are you looking for some start to finish examples of how to code a surgical case if so you're in luck because today we're going to go over a couple of example surgical cases [Music] [Applause] [Music] hey everyone i'm victoria i'm a medical coder auditor content creator blogger podcaster youtuber and on my channel i provide tips tricks and tutorials to help you succeed in a medical coding career so i have two coding cases we're going to look at today one is a hernia repair and a reduction mammoplasty and i just want to say a big shout out to mtsamples.com mtsamples.com is a free searchable database that has lots of samples that are used primarily for medical transcription everything from progress notes inpatient notes um surgical notes all types of medical records that are samples for medical transcription but they're also great if you want to practice your medical coding and they do allow for you to utilize the samples from their archive as long as you give them credit all right so let's take a look at this example pre-operative diagnosis right inguinal hernia post-operative diagnosis direct right inguinal hernia title of procedure marlix repair of right inguinal hernia anesthesia spinal and then the procedure in detail patient was taken to the operative suite placed on the table in the supine position and given a spinal anesthetic the right inguinal region was shaved and prepped and draped in a routine sterile fashion patient received one gram of ancest iv push so that really for professional coding doesn't give us anything to actually code a lot of times in these uh surgical notes this first little section is really just the preparation stuff which generally speaking not always but generally speaking there's there's not often things you can code out of that transverse incision was made in the intra-abdominal crease and carried through skin and subcutaneous tissue the external oblique fascia was exposed and incised down to through the external inguinal ring the spermatic cord and hernia sac were dissected bluntly when they say dissected bluntly that basically means that they were sticking their finger in there they were doing blunt dissection basically means they're like sticking their finger in there and like dissecting it apart with a finger or a blunt instrument off the under surface of the external oblique fascia exposing the uh attenuated floor of the inguinal canal the cord was surrounded with a penrose drain the hernia sac was separated from the cord structures so now we've got that hernia sac and we're separating it out the floor of the inguinal canal which was consisted of attenuated transversalis fascia was implicated upon itself with a locking with running locked suture of 2o proline marlek's plaque patch 1 by 4 inch dimension now so these patches sometimes in hernias are separately billable so let's take a look when we go and pick our codes if this is one of the ones where we bill separately for those patches it was trimmed to an appropriate shape with a defect to accommodate the cord it was placed around the cord and sutured to itself with 2o proline the patch was then sutured immediately to the pubic tubercle inferiorly to cooper's ligament and inguinal ligaments and superiorly to the conjoined tendon using 2o proline the area was irrigated with saline solution and 0.5 marking with epinephrine was injected to provide prolonged post-operative pain relief the cord was returned to its position external obedience flashove was closed with a running 20ds subcutaneous with 2o vicryl and the skin so this is our closure part here and the skin with running subdermal4o bicycle and steri-strips sponge needle counts were correct sterile dressing was applied okay so we can see in here that we did repair this inguinal hernia so here's the hernia sac and here is when they sutured it back up and then they closed the patient so it is in fact a direct right inguinal hernia repair let's start with our icd-10 code so we're going to look for hernia hernia hernia hernia see i just got done doing my tabbing book so now i can easily find stuff for you guys hernia hernia ah [Music] hernia hernia okay so this was an inguinal hernia incisional abdomen inguinal c hernia inguinal i'm getting there hernia inguinal direct okay so it says here anguano so one of the things i want to point out here is inguinal hernia direct um leads you to k 40.90 so even if this is one where it says not specified as recurrent it's the same code it doesn't say recurrent on here this wasn't one that said recurrent but some of these k40.90 default codes are the same um so even not specified as recurrent k 40.90 so that's probably the code we want to look up k 40.90 okay 40.90 unilateral inguinal hernia without obstruction or grangi grand green not specified as recurrent so that's what we're looking at here we're looking at a unilateral inguinal hernia and it doesn't say anything about dang green or recurrence so that's going to be our diagnosis code dxk 40.90 and our cpt is going to be the repair of an inguinal hernia and again we're going to check on that that mesh because i'm not sure if this is one where the mesh is allowed or not let's take a look here so when i having worked a lot in surgical coding look up surgical codes if you're learning coding you will probably go back here to the index and look up repair hernia but i know that the hernia repair codes are in the gi section so i would just go to digestive and in the index in the front of here i know it's going to tell me where those hernia repair codes are so here appendix abdomen repair of hernia is on page 355. now this wasn't laparoscopic i didn't see anything about um any of the scopes being inserted or anything like that 355 short-term memory 55 okay so look i even highlighted this in my book so it says with the exception of incisional hernia repairs the use of mesh or other prosthesis is not separately reported so this this isn't an incisional hernia this is an inguinal hernia so we're looking for and i made a note up here just because it wasn't on the note patient is 50 years old which does come into play with our code selection so if we're looking for a patient who has an initial inguinal hernia 37 weeks no that's not what we're looking for younger than six months nope repair ah initial inguinal hernia age six months to younger than five years new uh uh repair initial inguinal hernia age five years and older reducible okay that sounds like it's probably it it wasn't incarcerated or strangulated that i saw and the rest of these codes repair recurrent repair lumbar okay so this looks like it's our right code our 49505 so that's our cpt 49505 so that's how we code for that case now for this case we have a bilateral reduction mammoplasty where preoperative diagnosis is bilateral macromastia which means enlarged breasts and postoperative diagnosis same the opera operation that was performed bilateral so we have to make sure that when we're looking at this documentation that we make sure that it truly is bilateral because occasionally what will happen is providers will document a side but then they won't document the other side so we want to make sure that it's clear in this body of this operative report that it's bilateral so bilateral reduction mammoplasty findings patient has large pototic breasts bilaterally and chronic difficulty with pain in the back so what i'm going to tell you about mammoplasties is a lot of times the fact alone that they have these large breasts doesn't really support the medical necessity so it's good to include the signs and symptoms because that is really what helps support the medical necessity is the fact the patient had the back pain this patient had shoulder pain and uh right breast was slightly larger than the left this was repaired with a basic wise reduction mammoplasty with anterior pedicle so not only do we have the breasts pitosis which means that they're kind of pendulous we also have back pain and shoulder pain and those are really the things that support the medical necessity of it so you have to be very careful specifically with breast procedures because some of them are common for insurances to deny as cosmetic and oftentimes when you get a reduction they don't just reduce the volume they also take some skin samples out which does give you a lift effect so it's probably likely that in this operative report somewhere they have the grams because some insurances do require there be to be a minimum grams like taken out of each breast like there has to be a certain weight removed from each breast otherwise um you know it tends to be liable to get abused because you know physicians and surgeons could kind of mock up this documentation to make it look like they're getting a reduction but really they're getting a lift and your your medical insurance is not paying for you to get a breast lift just for the sake of getting a breast lift so that's why i like to also include the diagnosis for the the back pain the shoulder pain that the patient is also having this might be in their office note somewhere but you can't code from that remember every note stands alone so these surgeons really should have just like in this note the supporting medical necessity for this mammoplasty so that it when it goes out on the claim form they can see that the patient also had the qualifying back and shoulder pain so procedure description with the patient under satisfactory general endotracheal anesthesia the entire chest was prepped and draped in usual sterile fashion he previously placed mark to identify the neo nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory so that means it's symmetrical a keyhole wire ring was then used to outline the basic wise pattern with a six centimeter lamps inferiorly so what they do when they're doing some of these breast reconstructions is they use what they very commonly refer to as a cookie cutter and it is basically a round surgical instrument like a cookie cutter so they core out the nipple and that way when they're done doing their reduction they move the nipple right to the appropriate location where they want it this was then carefully checked for symmetry and appeared to be satisfactory all marks were then completed and lightly incised on both breasts both the right breast so we're starting with the right breast was approached first the neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelializedly using cutting cautery after this had been completed cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately this was taken down to the pre-pectoral fashion dissected for short distance superiorly and then the blunt dissection again remember we talked blunt dissection um the blunt dissection was used to mobilize under the superior portion of the breast tissues so they're freeing up the breast tissues by kind of pulling the tissues apart with their finger probably or a blunt instrument usually their finger to the lateral edge of the pectoral muscle there was very little bleeding with this procedure after this had been completed the tension was directed to the lateral side and the inferior incision was made and taken down to the serratus cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket after this had been completed cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast hemostasis was obtained with electrocautery after this had been completed cutting cautery was used to cut along the superior edge of the redundant tissue so they're removing that excess tissue remember we talked about that they're taking not just the volume but the excess tissue and this was tapered under the superior flaps now when they say flaps here this doesn't mean adjacent tissue transfer that me that's their normal closure that they're using there this isn't anything we bill out separately for on the right side there's a small palpable lobule which has shown up on mammogram but nothing except some fat density was identified the site had been previously marked carefully and there were no unusual findings and the superior tissue was then sent out separately for pathology after this had been completed the final hemostasis obtained and the wound was irrigated and tagged suture placed to approximate the tissues the rest was cleared and the nipple appeared good so the right one we're all done that's the whole mammal plastic attention was then directed to the left breast okay so now we're working on our second breath so we're supporting the bilateral procedure which was completed in a similar manner after this had been completed the piece was placed in a near upright position and symmetry appeared good but it was a bit poor on the lateral aspect to the right side which is a little larger and some suction like pectomy was carried out in this area after completion of this 100 1860 grams had been removed from the right and 1505 grams were removed from the left through separate stab wounds on the lateral aspect 10 millimeter flat blade drains were brought out and sutures then placed and irrigated the wounds were then closed with interrupted 4-0 monochrome and on the deep dermis and running intradermal for a monika on the skin packing sutures and stables were removed as they were approached the nipple was sutured with running intradermal 4-0 monocryl vascularity appeared good throughout so that vascularity means that the circulation is running correctly to the breast after this had been completed all wounds were cleaned and steri strips and steri-stripped the patient tolerated the procedure well all accounts were correct estimated blood loss was less than 150 milliliters and she was sent to a recovery room in good condition okay so here remember we talked about the grams there's those grams now one of the things you're probably going to look at here is the suction lipectomy now if they're just doing a little bit of suction lipectomy on a medically necessary procedure and it's not something that's like significant usually that's kind of included that's part of like the normal sort of contouring of these sort of breast procedures i mean the whole intent is that they're taking out some of the breast tissue so again let's just start with our diagnosis coding so we've got four diagnoses that we're going to put on here we have the macromastia we have back pain shoulder pain and breast pitosis so we're going to start with our alphabetic index macromaster which is enlarged breasts macromastia macromastia ssc hypertrophy of breath so we're going to go over to hyper trophy of breast cypher history hyperkeratosis hyper getting close hyper thyroid hypertrophy breast n62 so we're gonna i don't know if you guys know this but this flap here is to hold your page so n62 and 62. and 62. n62 hypertrophy of breast excludes breast engorgement of newborn nope excludes disproportion of reconstructive breast nope that's what any of these are hypertrophy of breast not otherwise specified so we've got n62 and then we have let's look up this breast protosis because that's probably i don't know wait we were under hypertrophy okay let's go to our pain codes pain pain pain there's a lot of pain codes okay pain of the back pain back m five four point nine i'm just gonna write that down so i don't forget it and 5 4.9 double check that 4.9 dorsalgia unspecified backache not otherwise special specified back pain not otherwise specified it says it needs a fifth character here but this one does not so we're good with just m5 4.9 uh so that one's okay next is shoulder pain so back to my book here pain shoulder m25.51 and there's that dash which means we need an extra character probably to tell us what shoulder is the left or the right m two five point five one two five five one m2551 pain in shoulder pain right left unspecified pain in the back pain in the shoulder he did not specify the type of shoulder so we're going to use the sixth character of nine which is the unspecified and then ketosis of the breasts is the last one ptosis ketosis of breast n64.81 and then that also needs an extra character probably again for if it is right or left and six four point eight one and six four four point eight okay one ptosis of the breast okay now n6481 is the whole code and it says potosis of native native breast in relation to reconstructive breast is an excludes one and that's not what this is so n6481 is correct so then we just need our cpt code so we're going to switch our books here for a second again i know breasts are considered part of the integumentary system so you can go to your surgical section skin nails destruction repairs breast okay so here we go here's our section for the breast introduction mastectomy procedures repair reconstruction and other so i'm gonna say it's probably in repairs and reconstruction 109. and we go to 109. so we have mastopexy reduction mammogram there we are reduction mammoplasty that is what we did we did the reduction mammoplasty and that is one nine three eight and don't forget this was a bilateral procedure so we slap on our modifier 50 which if you don't recall means that it is a bilateral procedure your modifiers are right here at the inside flap of your cpt book bilateral procedure or you can also find the full definition of them in your appendix a of your cpt manual so if you ever want to get the full description of it it is right here in appendix a of your cpt manual so there we have it we have fully coated out the bilateral uh reduction mammoplasty case so i really hope you found those case studies helpful if you did make sure you give this video a big thumbs up and as always don't forget to 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