Here are a few sample coded surgery reports for medical coders:
Report 1:
Procedure: Laparoscopic Cholecystectomy
Indications: Cholecystitis
Surgeon: Dr. John Smith
Assistant: Dr. Jane Doe
Anesthesia: General
Specimen: Gallbladder
Description of Procedure:
The patient was placed under general anesthesia and positioned supine. Four ports were placed, and the laparoscope was inserted. The cystic duct and artery were identified, clipped, and divided. The gallbladder was dissected free from the liver bed and extracted through the umbilical port. The specimen was sent to pathology for analysis. Hemostasis was achieved, and the ports were removed. The patient was awakened from anesthesia without complication.
ICD-10-PCS Code: 0FT43ZZ (Laparoscopic Cholecystectomy)
Report 2:
Procedure: Total Hip Replacement
Indications: Osteoarthritis
Surgeon: Dr. Sarah Johnson
Assistant: Dr. Michael Lee
Anesthesia: General
Implants: Ceramic Hip Prosthesis
Description of Procedure:
The patient was placed under general anesthesia and positioned laterally. An incision was made over the hip joint, and the hip was dislocated. The femoral head was removed, and the acetabulum was prepared for the implant. The ceramic hip prosthesis was inserted, and the joint was reduced. The muscles and tissues were repaired, and the incision was closed. The patient was awakened from anesthesia without complication.
ICD-10-PCS Code: 0SRF0J9 (Replacement of Right Hip Joint with Ceramic Prosthesis)
Report 3:
Procedure: Colonoscopy with Polypectomy
Indications: Colon Polyps
Physician: Dr. Mary Brown
Anesthesia: Conscious Sedation
Description of Procedure:
The patient was placed under conscious sedation, and a colonoscope was inserted through the rectum. The colon was examined, and two polyps were identified and removed using electrocautery. The specimens were sent to pathology for analysis. The colon was then thoroughly irrigated, and the scope was removed. The patient was awakened from sedation without complication.
ICD-10-PCS Code: 0DJ84ZZ (Colonoscopy with Polypectomy)