coding for surgical cases can be intimidating but it doesn't have to be today i have a sample operative report that we can go through together step by step and i can show you how to dissect the operative report hey there i'm victoria i'm a medical coder auditor educator and content creator and on my channel i provide tips tricks and tutorials to help you be successful in a medical coding career so let's take a look at this operative report [Music] so this is a surgical operative report for a patient that has a facial fracture it's not too bad a page and a half and what we do is we usually start in our surgical operative reports they have the pre-op and post-operative diagnosis procedure anesthesia fluid blood loss any hardware if this is a service that wouldn't involve hardware you wouldn't see that caption on it usually specimens any complications condition of the patient and then the indications for the procedure kind of the why are we doing this and then what happened so this is the why what happened when we look at our pre-op and post-op diagnoses we're going to code based off of our post-operative diagnosis we also have to look if there was a specimen so say maybe this was a patient who is coming in for something like a cholecystectomy they're removing the gallbladder we want to check the path report for that specimen because that's going to have our final diagnosis on it that it's going to say definitively what was wrong with that gallbladder was it gallstones was it cholecystitis what was going on that with that specimen there may also be things in the post-operative diagnosis though as well that we want to include now of course if we have something here like stomach pain and then this the specimen comes back that it's stomach cancer then we would code the stomach cancer but that pain would be a sign or a symptom we wouldn't include any signs or symptoms of that definitive diagnosis so in this one the pre-op and post-op diagnoses are the same because they probably did an x-ray on this patient already ahead of time to determine what kind of fractures this patient had so this patient had bilateral open mandibular fracture open left angle and open symphysis fracture and as we do the diagnosis coding on this i'll break this part down a little bit more now here's our procedure heading we can take a look at this and use it as a good jumping off point for how to code this service but everything that's in there has to be validated in this description of this service so if it says up here that they did a plural biopsy but you go down here and there's no description stating that they they biopsied the pleura then you can't code for it it has to be validated in the actual description saying that they did that procedure sometimes there may be additional things in the body of the operative report that you can code for additionally sometimes they'll list things in these procedures that are bundled um lysis of adhesions is a big one or explorations oftentimes those are bundled into a more major procedure that was performed so they might be included as an inherent part of a larger procedure that was done one of the things i like to do if there's going to be multiple codes so say maybe the provider said i did a license of adhesions and a debridement and some sort of surgery as well and i'm like i think those first couple are probably going to bundle in code them out and check them in the cci checker because sometimes they might be included sometimes they're not although the longer you work in a certain specialty with these types of surgical procedures you'll start getting that feel for what codes are bundled in and start maybe making yourself some reference sheets and so forth to speed up your coding process here's our anesthesia general anesthesia via nasal endotracheal intubation we have two liters of crystalloid fluids estimated blood loss was minimal no hardware no specimens no complications the patient was extubated to pack you in good condition so the indications for procedure sometimes these will have additional diagnoses in them so it's good to check these out because sometimes they will have maybe a comorbid condition that we also want to capture let's take a look at this one patient is a 17 year old female who has two days status post an altercation in which she sustained multiple blows to the face she was worked up on friday night two days earlier at hospital was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call patient was worked up initially on initial exam it was noted that she had a left v3 paresthesia on her initial exam doesn't say that she still has it she had a gross male on the facial ct and panoramic x-ray it was noted to be a displaced left angle fracture and non-displaced symphysis fracture and that looks to be what we kind of have here as well alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room to undergo general anesthesia to have a closed reduction of her fractures risks benefits and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother now one thing i will notice is while on some of this doesn't pertain to coding these are things that clinically need to be in the surgical report and are just good clinical things to know so even though we personally might not as coders use it for abstraction purposes it is very important that they're in there so description of procedure patient was taken to the operating room number four at the hospital and laid in the supine position on the operating room table monitor was attached and general anesthesia was induced with iv anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics patient was prepped and draped in the usual oral maxillary surgery fashion surgeon approached the operating table in sterile fashion approximately 10 milliliters of 2 percent lidocaine with 1 to 100 000 epinephrine was injected into the oral vestibule in a nerve block fashion a moistened ratex sponge was placed in the posterior oral pharynx and the mouth was prepped with paradex mouth rinse scrubbed with a toothbrush paradox was evacuated with a yanker suction eric archbars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24 gauge surgical steel wire so they're wiring things here so you can that might be an important thing here they're doing surgical steel wires on the teeth and they're doing these eric arch bars patient was then manipulated up and the maximum intercuspation and noted to be reproducible the throat was packed and then removed patient was remanipulated so they're manipulating up to the maximum intercuspation and secured with interdental elastics at this point in time the procedure was determined to be over because it was extubated and transferred to the pacu in good condition one of the first things i kind of want to draw your attention to here is let's take a look at this operative report so we have here an open fracture open fracture open fracture but what type of fracture repair did we do closed so this type of fracture doesn't always correlate with the type of treatment you can have an open fracture but a closed treatment so don't get tripped up on that these fractures are going to be coded as open fractures the treatment the cpt code is going to be coded as a closed reduction of the mandible fracture so the mandible is the lower part of your jaw so also this mmf so this is why it's kind of important to know some of your medical terminology here you know your abbreviations and of course we can go in and we can google this if you go into google and say what is mmf it will tell you that mmf is maxillomandibular fixation meaning that they are basically what they did in the description they are wiring these things back together so the fractures were open but this was a closed reduction and you can tell it was a closed reduction because the provider never said that he did an incision into the patient right there was nothing in here saying that he incised into the patient's mandible and was treating the fracture that way it was all closed there was no opening of the patient that was in this description of the procedure so that is consistent with what was done here this closed reduction of the mandible fracture with mmf if this was a case i was looking at in an exam i would probably just go ahead and look at this procedure code this see if that's one of the options and then just kind of quick survey and verify in the body of the operative report because on the exam you know time is of the essence and you want to quickly go through things as fast as you can when you're actually coding of course you want to keep up with your productivity but you still have to read through the operative report to make sure that you're not missing anything so we have here definitely through what we've seen here they did the manipulation they were doing surgical steel wire arch bar so this was validated in here we we definitely did the closed reduction of the mandibular fracture with the mmf so how do we code for this you could go on your cpt index and probably look up fracture i personally when i'm doing surgical coding like to go through the chapter headings so i would go right to my section that says surgery musculoskeletal and i'm going to look for so maxilla so maxilla's in the skull and we go head to toe usually in our surgeries meaning that the codes that you're going to see first are going to be at the top of your body and then downward so we're going to go the codes are going to go from head to neck to back to flank so we're going from top to bottom of your body in the order for the cpt codes so here's our head fracture and other dislocations two one three zero through two one four nine seven and that starts at page 149. so again we're looking for a closed reduction with fixation of the mandible so we have here nasal fractures nasal septal nasal ethmoid nasal ethmoid nasal maxillary we're getting closer maxillary is the upper jaw um cranial malar open treatment of orbital floor those are tough fractures fracture of orbit maxillary craniofacial separation we're doing close treatment of mandible or maxillary alveolar ridge fracture nope we have this is an open so we don't want that we want to close treatment because we had open fractures but closed treatment so let's get down a little closer here and we've got closed treatment of mandibular fracture without manipulation and with manipulation but that doesn't encompass the uh fixations that we did here we have close treatment of mandibular fracture with interdental fixation and you can see that we did the interdental fixation here that's all these parts that we talked about where we're doing the surgical steel wire on the posterior teeth right so that's the code that we're looking for here for our procedure which is two one four five three i actually have a mark there from a different case i was coding a couple weeks ago where this was actually the patient's outcome now if this is something you're doing in practicode or in your studies or anything basically but taking the exam and you want to kind of double check what you're doing one thing i used to do when i wasn't 100 certain is i would just type the cpt code into my encoder program 21453 and look at the lay description and see if what they're describing in the lay description matches what was in my operative report the provider treats a fracture of the mandible or lower jaw to repair damage caused by blunt force trauma to the face he uses a device that connects the teeth to secure the fractures in place while it heals and then it gives you some information about terminology and additional information kind of reiterates it looks like here close fracture doesn't automatically require closed treatment but let's get back to those diagnoses so we're going to switch from our cpt to our icd-10-cm book by the way if you're enjoying this type of content i would highly encourage you to subscribe and hit the notification bell so you can get alerts when i post new episodes we have a bilateral open mandible fracture open left angle and open symphysis fracture so the left angle and symphys fracture are also types of mandible fractures we have bilateral open mandible open left angle and open symphys fracture so if we go here to bilateral mandible fracture mandible mandible mandible so here we have our mandible there is our just general mandible code if we don't have a more definitive diagnosis and then actually let me zoom you guys in here so we can see a little bit better we have angle of jaw and then we also have down here the other one the symphys so let's see we have the bilateral mandible we have the angle and we have the symphys so let's just jot these three down here mandible so2609 and then we have so264 so2.65 and then we have our so266 that way you can see these are all right in the same area so instead of flipping back and forth and back and forth we'll just validate these three get the additional characters that are needed as we look at them so you can tell here if you look at the angle for example there's this little green check mark in it and that means that there are going to be additional characters that we need now as i'm kind of looking at this again it says bilateral open mandible fracture open left angle and open symphysis and i was assuming that these were different fractures but if you kind of look again at this indication for procedures look it says here on the x-ray it was noted to be a displaced left angle fracture and non-displaced synthesis fracture so those are probably the bilateral the left angle and the simphis not that there's a bilateral and an open left angle and a symbol so let's cross that one out and we just need the additional characters and to verify these so so265 so265 fracture of angle of mandible and this was the left angle it said so fracture angle of left mandible s0652 and then we still need an additional character on that our seventh character extension so for our so2 category we need either a for initial closed uh b for open initial and then we have our subsequence that was this and it wasn't a sequela so it wasn't an initial encounter for a closed fracture or initial encounter for an open fracture so we had closed treatment but this was an open fracture so if you recall this is open fracture so we're going to use our b initial encounter for open fracture so so2 652 b and then we have so266 fracture of symphysis of mandible and we need our seventh character for that but we have to use our placeholders because we don't have anything in the um sixth character spot here so we're going to have to do our s0266 placeholder x to hold that sixth spot because there's no additional character that we have indicated here for that but we need to use our seventh character to indicate that this was an open fracture because again it says here open open symphysis fracture so this would be our full case that we've coded out here we've got the 21453 for our cpt code with icd-10-cm codes s02652 and s0266xb for our icd-10 codes so i hope you found this type of case study very very helpful i know i've gotten a lot of requests to go through code a whole case do the diagnoses do the cpt as well if you want me to do more of these case studies definitely let me know in the comments below i will see you guys in the next episode and until then just keep on coding on