PCS Pivot Content ¶

Fusion -- 0RG20K0¶

Anterior interbody fusion with tricortical bone allograft at the C3-C4.
Anterior interbody tricortical graft with allograft bone at the C4-C5.
Complete microsurgical dissection.

Laser Lithotripsy¶

Dr. Savage, he felt the patient was stable to proceed with ureterorenoscopy with laser lithotripsy as his pain exclusively was from the left flank from the stone. -- 0TC18ZZ
At this time, the flexible ureteroscope was then passed into the sheath and into the area of the UPJ at which point, the stone under pressure of irrigation and passage of the scope right at the UPJ with dislodgement back into the kidney, photographic documentation was obtained. At this time, laser lithotripsy was carried out using a 273 watt laser at 8 hertz and proximal 1.2 and 1.5 joules, approximately 280 joules were used to break up the stone. -- 0TC38ZZ

colonoscope¶

With the patient in the left lateral decubitus position, the video colonoscope was introduced to the anus without any difficulty revealing a well-cleaned and well-prepped colon. --- 0DJD8ZZ

PTA 047S3ZZ JObid(40131530)¶

Percutaneous left leg tibioperoneal trunk and posterior tibial artery cutting balloon angioplasty (using a 2.5 mm x 20 cm VascuTrak Bard balloon) via left common femoral artery antegrade

JobID:70487 For getting DTime¶

Final Diagnosis performed by Galen Cortina M.D., PhD Electronically signed 10/19/2017 15:59

JobID:40122119 Wrong code selected (0JH606Z) -- History true so Pcs was removed.¶

The patient has atrial fibrillation and also automated implantable cardioverter-defibrillator, biventricular pacemaker.

JobID:40130903 Wrong code selected (0JH606Z, 02HK3JZ)¶

Temporary pacemaker wire was placed on the right ventricular surface.

Gastrostomy tube -- By defaultly we are giving percutaneous approach¶

Semicomatose with dysphagia secondary to cardiac arrest from substance use with gastrostomy tube placement, 20-French without complications.

FractureRduction, RotatorCuff Repair -- (0PSF04Z, 0LQ10ZZ) -- 40118804¶

Open reduction and internal fixation of right humerus with Stryker 8 x 203 mm IM rod, 2 proximal locking screws distally dynamization, and also repair of rotator cuff of right shoulder.

Right colectomy -- 0DTF4ZZ --- 40118758¶

Hand-assisted laparoscopic right colectomy.

Arthroplasty --- 0RRJ00Z --- 40122825¶

Reverse right total shoulder arthroplasty with Lima 90 mm humeral stem, reverse humeral body

Loop Ilostomy--- 0DBB0ZZ (Excision) --- 40122465¶

Loop Ilostomy Take down

40123440 --- 0D20XUZ¶

Upper endoscopy with gastrostomy tube replacement. Gastrostomy tube replaced without complications endoscopically.

40180611 --- 0WQF4ZZ, 0DNU4ZZ -- (hernia Repair, Release Omentum)¶

OPERATIONS PERFORMED: 1. Laparoscopic cholecystectomy. 2. Laparoscopic lysis of dense inflammatory adhesions. 3. Umbilical hernia repair.

umbilical hernia 2.5 x 2.5 cm was encountered during placement of the first infraumbilical trocar and during closing, repair of this hernia is mandatory

There were adhesions between the greater omentum and gallbladder.

40179873 -- Myomectomy -- Surgical removal of the Uterus --- 0UB90ZZ¶

Abdominal Myomectomy, Ureteral dissection

40160027 -- 0UB90ZZ(myomectomies) 0UB60ZZ,0UB10ZZ -- cystectomy¶

multiple myomectomies, 23 fibroids were removed, drilling of both ovaries for polycystic ovaries, lysis of severe pelvic and abdominal adhesions, left paratubal cystectomy, and left ovarian cystectomy.

40182602 -- Trimalleolar/Bimalleolar Fracture -- 0QSH04Z, 0QSK04Z, 0QSHXZZ¶

POSTOPERATIVE DIAGNOSIS: Trimalleolar fracture, left ankle.

OPERATION: Open reduction and internal fixation of bimalleolar fracture such as lateral malleolus with Stryker plate and screws x8, medial malleolus with two cognitive screw fixation and closed reduction of posterior malleolus of left ankle followed by short leg cast immobilization.

40162043 -- Trimalleolar/Bimalleolar Fracture -- 0QSG04Z, 0QSJXZZ(OPT)¶

POSTOPERATIVE DIAGNOSES: 1. Right trimalleolar ankle fracture dislocation. 2. Osteoporosis.

PROCEDURE PERFORMED: 1. Open reduction and internal fixation of right ankle. 2. Bone graft.

40181878 --- Trimalleolar/Bimalleolar Fracture -- 0QSH04Z,0QSK04Z¶

POSTOPERATIVE DIAGNOSIS: Left ankle trimalleolar severely displaced fracture.

PROCEDURE DONE: Open reduction and internal fixation of the left ankle trimalleolar fracture with repair of the anterior syndesmosis ligament.

Detoxification --- HZ2ZZZZ --- 40183980¶

thiamine, folic acid. banana bag Alcohol abuse

Vaccination --- 3E0234Z -- 40186095¶

Here we are inserting 7 - digit direct Vaccination code if Z23(Icd10) present. As per the coder Rambabu

Picc lIne ---- 02HV33Z --- cavoatrial junction,caval junction(Added for Superior Vena Cava)¶

IMPRESSION: No acute cardiopulmonary disease. Left arm PICC line in place with tip at the cavoatrial junction. Tracheostomy tube in place.
A right PICC line is seen with the tip in the caval junction.

Multiple Angiography -- (B2111ZZ) --- 350527189¶

Procedure Medications - Versed I.V. 1 mg. Diagnostic Catheters - A6 FrBSCI 6Fr FL4 angiographic catheterwas used for:Left Coronary Angiography. - A6 FrBSCI 6Fr FR4 angiographic catheterwas used for:Right Coronary Angiography.

350521296¶

PROCEDURES: 1. Left cardiac catheterization. 2. Selective coronary angiogram. 3. Left ventricular angiogram.

Ventricular Angiogram -- (B2151ZZ) --- 350522500¶

A6 FrBSCI 6Fr Ang Pig angiographic catheterwas used for:LV pressure/ Left Ventriculogram.

Malleolus Fracture --- i.e Tibia,Fibula Fracture (0QSH,0QSK) -- FractureReduction.jape --- 350520188¶

OPERATION: Open reduction and internal fixation of left distal tibia with Stryker medial plate and multiple screws and also lateral malleolus fracture with lateral plate and multiple screws in the left ankle followed by short-leg cast immobilization.

Thoracentisis(0W993ZZ) -- 350521487 , Paracentisis(0W9G3ZZ) -- 350526204 --- Hemodialysis.jape¶

US-guided right thoracentesis yielding 2400 cc of clear yellow pleural fluid given to nurse for testing to be ordered by referring clinician.

IMPRESSION: CT-guided paracentesis of 4.5 liters of turbid yellow ascites from the right abdomen. -- 350526204

Extirpation(04CM3ZZ,04CP3ZZ,04CQ3ZZ(W),04CR3ZZ,04CT3ZZ),Dialtion (047M3ZZ,047P3ZZ,047R3ZZ,047T3ZZ) --- 40199258 (350529111)¶

PROCEDURES: 1. Abdominal aortoiliac angiogram and bilateral leg runoff via left common femoral artery approach. 2. Selective right common femoral artery antegrade angiography and right leg runoff via right common femoral artery antegrade approach. 3. Percutaneous right leg below-knee popliteal artery atherectomy (EXL SilverHawk) via right common femoral artery approach. 4. Percutaneous right leg below-knee popliteal artery cutting balloon angioplasty via right common femoral artery antegrade approach. 5. Percutaneous right leg anterior tibial artery atherectomy via right common femoral antegrade approach (using an EXL SilverHawk). 6. Percutaneous right leg anterior tibial artery cutting balloon angioplasty (using a 2.5 mm x 30 cm VascuTrak Bard balloon). 7. Percutaneous right leg tibioperoneal trunk and right leg posterior tibial artery atherectomy (EXL SilverHawk) via right common femoral artery approach. 8. Percutaneous right leg tibioperoneal trunk and posterior tibial artery cutting balloon angioplasty (2.5 mm x 30 cm VascuTrak Bard balloon) via right common femoral artery approach. 9. Percutaneous right leg tibioperoneal trunk, posterior tibial artery, and right leg anterior tibial artery aspiration thrombectomy and catheter directed thrombolysis infusion (2 mg of tissue plasminogen activator). 10. Interpretation and supervision of direct fluoroscopy, radiography, and intervention.

Excisional Debridement (0JB70ZZ) --- 350529460¶

Excisional debridement of presacral pressure ulcer

Excisional Debridement (0JB80ZZ) --- 350520870¶

Excision of left cord lipoma

Excisional Debridement (0J990ZZ) --- 350522225¶

Incision and drainage of left buttock abscess with debridement.

Excisional Debridement (0JBC0ZZ) --- 350524329¶

Excisional debridement of left groin abscess

18-12-2017¶

1.Extirpation codes (00C(47)(03)ZZ) --- ESWL.jape¶

OPERATION: Right frontoparietal craniotomy for evacuation of subdural hematoma. -- 004C0ZZ -- 350527755

Removal of an acute SDH -- 00C40ZZ -- 350518430

Removal of an acute frontal ICH -- 00C70ZZ -- 350518430

00C43ZZ -- 350526143 OPERATION PERFORMED: Burr hole trephination on the bifrontal and parietal area and evacuation of the bilateral subdural hematoma.

2. Working on Thoracentisis procedure coding (0UT___) -- Hysterectomy.jape -- 40201333¶

0UT90ZZ, 0UT10ZZ, 0UT60ZZ, 30233N1, 0UTC0ZZ(WR)

Throbosis procedure coding (3E03317) --- Thrombectomy.jape -- 40191591¶

Percutaneous left subclavian vein catheter directed thrombolysis (2 mg of tissue plasminogen activator). --- 3E03317 --- 40191591

Throbosis procedure coding (3E05317) --- Thrombectomy.jape --¶

Selective right common femoral artery tissue plasminogen activator thrombolysis infusion (2 mg of TPA) via left common femoral approach. -- 350504795 -- 40123512

Percutaneous left arm AV graft aspiration thrombectomy and catheter-directed thrombolysis infusion (4 mg of tissue plasminogen activator). -- 40117140

Insertion of infusion device (05HM33Z)¶

Placement of right internal jugular vein tunneled hemodialysis PermCath (14.5-French x 23 cm HemoStar Bard). --- 40070200

Bedside ultrasound guided placement of a right jugular temporary dialysis catheter. -- 79217

Peritoneal Dialysis --- 0WHG43Z ---40109579¶

Laparoscopic insertion of peritoneal dialysis catheter.

needle core biopsy -- 0JBC3ZX --- Debridement.jape -- 68894¶

CT-guided coaxial 17/18-gauge needle core biopsy of a soft tissue mass along the right pelvic wall.

foraminotomy and decompression --- 40006961 --- 01NB0ZZ¶

45 degree angled Kerrison rongeur, a complete decompression of the left L5 nerve root was nicely accomplished.

extended foraminotomy, decompression of the left S1 nerve root as well as the traversing left S1-L5 nerve root decompression --- 350471029

Left Ventriculogram --- Angiography.jape --- B215YZZ --- 40040656¶

Left Ventriculogram -- we are defaultly given -- Low osmolar code--but if 'Visipaque' med present then we are giving 'Other Contrast'

LEFT VENTRICULOGRAM: Catheter 6-F pigtail. It was performed with the patient in the right anterior oblique projection using 10 mL of Visipaque injected manually.

Foley catheter --- 0T9B70Z --- Diectcode¶

PROCEDURE PERFORMED: Placement of Foley catheter. --- 40209763

RA/RV -- 02HK3JZ/02H63JZ -- Defebrillator.jape 08-Jan-2018 -- 40206387¶

stimulation threshold of right atrial lead which is bipolar - pulse with 0.5 with 0.9 volt with a current of 1.7 mA and impedance of 612 stimulation threshold of right ventricular lead which is bipolar - pulse width 0.5 millisecond, 0.7 volts, 0.7 milliamps with impedance of 1068

PTCA Extirpation --- PTCA.jape -- 08-Jan-2018 (02C03ZZ)¶

Rotational atherectomy of the LAD. --- 40205672

Arthroplasty --- Arthroplasty.jape --- 0SR --- 40217429¶

PROCEDURE DONE: Left total knee replacement using size #3 femoral and tibial component with 23 mm patella and correction of the varus deformity with medial release.

DESCRIPTION OF THE PROCEDURE: one bag of cement was mixed and the tibia was fixated first followed by femur and excess cement was removed.

Ballon Angioplasty --- 03783ZZ, 027V3ZZ, 05743ZZ, 05763ZZ, 05783ZZ, 03C83ZZ¶

PROCEDURES: 1. Percutaneous left arm AV graft thrombectomy (using a mechanical Trerotola Arrow device). 2. Left arm AV graft fistulogram, selective central venogram, selective left brachial artery angiogram via two access sheath placement, one antegrade and one retrograde. 3. Percutaneous left arm brachial artery thromboembolectomy (using a 4 mm x 2 cm EverCross balloon) and left brachial artery anastomosis and brachial artery balloon angioplasty (using a 6 mm x 10 cm EverCross balloon). --- 03783ZZ 4. Percutaneous left arm AV graft and left axillary vein balloon angioplasty (up to 8 mm x 10 cm Dorado balloon).--- 05783ZZ 5. Percutaneous left subclavian vein balloon angioplasty -- 05763ZZ, left innominate vein balloon angioplasty --- 05743ZZ, and superior vena cava balloon angioplasty (using up to 10 mm x 4 cm Dorado balloon). --- 027V3ZZ 6. Percutaneous left arm AV shunt aspiration thrombectomy with catheter directed thrombolysis infusion (5 mg of tissue plasminogen activator) and primary surgical suture repair of the two arterialized AV shunt access site x2 with interpretation and supervision of direct fluoroscopy, radiography, and intervention.

Amputation --- 15-Feb-2018 --- 40224179¶

40224179 --- 5 codes (0Y6M0Z[45678]¶

Pathology: Amputated forefoot right foot

Procedure: Transmetatarsal amputation with myocutaneous flap closure of amputation site right foot