I can provide you with an example of how a medical coding chart may look like for a surgical procedure:
Patient Name: John Doe Date of Surgery: 04/08/2023 Procedure: Laparoscopic Cholecystectomy
ICD-10-CM Diagnosis Code(s): K80.20 – Calculus of gallbladder with acute cholecystitis without obstruction Z53.09 – Procedure and treatment not carried out due to patient’s decision for other reasons
CPT Procedure Code: 47562 – Laparoscopy, surgical; cholecystectomy
Modifiers: -52 – Reduced services: The surgeon performed a less extensive operation than what was planned.
Anesthesia: CPT Code: 00812 – Anesthesia for all procedures on the lower abdominal area, including laparoscopy; not otherwise specified.
Total time: 2 hours 30 minutes
In this example, the patient underwent a laparoscopic cholecystectomy for calculus of the gallbladder with acute cholecystitis without obstruction. However, the procedure was not completed due to the patient’s decision for other reasons, and the surgeon performed a less extensive operation than what was planned, which is why modifier -52 was used. The anesthesia used was for all procedures on the lower abdominal area, including laparoscopy, and the total time for the surgery was 2 hours and 30 minutes.