Medical coding profession is growing everyday. Many professionals are taking medicalcoding as their career. Now, with the implementation of ICD 10 codes, the requirement for coders has increase significantly. Hence, you can have lot of opportunities as medical coder now and also in future. The salary of a medical coder in coding is also very good compared to other profession. I am just here to share some medical coding examples or sample charts which might help professionals who are interested in medical coding. Just analyse the document reports in the medical coding examples and learn how to interpret them. If you are able to solve these sample medical coding reports, you can then start preparing for medical coding certification exams. So, let us go through these sample charts and checkout how to code the ICD 10 and CPT code for them.
Medical coding Examples 1
VAS/SP CENTRAL VENOUS CATHETER
CLINICAL DATA: Pancreatic mass with metastatic disease
EXAM:
TUNNEL POWER PORT PLACEMENT WITH SUBCUTANEOUS POCKET UTILIZING
ULTRASOUND \T\ FLUOROSCOPY
ANESTHESIA/SEDATION:
Versed 1 mg., 25 mcg IV fentanyl
Total Moderate Sedation Time
30 minutes .
CONTRAST: None
MEDICATIONS:
1 g IV Ancef
FLUOROSCOPY TIME: 48 seconds
COMPLICATIONS:
None
PROCEDURE:
After written informed consent was obtained, patient was placed in
the supine position on angiographic table. The right neck and chest
was prepped and draped in a sterile fashion. Lidocaine was utilized
for local anesthesia. The right internal jugular vein was noted to
be patent initially with ultrasound. Under sonographic guidance, a
micropuncture needle was inserted into the right IJ vein Ultrasound
and fluoroscopic image documentation was performed. The needle was
removed over an 018 wire which was exchanged for a Bentson wire.
This was advanced into the IVC. An 8-French dilator was advanced
over the Bentson.
A small incision was made in the right upper chest over the anterior
right second rib. Utilizing blunt dissection, a subcutaneous pocket
was created in the caudal direction. The pocket was irrigated with a
copious amount of sterile normal saline. The port catheter was
tunneled from the chest incision, and out the neck incision. A
peel-away sheath was advanced over the Bentson wire. The port
catheter was cut to 18.5 cm length and inserted through the
peel-away sheath. The peel-away sheath was removed. The catheter was
then attached to the port reservoir in the reservoir placed in the
port pocket. The chest incision was closed with 4-0 Vicryl
interrupted stitches for the subcutaneous tissue and a running of
4-0 Vicryl subcuticular stitch for the skin. The neck incision was
closed with a 4-0 Vicryl subcuticular stitch. Derma-bond was applied
to both surgical incisions. The port reservoir was flushed and
instilled with heparinized saline. No complications.
FINDINGS:
A right IJ vein Port-A-Cath is in place with its tip at the
cavoatrial junction.
IMPRESSION:
Successful 8 French right internal jugular vein power port placement
with its tip at the SVC/RA junction.
CPT - 36561
Ultrasound Guidance - 76937
Fluoroscopic guidance-77001
ICD 10 - Z45.2
Medical coding Examples 2
MRI/MRI KNEE LEFT WO
CLINICAL DATA: Left knee pain, radiates the left thigh
EXAM:
MRI OF THE LEFT KNEE WITHOUT CONTRAST
TECHNIQUE:
Multiplanar, multisequence MR imaging of the knee was performed. No
intravenous contrast was administered.
COMPARISON: None.
FINDINGS:
MENISCI
Medial meniscus: Complex tear within oblique component extending to
the inferior articular surface, involving the posterior horn and
body of the medial meniscus.
Lateral meniscus: Intact.
LIGAMENTS
Cruciates: Intact ACL and PCL.
Collaterals: Medial collateral ligament is intact. Lateral
collateral ligament complex is intact.
CARTILAGE
Patellofemoral: No chondral defect.
Medial: High-grade partial-thickness cartilage loss of the medial
femoral condyle. Full-thickness cartilage loss of the medial tibial
plateau. Mild subchondral marrow edema in the periphery of the
medial tibial plateau.
Lateral: Mild partial-thickness cartilage loss of the medial aspect
of the lateral tibial plateau and lateral femoral condyle.
Joint: Small joint effusion. Minimal edema in Hoffa's fat. No plical
thickening.
Popliteal Fossa: No Baker cyst. Intact popliteus tendon.
Extensor Mechanism: Intact.
Bones: No focal marrow signal abnormality. No fracture or
dislocation.
IMPRESSION:
1. Complex tear within oblique component extending to the inferior
articular surface, involving the posterior horn and body of the
medial meniscus.
2. Medial and lateral femorotibial compartment cartilage
abnormalities most severe in the medial femorotibial compartment as
described above.
CPT- 73721-LT
Medical coding Examples 3
RAD/DG LUMBAR SPINE COMPLETE 4+V
CLINICAL DATA: Lower back pain. No known injury.
EXAM:
LUMBAR SPINE - COMPLETE 4+ VIEW
COMPARISON: 03/07/2008
FINDINGS:
There is disc height loss at numerous levels, most notably at L2-3
and L4-5. There is no spondylolisthesis or spondylolysis. No acute
fracture. No suspicious lytic or blastic lesions are identified.
IMPRESSION:
1. Mild degenerative changes.
2. No evidence for acute abnormality.
CPT – 72110
ICD – M54.5 for Low back pain
Medical coding Examples 4
US/US BREAST CORE BIOPSY
CLINICAL DATA: 51-year-old female presenting for ultrasound-guided
biopsy of a mass in the left breast initially seen on CT.
EXAM:
ULTRASOUND GUIDED LEFT BREAST CORE NEEDLE BIOPSY
COMPARISON: Previous exam(s).
FINDINGS:
I met with the patient and we discussed the procedure of
ultrasound-guided biopsy, including benefits and alternatives. We
discussed the high likelihood of a successful procedure. We
discussed the risks of the procedure, including infection, bleeding,
tissue injury, clip migration, and inadequate sampling. Informed
written consent was given. The usual time-out protocol was performed
immediately prior to the procedure.
Using sterile technique and 2% Lidocaine as local anesthetic, under
direct ultrasound visualization, a 12 gauge spring-loaded device was
used to perform biopsy of small mass in the left breast at 12
o'clock using a lateral approach. At the conclusion of the procedure
a ribbon shaped tissue marker clip was deployed into the biopsy
cavity. Follow up 2 view mammogram was performed and dictated
separately.
IMPRESSION:
Ultrasound guided biopsy of small mass in the left breast at 12
o'clock. No apparent complications.
CPT - 19083-LT
ICD – N63 for Breast Mass or Lump
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