A Foley catheter had been previously placed. A Pfannenstiel incision was made 2 fingerbreadths above the pubic symphysis and
carried down to the fascia sharply. The fascia was incised in midline with a scalpel and extended laterally with Mayo scissors. The fascia was dissected off the underlying rectus muscles sharply. The rectus muscles were separated. The peritoneum was isolated and entered. The peritoneal incision was extended superiorly and inferiorly with Metzenbaum scissors, bladder blade was placed.
The peritoneum overlying the lower uterine segment was incised with Metzenbaum scissors to creat a  bladder flap behind on which the bladder blade was placed. A 1 centimeter incision was made in lower uterine segment with a scalpel and extended laterally in a blunt fashion. The infant was
delivered from the vertex presentation and suctioned on the maternal abdomen. The umbilical cord was clamped and cut. The baby was handed off to the awaiting pediatrician. The placenta was manually delivered and the uterus was externalized. The uterine cavity was wiped clean with a lap pad and noted to be devoid of any retained placental fragments. The uterine incision was closed with a running locking #1 chromic suture and a second #1 imbricating running suture. The uterus was then returned to the abdomen and irrigated with copious amounts of sterile saline, hemostasis was noted to be adequate at that time. A wedge of interceed was placed over the uterine incision.
The rectus muscles and peritoneum were reapproximated using running 2-0 vicryl sutures. The rectus fascia was closed with a running 0 Vicryl suture.
Subcutaneous tissue was closed with running 2-0 vicryl suture. The skin incision was closed with a subcuticular 4-0 moncryl suture. Once sponge and instrument counts were correct x3. The patient was taken to the LDRP in stable condition. The baby was also brought to the LDRP. 

IVF: 2100 ml
UOP 550 ml

ICD 10 PCS:
 10D00Z1 – Extraction of Products of Conception, Low Cervical, Open Approach
3E033VJ –  Introduction of Other Hormone into Peripheral Vein, Percutaneous Approach 
3E0P7GC - Introduce of Oth Therap Subst into Fem Reprod, Via Opening

  

Sample Report 5 - Inpatient Coding training 


PREOPERATIVE DIAGNOSIS:
1. Fibroid uterus
2. Menorrhagia

POSTOPERATIVE DIAGNOSIS: Same

PROCEDURE: Total abdominal hysterectomy and bilateral salpingectomy

ANESTHESIA: General.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS:  650 mL.

URINE OUTPUT: 500 mL of clear urine drained at the end of procedure.

SPECIMEN: Uterus, cervix and bilateral tubes, specimen weighed greater than 1078 g

PROCEDURE IN DETAIL: The patient was taken to the operating room, where she was prepped and draped in a sterile fashion. A Pfannenstiel skin incision was made through an old C-section scar and carried through to the underlying layer of fascia. The fascia was incised in the midline and this incision was extended laterally with the use of the Mayo scissors. The superior aspect of the
fascial incision was grasped with Kocher clamps, tented up, and the rectus muscles were dissected off bluntly and with the Mayo's. This procedure was repeated on the anterior aspect of the fascial incision. The muscles and peritoneum were separated in the midline using hemostats and entered
Sharply using the Metzenbaum scissors. This incision was extended superiorly and inferiorly with the use of the Metzenbaum scissors. Once intraperitoneal position had been verified, the specimen was palpated and noted to
be a large bulky fibroid uterus.  The uterus was delivered through the abdominal cavity.  Due to the size of the uterus it was not possible to place a self-retaining retractor. The ovaries were inspected and noted to be normal in appearance. The utero-ovarian ligaments were clamped, cut, and suture ligated, and the uterus was freed from the ovaries bilaterally.  The tube on the right side remained attached to the specimen however tube on the left side had to be cut from the specimen due to visualization.  The broad ligament was clamped, cut, and suture ligated sequentially and the bladder flap was created anteriorly. The cervix was sequentially clamped, cut, and ligated.  Right angle clamps were placed was the bottom of the cervix and this area was cut and suture ligated.  The edge of the cervix was noted on the left side so the cervix was hugged using the Jorgenson scissors and the specimen was amputated from the vaginal cuff. The vaginal cuff was closed using #0 Vicryl and figure-of-eight stitches.  Attention was then turned to the left tube and this was removed after clamping cutting and suture-ligated, and then the pelvis was irrigated.  There appeared to be a small area of bleeding on the right side so to visualize this the bowels were packed away with moist lap sponges.  There is noted to be bleeding on the right ovary.  This area was made hemostatic using figure-of-eight stitches.  After good hemostasis was noted, the moist lap sponges were removed from the abdominal cavity, and the sponge count was correct.  Ureters were palpated bilaterally to be intact.  The peritoneum was closed using 2 0 Vicryl in a running fashion.  The fascia was closed using #0 PDS in a running fashion, subcutaneous tissue was closed using 3 0 plain gut in a running fashion.  The skin was closed using 4 0 Monocryl in a subcuticular stitch with Dermabond on top.  The procedure was ended and the patient was brought to recovery room in stable condition.

ICD 10 PCS
0UT90ZZ  Resection of Uterus, Open Approach
0UTC0ZZ  Resection of Cervix, Open Approach
0UT70ZZ   Resection of Bilateral Fallopian Tubes, Open Approach

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