Here’s a sample operative report with medical coding:
OPERATIVE REPORT
Preoperative Diagnosis: Left inguinal hernia.
Postoperative Diagnosis: Left inguinal hernia.
Procedure: Laparoscopic left inguinal hernia repair.
Anesthesia: General endotracheal.
Procedure Summary: The patient was brought to the operating room and placed in the supine position. General anesthesia was induced, and the patient was prepped and draped in a sterile fashion. A 10mm umbilical port was placed, and the laparoscope was introduced. Two additional 5mm ports were placed under direct visualization. The peritoneum was opened, and the hernia sac was identified. The sac was reduced, and the left inguinal ring was visualized. A 15cm x 10cm piece of polypropylene mesh was trimmed to size and secured with tacks. The peritoneum was closed with a running 3-0 Vicryl suture. The ports were removed, and the fascia and skin were closed with 4-0 monocryl sutures. The patient was awakened from anesthesia and transferred to the recovery room in stable condition.
CPT code: 49650 – Laparoscopy, surgical, repair of hernia, with or without graft, initial, reducible
ICD-10 code: K40.10 – Unilateral inguinal hernia, with gangrene, not specified as recurrent
Anesthesia code: 00528 – Anesthesia for all procedures on inguinal region, including both femoral and inguinal hernias; radical orchiectomy; urethral suspension, each; complicated or extensive procedures, except when performed with local anesthesia
Pathology report: None
Estimated blood loss: Minimal
Complications: None
Next Follow-up: 2 weeks post-operative.
Dictated by: Dr. John Smith, MD
Transcribed by: Jane Doe, Medical Transcriptionist