Patient Name: [Insert patient name here]
Date of Surgery: [Insert date of surgery here]
Procedure performed: [Insert the name of the surgery here]
Surgeon: [Insert name of the surgeon who performed the surgery]
Assistant: [Insert name of the assistant surgeon]
Anesthesia: [Insert type of anesthesia used during the surgery]
CPT Code: [Insert the appropriate CPT code for the procedure]
ICD-10 Diagnosis Code(s): [Insert the appropriate ICD-10 code(s) for the patient’s diagnosis]
Surgical Notes: [Insert any relevant notes or details about the surgery and its outcome]
Complications: [Insert any complications that may have arisen during or after the surgery]
Post-operative Instructions: [Insert any post-operative instructions given to the patient]
Follow-up: [Insert the date and time for the follow-up appointment with the surgeon]
This is just an example of what a surgery medical coding chart may look like. It’s important to note that each patient’s chart will vary based on their individual circumstances and medical history.