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Surgical Op Reports (12) - Difficult
 
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Surgical Op Reports

12 Surgical Operative Reports (Op Reports)   New Price $13.11 ! 

The most challenging (and the best paying) coding jobs are for surgical coders. Whether you're preparing for a career as a medical coder, or a Medical Coding Certification Exam, these sample Operative Reports will help. 

These are not just classroom exercises but Op Reports dictated by an actual surgeon. They are the type of charts you will code as a medical coding professional.

As a national, coding consulting firm, we have coded thousands of Op Reports. We don't just hand you the answer, but work you through the thought process of how to find the code in the ICD-10 or CPT manual. Each Op Report includes complete, step-by-step explanations for the CPT Codes.

A current ICD-10 and CPT book is necessary to code the encounters.

Each group of twelve (12) document will be E-mailed to you free as a MS Word, rtf or pdf (Adobe) file. Regular mail delivery is $8 per set of 12 Op Reports. Scroll to the end for a list.


Integumentary Op Report  - EXAMPLE

DIAGNOSIS: Left thumb nail remnant

NAME OF OPERATION:  1. Thumb nail remnant excision.  2. Nail matrix obliteration. 

ANESTHESIA: General. 

PROCEDURE: In the preoperative holding area the site and side and the procedure were confirmed with the patient. The risks, benefits, and alternatives were discussed, particularly recurrence. He voiced understanding and desired to proceed. After adequate general anesthesia, the left hand was carefully fitted with a finger cot after it had been prepped and draped in sterile fashion. Using loupe magnification the nail remnant was carefully excised. Copious irrigation was utilized. A sterile dressing was applied, and the patient was aroused from anesthesia and taken to the recovery room having tolerated the procedure well.


 Integumentary  Nail Excision Explanation

ICD-9: 

Remnant is the main diagnostic term.

ICD-9: 

Subterm is nail, code 703.8

ICD-9 Answer:  

703.8

CPT: 

Main term in the CPT index is Excision, modifying term nails, codes 11750-11752.

CPT: 

Code 11750 is selected because the tuft of distal phalanx was not amputated.

CPT: 

Modifier –FA is added to indicate left thumb.

CPT Answer:  

11750-FA

Difficulty Level

Op Report #

Op Report Description

DIFFICULT1

1

Excision of pilonidal cyst with primary closure

DIFFICULT1

2

Skin Graft - Full Thickness

DIFFICULT1

3

Implant Removal

DIFFICULT1

4

Excision of Morton's Neuroma

DIFFICULT1

5

Aortic valve replacement

DIFFICULT1

6

Coronary artery bypass graft 2

DIFFICULT1

7

Laparotomy - exploratory

DIFFICULT1

8

Cystoscopy, Ureteroscopy, Retrograde more…

DIFFICULT1

9

Bilateral Retrogrades & Ureteroscopy.

DIFFICULT1

10

Facet injection, bilateral.

DIFFICULT1

11

Vitrectomy

DIFFICULT1

12

Repair of ptosis, by repair of levator dehiscence, bilateral upper lids.

DIFFICULT1

13

Canaliculus Repair; Intubation nasolacrimal duct system.

DIFFICULT1

14

Catheterization Procedure,  Injection Procedure and  Imaging Supervision.


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