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

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 the CCS-P or CPC Medical Coding Certification Exams, these sample Operative Reports will help.

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

As a national, coding consulting firm, we code thousands of charts each week. We don't hand just you the answer, but work you through the thought process of how to find the code in the ICD-9 or CPT manual. Each includes complete, step-by-step explanations for both the ICD-9 and the CPT Codes.  

A current ICD-9 and CPT book is necessary to code the encounters..

Each document will be e-mailed to you as a MS Word or .pdf (Adobe) file.

Options include:

Op Reports 1 - Basic
Op Reports 2 - Basic
Op Reports 1 - Intermediate
Op Reports 2 - Intermediate
Op Reports 1 - Difficult

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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

12 Operative Reports - Basic - Group 1

1. Anesthesiology Epidural  - Cesarean Delivery
2. Anesthesiology - Regional Anesthesia - Surgery on Arm
3. Integumentary - Excision Benign Lesion 
4. Musculoskeletal - Arthroscopy with Excision 
5. Musculoskeletal - Trigger Thumb Release 
6. Cardiology - Vascular "Vein Stripping" 
7. Digestive System - Hemorrhoidectomy 
8. Gastroenterology - Laparoscopic Cholecystectomy 
9. Female Urinary - Laser Conization 
10. Nervous System - Carpal Tunnel Release 
11. Pathology - Op Report
12. Ophthalmology - Trabeculectomy

12 Operative Reports - Basic - Group 2

1. Anesthesiology - Vaginal Delivery
2. Integumentary - Nail excision
3. Integumentary  - Amputation
4. Musculoskeletal - Arthroscopy with Excision
5. Musculoskeletal - Excision of cyst
6. ENT - Microlaryngoscopy
7. Urinary  - TURP
8. Female Reproductive - D & C
9. Pathology - Cataract OD
10. Ophthalmology - Gonioscopy
11. Auditory  - Stapedectomy
12. Auditory - Tympanostomy/Tonsillectomy

12 Operative Reports - Intermediate - Group 1

1, Integumentary Basal cell carcinoma excision
2. Musculoskeletal - Rotator Cuff Repair.
3. Musculoskeletal - Austin Bunionectomy
4. Ophthalmology - Obstruction repair
5. Auditory - Tympanoplasty
6. Nervous System  - Hemilaminotomy
7. Nervous System - Nerve Sleeve Injection
8. Respiratory - Multiple Sinus Surgery
9. Respiratory - Sinus Surgery, Septoplasty
10. Auditory - T-Tube Removal
11. Digestive - Appendectomy
12. Urinary - Cystoscopy

12 Operative Reports - Intermediate - Group 2

1. Integumentary - Scar Revision
2. Musculoskeletal - Excision Soft Tissue Mass 
3. Musculoskeletal - Bone Graft 
4. Female Reproductive - Hysteroscopy 
5. Musculoskeletal - Bankart Reconstruction 
6. Nervous System - Epidural Blood Patch 
7. Neurology - Facet Injection 
8. Cardiology -  Tamponade Vascular Relief 
9. Gastroenterology - Catheter Removal 
10, Digestive System - Sigmoidoscopy 
11. Digestive System - Sigmoidoscopy 2
12. Urinary - TUR 
 
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