Practicode - Module 1

87-year-old female Diagnosis right hip joint, primary osteoarthritis Right hip Cortizone injection

20610/RT 77002 M16.11

Patient 69-year-old male Postoperative diagnosis, bilateral wedge compression fractures of T11 and T12 Procedure performed T 11 and T 12 vertebral kyphoplasties

22613 22515 S22.080A

Age : 16 Sex : Female PREOPERATIVE DIAGNOSIS : Left fifth metacarpal base fracture . POSTOPERATIVE DIAGNOSIS : Left fifth metacarpal base fracture . NAME OF PROCEDURE : 1. Closed reduction pin fixation of the left fifth metacarpal base fracture . 2. Intraoperative use of fluoroscopy .

26608/LT S62.317A

Age 68 Sex : MALE PREOPERATIVE DIAGNOSIS : Arteriovenous malformation with severe primary osteoarthritis of the right hip POSTOPERATIVE DIAGNOSIS : Same . NAME OF PROCEDURE : Right total hip arthroplasty .

27130/RT M16.11 M85.451 Q27.30

OPD7004 OPERATIVE NOTE PATIENT : AGE : 26 PREOPERATIVE DIAGNOSIS : Pelvic pain . POSTOPERATIVE DIAGNOSIS : Pelvic pain . OPERATIVE PROCEDURE : Diagnostic laparoscopy .

49320 - Diagnostic Laparoscopy R10.2 - Pelvic Pain

Emergency department visit Critical care 74-year-old male Chief complaint, black stools

99291 K92.2 Z79.01

Operative note 71-year-old female History of left breast cancer status post first stage breast reconstruction with placement of tissue expander Left breast, cellulitis, with infected tissue expander Removal of left breast tissue expander with white pocket to Bremen and irrigation

11971/LT T85.79XA N61.0 Z85.3 Z45.812

Patient 72-year-old male Postoperative diagnosis, chronic, venous, stasis, ulcers, bilateral lower extremity Procedure performed bilateral lower extremity split thickness skin grafting

15120 I87.2 L97.411 L97.421

OPERATIVE NOTE PATIENT : AGE : 47 PREOPERATIVE DIAGNOSIS : Family history of colon cancer and multiple colon polyps . POSTOPERATIVE DIAGNOSIS : Normal colon . OPERATIVE PROCEDURE : Screening Colonoscopy with Conscious Sedation . Time 19 min .

45378 99152/59 Z12.11 Z80.0 Z83.71

OPERATIVE NOTE PATIENT : AGE : 26 Sex : Female PREOPERATIVE DIAGNOSIS : Biliary dyskinesia . POSTOPERATIVE DIAGNOSIS : Biliary dyskinesia . OPERATIVE PROCEDURE : Laparoscopic cholecystectomy .

47562 K82.8

PATIENT : AGE : 33 SEX : Male PREOPERATIVE DIAGNOSES : 1. Biliary dyskinesia . 2. Umbilical hernia . POSTOPERATIVE DIAGNOSES : 1. Biliary dyskinesia . 2. Umbilical hernia . OPERATIVE PROCEDURES : 1. Laparoscopic cholecystectomy . 2. Repair of incarcerated umbilical hernia .

47562 49587/59 K82.8 K42.0

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : SEX : Male AGE : 29 DOS : 1 / 1 / 20XX PREOPERATIVE DIAGNOSIS : Left inguinal hernia . POSTOPERATIVE DIAGNOSIS : Incarcerated left inguinal hernia ( indirect ) . OPERATIVE PROCEDURE : Repair of incarcerated left inguinal hernia with mesh ( PHSL ) .

49507/LT K40.30

PATIENT : Age : 68 SEX : FEMALE This is a Commercial Payer ( Follow Medicare rules ) DATE OF OPERATION : 1 / 1 / 20XX PREOPERATIVE DIAGNOSIS : PARACOLOSTOMY HERNIA . PROCEDURES : EXPLORATORY LAPAROTOMY , LYSIS OF ADHESIONS AND REPAIR PARACOLOSTOMY HERNIA WITH MESH . POSTOPERATIVE DIAGNOSIS : PARACOLOSTOMY HERNIA .

49560 49568 K43.5

PATIENT : SEX : MALE AGE : 51 PREOPERATIVE DIAGNOSIS : INCARCERATED VENTRAL HERNIA . PROCEDURES : REPAIR OF INCARCERATED VENTRAL HERNIA , PARTIAL OMENTECTOMY . POSTOPERATIVE DIAGNOSIS : INCARCERATED VENTRAL HERNIA

49561 K43.6

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : AGE : 42 SEX Male PREOPERATIVE DIAGNOSIS : Painful epigastric hernia . POSTOPERATIVE DIAGNOSIS : Incarcerated epigastric hernia . OPERATIVE PROCEDURE : Repair of incarcerated epigastric hernia .

49572 K43.6

OPERATIVE REPORT PATIENT : AGE : 43 SEX : FEMALE PREOPERATIVE DIAGNOSIS : MULTIPARITY CERCLAGE IN PLACE ADMITTED WITH PREMATURE PRETERM RUPTURE OF MEMBRANES , AND ABDOMINAL PAIN . , AT 15 WEEKS . INTRAUTERINE PREGNANCY WITH CERVICAL INCOMPETENCE CERVICAL PROCEDURES : REMOVAL OF THE CERCLAGE . POSTOPERATIVE DIAGNOSIS : MULTIPARITY AND STATUS POST CERCLAGE REMOVAL FOR PREMATURE PRETERM , AT 15 WEEKS INTRAUTERINE PREGNANCY WITH CERVICAL INCOMPETENCE , SHORT CERVIX RUPTURE OF MEMBRANES , AND ABDOMINAL PAIN INEVITABLE ABORTION

59871 042.912 034.32 O26.872 Z3A.15 Z64.1

PATIENT : SEX : Female PREOPERATIVE DIAGNOSIS : BILATERAL SUBDURAL HEMATOMAS . PROCEDURES : BILATERAL BURR HOLE X 2 , DRAINAGE OF BILATERAL SUBDURAL HEMATOMAS WITH PLACEMENT OF EXTERNAL SUBDURAL DRAINS . POSTOPERATIVE DIAGNOSIS : BILATERAL SUBDURALHEMATOMAS .

61154/50 S06.5X0A

Emergency department visit 75-year-old female History of present illness chief complaint, dizziness, feel shaky the Starla just prior to arrival and is still present, but is improving. It was a bra on sad that has been waxing/Waning after argument with husband. Described as feeling lightheaded. Not described as a sense of rotation, movement, falling or confusion. Not described as feeling, off-balance, faint, or weak all over.

99285/25 93010 93042/59 R42 I10

Patient 52-year-old male Postoperative diagnosis, right ankle displaced, distal, fibula, lateral malleous fracture with Syndesmosis instability Procedure performed right ankle ORIF lateral malleolus with syndesmotic screws

27829/RT with linkage S93.431A And 27792/RT with linkage S82.61XA

PATIENT : AGE : 67 PREOPERATIVE DIAGNOSIS : HERNIA DISC L4-5 . PROCEDURES L4-5 LAMINECTOMY , MEDIAL FACETECTOMY AND DISCECTOMY . POSTOPERATIVE DIAGNOSIS : HERNIA DISC L4-5 LT SIDE

63030/LT M51.26

RADIOLOGY REPORT NAME : SEX : Male AGE : 34 PROCEDURE : CHEST TWO VIEWS , PA AND LATERAL COMPARISON : None . INDICATIONS : Chest pain . Shortness of breath . TECHNIQUE : PA and lateral radiographs of the chest were performed CONCLUSION : Acute Respiratory Distress

71046/26 R06.03

Cardiology 73-year-old male Chief complaint, he is here for postop and medication check

99214 E78.00 Z95.1 Z95.5

Global services Stress, echocardiogram 75 year old male Indication coronary atherosclerosis of native vessels

99214/25 93350 93325 I25.10 E78.5 I51.7 L53.9 Z79.02

Emergency department report 86 year old, female Chief complaint, fall, stroke, head at home

99282 S00.03XA S09.90XA F10.929 Y90.7 W18.30XA Y92.009

Emergency department 78 year old female Chief complaint, shortness of breath The patient has a female status post, right total knee replacement when we could go performed at an outpatient hospital in Fremont California. It was presenting with shortness of breath. I have been getting worse for the last two

99285/25 93010 D64.9 R09.02 I50.9 K92.2 D68.32 T45.516A Z96.651 Z79.01

Emergency department visit 39-year-old male Chief complaint, motor vehicle collision, locations of injuries, chest, abdomen and left knee

99285/25 93010 S20.219A S80.02XA

Emergency Department Report -Critical Patient : AGE : 81 Male CHIEF COMPLAINT : Weak and not eating . HISTORY OF PRESENT ILLNESS : This is a male with severe the last few days . The patient states he has some mild loose weakness , poor urinary output , poor intake of food and fluids , no appetite for stools , no actual vomiting . He denies any significant pain in the belly , no pain in the back or chest , no palpitations or cardiac symptoms . Nobody else is sick with similar symptoms at home.

99291 I95.9 E86.9 D72.829 E87.2 N18.32 A41.9 Z79.01

Emergency department report critical Patient 63-year-old female Chief complaint, abdominal pain, vomiting, and diarrhea History of present illness; this female, who was brought by ambulance, with the sudden onset of severe cramping, abdominal pain associated with multiple episodes of vomiting and several episodes of loose store. She was sleeping with the symptoms began. She states that she spent two hours in the bathroom vomiting, and was very lightheaded and dizzy.

99291 K52.9 I95.9 E86.9 N17.9

RADIOLOGY REPORT NAME : Sex : Male AGE : 87 PROCEDURE : CHEST PORTABLE , 1 - VIEW COMPARISON : XX / 1 / 20XX INDICATIONS : PICC line placement . TECHNIQUE : A single AP portable view of the chest was performed at 1 / 01 / 20XX at 20:56 .

71045/26 Z45.2 R91.8

Emergency department report 18-year-old male Chief complaint, headache, and head injury History of present illness this is an 18-year-old male with history of the above. He states that approximately seven hours ago. He was at high school approximately 1230. He was playing basketball on the court in the gym at school and went up for a layup, another student landed on top of him, getting a knee into the left side of his head. It caused him to fall to the ground, he states he was down on his knees for an unknown period of time PE was over, so there was no further activity at that point.

99282 S09.90XA W50.XXA Y93.67 Y92.310 Y92.213 Y99.8

Progress note Smith, Jeff 44 years old Problem list 1.44-year-old with hypertension, with left ventricular hyper trophy. Chest pain

99214 R07.9 I51.7 I10

Emergency department report Patient name Smith, Pamelia 30 year old female History of present illness, chief complaint, pelvic pain. This started today, and is still present. The symptoms are described as mild.

99284 R10.2 Z33.1

Emergency department visit 83-year-old male Chief complaint, cough, and congestion History of present illness, this milk, complains of cough, congestion, and shortness of breath, worsening over the last few days. The patient's roommate at his local board and care facility has pneumonia. He has had feverish is an increase in congestion, according to the wife.

99291 J18.1 R09.02 I50.1 J44.0 Z95.810 Z87.01

******** PROFESSIONAL FEE SERVICES ******** Robert Jones 101 Ridge Road Apple Creek , MI 42328 Patient Name : Smith , Camy Age : 89 CHIEF COMPLAINT : She is here for pacemaker check and six - month office visit . PROBLEM LIST 1.89 - year - old S / P biventricular pacemaker for cardiomyopathy ( 201X ) . Ejection fraction initially 25 % and improving to 35 % . 2. Moderate LAD stenosis per angiography ( 20XX ) . 3. Echocardiogram ( 01 / 20XX ) showing normal left ventricle . 4. S / P hospitalization for palpitations and chest pain ( 20XX ) diagnosed with pulmonary emboli , right lung ; now maintained on Warfarin 5. Hypothyroidism , on replacement therapy . Complete right bundle - branch block and a left anterior hemiblock . ALLERGIES : Codeine

Look in the CPT index for pacemaker/pacemaker system with leads/device evaluation. The patient has a VIVP speaker that is LV pacing only and this was not performed remotely. Report only pacemaker interrogation modifier 26 and 52. 93279, 93286, 93288, 93294, 93296 Z45.018 I48.0 I42.9

Operation report 56 year-old male Procedure left total knee arthroplasty Postoperative diagnosis primary degenerative joint disease left knee

27447/LT M17.12

Postoperative diagnosis left a bone forearm open fracture displays comminuted due to a gunshot wound ulna and radius. Shafts type two. Procedure performed left forearm intermedullary nailing with acumen intramedullary nails, repeat irrigation of gunshot

25575/LT S52.252C S52.353C

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : Jess Smith AGE : 41 PREOPERATIVE DIAGNOSIS : Bilateral inguinal hernias . POSTOPERATIVE DIAGNOSIS : Bilateral direct inguinal hernias . OPERATIVE PROCEDURE : Laparoscopic bilateral inguinal herniorrhaphy . FINDINGS : The patient had large right and left direct inguinal hernias . There were no indirect components

49650/50 K40.20

AGE : 64 SEX : MALE OPERATIVE NOTE : PREOPERATIVE DIAGNOSIS : Primary Degenerative arthritis of both knees POSTOPERATIVE DIAGNOSIS : Primary Degenerative arthritis of both knees . NAME OF PROCEDURE : Bilateral total knee arthroplasty .

27447/50 M17.0

PATIENT : SEX : MALE AGE : 78 This is a Commercial Payer ( Follow Medicare rules ) DATE OF OPERATION : 1 / 1 / 20XX PREOPERATIVE DIAGNOSIS : RUPTURED QUADRICEPS TENDON - LEFT LOWER EXTREMITY . PROCEDURES : REPAIR OF LEFT QUADRICEPS - LEFT LOWER EXTREMITY . POSTOPERATIVE DIAGNOSIS : SPONTANEOUS RUPTURED QUADRICEPS TENDON LEFT LOWER EXTREMITY .

27385/LT M66.252

Operative note 47-year-old female Post operative diagnosis Localized abdominal Adiposty Left axillary glandular tissue Bilateral breast ptosis Left breast lump upper inner quadrant Procedure performed Bilateral mastopexy Bilateral axillary and chest wall suction assisted lipectomy Excision of left breast lump, upper inner quadrant Abdominoplasty with upper abdomen and flank liposuction

15830 dx linkage Z41.1 E65 L98.7 19316/50 dx linkage Z41.1 N64.81 Q83.1 19120/LT dx linkage N64.81 15877 dx linakage Z41.1 E65 15847 dx linkage z41.1 L98.7 Z41.1 N64.81 N63.22 Q83.1 E65 L98.7

Operation report Post operative diagnosis, reoccurring right breast mass Procedure the patient is a female who has a recurrent mask that was multilobulated in the entire right upper outer quadrant, and also a Separate mass, which was farther away from the nipple out at 9 o'clock position. These were identified. After skin, local infiltration anesthesia was given.

19120-RT Diagnosis codes N63.11 N63.13

Operative note Postoperative diagnosis bilateral breast hypoplasia Operative procedure bilateral argumentation using mentor moderate Dash plus profile, silicone field, implants, volume 375 mL, serial number on the patient left is XXX

19325/50 Z41.1 N64.82

PATIENT : SEX : MALE AGE : 68 PREOPERATIVE DIAGNOSIS : REMOVAL OF HARDWARE DUE TO PAIN STATUS POST OP - KNOWLES PIN ( X 3 ) FIXATION OF RIGHT HIP PROCEDURES : REMOVAL OF KNOWLES PIN X 3 ; RIGHT HIP . POSTOPERATIVE DIAGNOSIS : REMOVAL OF HARDWARE DUE TO PAIN / STATUS POST OP - KNOWLES PIN ( X 3 ) FIXATION OF RIGHT HIP

20608 T48.84XA

PATIENT : SEX : MALE AGE : 62 Private Payer ( Medicare rules for 65 and older ) PREOPERATIVE DIAGNOSIS : RIGHT LOWER END TIBIA STATUS POST ORIF WITH RETAINED SYNDESMOTIC SCREW , LEFT LOWER END TIBIA STATUS POST EXTERNAL FIXATION WITH RETAINED HARDWARE . RIGHT LEG PROCEDURES : RIGHT LOWER END TIBIA REMOVAL OF SYNDESMOTIC SCREWS , LEFT LOWER END TIBIA REMOVAL OF EXTERNAL FIXATOR . RIGHT LEG POSTOPERATIVE DIAGNOSIS : RIGHT LOWER END TIBIA STATUS POST ORIF WITH RETAINED SYNDESMOTIC SCREW AND LEFT LOWER END TIBIA STATUS POST EXTERNAL FIXATION WITH RETAINED HARDWARE . RIGHT LEG

20680/RT 20694/59-LT S83.301D Z47.89

PATIENT : Age : 68 Sex : Male PREOPERATIVE DIAGNOSIS : PROLAPSE RECTUM . PROCEDURES : REDUCTION OF PROLAPSED RECTUM UNDER ANESTHESIA . POSTOPERATIVE DIAGNOSIS : PROLAPSE RECTUM .

45900 K62.3

Age 82 Sex : FEMALE This is a Commercial Payer ( Follow Medicare rules . External causes are NOT required ) Date of Service : 1 / 1 / 20XX Service Department : Orthopedic Group General PREOPERATIVE DIAGNOSIS : Pathological fracture , thoracic spine , T11 . SECONDARY DIAGNOSIS : Osteoporosis T12 ( senile osteoporosis ) . NAME OF PROCEDURE : 1. Percutaneous vertebroplasty , one vertebral body , unilateral , with cavity creation , including biopsy 2. Percutaneous vertebroplasty , one vertebral body , unilateral , thoracic .

22513-79 22515-79 M80.08XA M81.0

PATIENT : AGE : 60 SEX : MALE PREOPERATIVE DIAGNOSIS : RIGHT CRANIAL DEFECT . PROCEDURES : RIGHT CRANIOPLASTY WITH WIRE MESH AND METHYL METHACRYLATE . POSTOPERATIVE DIAGNOSIS : RIGHT CRANIAL DEFECT .

62140 M95.2 Z87.820

PATIENT : AGE : 60 SEX : MALE PREOPERATIVE DIAGNOSIS : WOUND INFECTION . PATHOLOGY CONFIRMED : STAPHYLOCOCCUS PROCEDURES : REOPENING OF RIGHT FRONTOTEMPORAL PARIETAL CRANIOTOMY INCISION WITH WOUND DEBRIDEMENT REMOVAL OF METHYLMETHACRYLATE / MESH CRANIOPLASTY ; COMPLEX WOUND CLOSURE . POSTOPERATIVE DIAGNOSIS : WOUND INFECTION , STAPHYLOCOCCUS

62142/78 T81.42XA B95.8

OPD7024 PATIENT : SEX : FEMALE AGE : 20 PREOPERATIVE DIAGNOSIS : PSEUDOTUMOR CEREBRI . PROCEDURES : PLACEMENT OF A LUMBOPERITONEAL SHUNT . POSTOPERATIVE DIAGNOSIS : PSEUDOTUMOR CEREBRI .

63741 - Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other, NOT incl laminectomy G93.2 - Pseudtumor Cerebri

PATIENT : AGE : 77 SEX : MALE PREOPERATIVE DIAGNOSIS : CHRONIC BLEB LEAK , RIGHT EYE . PROCEDURES : REVISION OF TRABECULECTOMY AND REPAIR OF BLEB LEAK RIGHT EYE . POSTOPERATIVE DIAGNOSIS : CHRONIC BLEB LEAK , RIGHT EYE .

66250/RT H59.89 Z98.93XA

** GLOBAL FEE ** RADIOLOGY REPORT NAME : Sex : Male Age : 74 PROCEDURE : CT HEAD WITHOUT CONTRAST COMPARISON : None . INDICATIONS : Status - post fall with loss of consciousness . TECHNIQUE : Noncontrast head CT was performed with axial 5 mm reformations . CONCLUSION : 1. SMALL RIGHT SIDED SUBDURAL HEMATOMA WITH MILD MASS EFFECT .

70450 S06.5X9A

****** PROFESSIONAL FEES ****** RADIOLOGY REPORT NAME : SEX : Female AGE : 72 PROCEDURE : CT HEAD WITHOUT CONTRAST INDICATIONS : Altered level of consciousness ( Loss of Consciousness LOC ) Patient in coma TECHNIQUE : Noncontrast head CT was performed with axial 5 mm reformations .

70450/26 R40.20

OPD7033 ** GLOBAL ** RADIOLOGY REPORT NAME : Sex : F AGE : 75 PROCEDURE : MRI BRAIN WITHOUT CONTRAST COMPARISON : CT study dated 08 / 30 / 20XX . INDICATIONS : Encephalopathy . Question of a pineal cyst . TECHNIQUE : Sagittal FLAIR ; axial T1 , FLAIR , fast spin echo T2 , and diffuse weighted images were obtained . CONCLUSION : 1. Encephalopathy

70551 - MRI (eg proton) brain (including brain stem) without contrast G93.40 - Encephalopathy unspecified

Study performed at Hospital - Global Fee PROCEDURE : MRI ORBIT WITHOUT AND WITH CONTRAST MRI BRAIN WITHOUT AND WITH CONTRAST Patient : Sex : Male Age : 52 COMPARISON : None . INDICATIONS : Pain in both eyes . TECHNIQUE : Sagittal T1 : axial FLAIR ; TSE T2 , and DW ; coronal and axial T1 pre and post gadolinium , and coronal TSE T2 weighted images through the orbits ; sagittal , axial , and coronal post gadolinium T1 weighted whole brain images .

70553 70543 H57.13

Robert Jones, 1:0 one Ridge Rd., Apple Creek, MI 42328 Progress note Patient name Smith, Jeanette Age 58 Chief complaint, she is here for a four month check up

99213 I25.5 Z95.1 Z95.5 Z95.810 Z79.02

EMERGENCY DEPARTMENT Patient : Sex : Male AGE : 95 HISTORY OF PRESENT ILLNESS Chief Complaint : COUGH , FEVER and CHILLS . This started 1 1/2 weeks ago and is still present . It was gradual in onset and has been constant . The illness is described as severe . He has had a cough and chills . The patient has had He has had a subjective fever . No sputum production , muscle aches , sore throat , hoarseness or nasal congestion . difficulty breathing on exertion and at rest .

99285/25 93010 J20.9 N17.9 R09.02 Z79.82

PATIENT : SEX : FEMALE AGE : 78 PREOPERATIVE DIAGNOSIS : A GANGRENE OF RIGHT THIRD TOE . PROCEDURES : OPEN AMPUTATION OF RIGHT THIRD TOE . POSTOPERATIVE DIAGNOSIS : A GANGRENE OF RIGHT THIRD TOE .

28820/T7 E11.52

OPERATIVE NOTE PATIENT : AGE : 35 SEX : Male PREOPERATIVE DIAGNOSIS : Biliary colic . POSTOPERATIVE DIAGNOSIS : Biliary colic . OPERATIVE PROCEDURE : Laparoscopic cholecystectomy .

47562 K80.50

OPERATIVE REPORT PATIENT : AGE : 50 SEX : FEMALE PREOPERATIVE DIAGNOSIS : PERIMENOPAUSAL BLEEDING . PROCEDURES : HYSTEROSCOPIC HYDROTHERMAL ENDOMETRIAL ABLATION POSTOPERATIVE DIAGNOSIS : MYOMA AND ENDOMETRIAL POLYPS

58563 D25.0 N84.0

SEX : Male Age 68 This is a Commercial Payer ( Follow Medicare rules . External causes are NOT required ) PREOPERATIVE DIAGNOSIS : Previous spinal fusion at the L5 - S1 level with stenosis at L4 - L5 with claudication . POSTOPERATIVE DIAGNOSIS : Previous spinal fusion at the L5 - S1 level with stenosis at L4 - L5 with claudication NAME OF PROCEDURE : Repeat spinal surgery . Lumbar laminotomy L4-5 with foraminotomy .

63042-LT M48.062 Z98.1

RADIOLOGY REPORT NAME : Sex : Female AGE : 77 PROCEDURE : X - RAY CHEST , ONE VIEW COMPARISON : XX / 13 / 20XX INDICATIONS : Post valve replacement . TECHNIQUE : A single AP portable view of the chest was performed . CONCLUSION : 1. INTERVAL REMOVAL OF THE RIGHT INTERNAL JUGULAR SWAN - GANZ CATHETER AND SHEATH OTHER SUPPORT LINES AND TUBES ARE UNCHANGED . 2. CARDIOMEGALY AND CHANGES OF PREVIOUS STERNOTOMY . UNCHANGED LEFT LUNG BASE OPACITY OBSCURING THE LEFT DIAPHRAGM , LIKELY ATELECTASIS . 44 ° F Mostly cloudy

71045 Z48.812 I51.7 R91.8 Z95.2

PROFESSIONAL FEE ** RADIOLOGY REPORT NAME : SEX : Female AGE : 90 PROCEDURE : CHEST , ONE VIEW COMPARISON : 05 / 29 / 20XX . INDICATIONS : Mid anterior chest pain . TECHNIQUE : An AP portable chest radiograph was obtained on 01 / 1 / 20XX at 11:01 a.m. CONCLUSION : No acute chest abnormalities .

71045/26 R07.89

** PROFESSIONAL FEE ** RADIOLOGY REPORT NAME : Sex : Female AGE : 60 PROCEDURE : CHEST , ONE VIEW COMPARISON : OX / 30 / 20XX . INDICATIONS : Follow - up . Mechanical ventilation . TECHNIQUE : A single AP semierect portable view of the chest was performed . CONCLUSION : 1. Support lines and tubes are unchanged . 2. Minimal left basilar linear opacity , likely atelectasis .

71045/26 Z45.0 R91.8 Z99.11 Z93.1 Z93.0

NAME : Sex : Female AGE : 64 PROCEDURE : X - RAY CHEST TWO VIEWS , PA AND LATERAL COMPARISON : None . INDICATIONS : Fever , cough , and weakness . TECHNIQUE : PA and lateral radiographs of the chest were performed . CONCLUSION : 1. CARDIOMEGALY 2. PATCHY AIR SPACE CONSOLIDATION IN THE RIGHT LOWER LOBE - LOBAR PNEUMONIA

71046/26 I51.7 J18.1

***** PROFESSIONAL FEE ***** RADIOLOGY REPORT NAME : Smith , Abby SEX : Female AGE : 52 PROCEDURE : X - RAY CHEST TWO VIEWS , PA AND LATERAL COMPARISON : None . INDICATIONS : Cough TECHNIQUE : PA and lateral radiographs of the chest were performed . CONCLUSION : NORMAL TWO VIEW CHEST .

71046/26 R05.9

GLOBAL SERVICES ** PROCEDURE : MRI LUMBAR SPINE WITHOUT CONTRAST Patient : Sex : Female Age : 62 COMPARISON : None . INDICATIONS : Lower back pain . Question degenerative disc disease . TECHNIQUE : Sagittal T1 , TSE T2 , STIR ; axial TSE T2 images parallel to the disc spaces ; coronal TSE T2 weighted .

72148 M51.36 M47.817

** PROFESSIONAL FEE ** NAME : Sex : Male AGE : 7 PROCEDURE : MRI LUMBAR SPINE WITHOUT CONTRAST COMPARISON : None . INDICATIONS : Frequent urinary incontinence , epilepsy , question of tethered cord . TECHNIQUE : Sagittal T1 , FSE T2 , STIR ; axial FSE T2 images parallel to the disc spaces CONCLUSION : 1. NORMAL STUDY .

72148/26 G40.909 R32

***** GLOBAL SERVICES ******* Patient : Sex : Male Age : 62 COMPARISON : None . INDICATIONS : Right shoulder pain with decreased range of motion . PROCEDURE : MRI RIGHT SHOULDER WITHOUT CONTRAST TECHNIQUE : Axial T2 GRE ; oblique coronal TSE PD fat sat , TSE T2 fat sat , T1 weighted ; oblique sagittal T1 , and TSE PD fat sat sequences . FINDINGS : ROTATOR CUFF : There is a laminated interstitial tear at the conjoined distal supraspinatus / infraspinatus tendon . No full thickness rotator cuff tear is present MUSCLES : Normal in signal and volume . No fatty infiltration , edema , or atrophy . LIGAMENTS : The glenohumeral ligaments are intact . The coracoclavicular , LABRUM : There i is a detached but nondisplaced tear of the posterior labrum . The superior , anterior , and inferior labra are intact . coracoacromial , and coracohumeral ligaments are intact .

73221/RT M24.111

PROFESSIONAL FEE ** NAME : AGE : 27 Gender : M PROCEDURE : RIGHT TIBIA + FIBULA X - RAY , TWO VIEWS . COMPARISON : None . INDICATIONS : Shin pain . FINDINGS : BONES : No acute fracture or displacement . No evidence for periosteal reaction . SOFT TISSUES : No radiopaque foreign bodies identified . OTHER Negative . CONCLUSION : No acute ossific abnormality

73590/26/RT M79.661

RADIOLOGY REPORT NAME : Sex : M AGE : 31 PROCEDURE : X - RAY ABDOMEN / KUB SUPINE , ONE VIEW COMPARISON : None . INDICATIONS : Abdomen pain . History of stones . TECHNIQUE : A single AP supine view of the abdomen was performed . CONCLUSION : 1. NORMAL EXAM . NO KIDNEY STONES IDENTIFIED .

74018 R10.9 Z87.442

** GLOBAL FEES ** NAME : Sex : Female Age : 41 PROCEDURE : LEFT BREAST ULTRASOUND INDICATIONS : Question of a left breast mass , prior screening mammogram was inconclusive due to dense breast tissue . TECHNIQUE : Left breast ultrasound was performed , evaluating specific areas of concern . The breast was NOT scanned in entirety FINDINGS : Ultrasound was performed over the area in question . We cannot identify any mass associated with the skin marker . Echo pattern of the breast is very homogeneous . CONCLUSION : Normal exam .

76642/LT Z12.39 R92.2

***** GLOBAL SERVICES ****** PROCEDURE : ABDOMINAL ULTRASOUND Patient : Sex : Female Age : 62 COMPARISON : None . INDICATIONS : Abdominal pain . TECHNIQUE : High - resolution sonographic examination was performed of the abdomen . CONCLUSION : Negative abdominal ultrasound . No evidence of cholelithiasis , cholecystitis , or bile duct dilation .

76700 R10.9

***** GLOBAL SERVICES ******* PROCEDURE : TRANSABDOMINAL PELVIC ULTRASOUND Patient : Sex : Female Age : 27 COMPARISON None . INDICATIONS : Routine monitoring of IUD placement . TECHNIQUE : A pelvic ultrasound was completed in the usual manner . CONCLUSION : 1. Intrauterine device in the endometrial cavity . 2. Otherwise , negative transabdominal only pelvic ultrasound .

76856 Z30.431

OFFICE - POST OP Patient : Sex : Female Age : 67 SUBJECTIVE : The patient is status post numerous episodes of sclerotherapy for venous insufficiency , at least three now . last one two days ago . She has also had one microthrombectomy . She states that overall , the veins treated individually feel okay but there has been no significant improvement in the overall swelling of her legs and the right remains the same as the left . Measurements today demonstrate 41 cm symmetric bilaterally . There is some discoloration along the treated segments of veins . These are somewhat tender to touch but there is no evidence for inflammation . It appears to me that there is some improvement overall in the telangiectatic and reticular pattern of the right compared to the left leg ; however , because she has no significant improvement in the swelling , which was the goal , I am reticent to continue further with extensive sclerotherapy . I discussed with her the option of targeting those individual varicose veins that are painful and closing those down . She states the one along the lateral left thigh and calf region is large and painful on occasion . After further discussion , it was decided to target that vein next week . I would like to wait an additional week before continuing treatment PLAN : Sclerotherapy follow - up . Treatment to continue next week

99024 Z48.812 I87.2

Examination first visit Patient Velma Smith 79-year-old female Weight 155 pounds History the patient is self refer to our clinic. She's a female and has a main complaint of her legs hurting. She has some component of unsightly veins in both legs. She has heaviness in tiredness and pain in her right leg. The heaviness in tiredness is in both legs. She has a component of itching bilaterally.

99203 I83.893 I83.813 D68.51 Z79.01 Z86.718 Z96.642

Office visit 86 year old, female New patient visit; the patient has a female with complaints of a three week history of low back pain radiating laterally across her, but all region into her lateral right knee. She states that approximately three weeks ago she attempted to lift her husband who she cares for at their home. The pain has progressed since that time and is described as a sharp and stabbing in character and graded 10 out of 10.

99203 M53.3 M25.561 M54.6 M54.50

CARDIOLOGY - NEW PATIENT Patient Name : James Smith AGE 82 HISTORY OF PRESENT ILLNESS : Patient asbestosis and pulmonary hypertension . He has had some evaluation of exertional 12 / 01 / 20XX . This showed enumerable calcified pleural plaques compatible is a male , new pt , referred by his physician with a history of pulmonary shortness of breath per his physician , leading to a CT scan of the chest an with prior asbestos exposure as a carpenter , slight basilar scarring CORONARY RISK FACTORS 1. Hypertension for four years 2. He is not obese , BMI 29 . 3.Nonsmoker . 4 Nondiabetic 5. No recent lipid panel .

99204 I49.3 J61 I27.23 I34.0 I34.1 R55 Z77.090

Post Op and followup visit - S / P aortic valve surgery by Dr. Jones Patient Name : Sex : Female Date of Birth 01/01/1959 PROBLEM LIST 1. Female with five weeks S / P St. Jude aortic valve 2. Medical Center visit 10 days ago for chest wall pain associated replacement for severe symptomatic aortic valve stenosis . with diuretics with shortness of breath , sinus tachycardia and fluid retention , managed

99204 I97.89 R60.0 Z95.2 Z79.01

Procedure clinic visit new patient 73-year-old female History the patient is a female referred by Dr. Thomas for a nonhealing left great toe wound. She is being taken care of at a care center with frequent hyperbaric therapy with no significant change in the womb. She denies diabetes. .

99204 L03.032 T82.898A I73.9 Z79.01

NEW PATIENT Patient Name : Smith , Bertha Sex : Female AGE : 25 HISTORY OF PRESENT ILLNESS : New female pt , who is 32 weeks pregnant and here for tachycardia , which is not affecting the pregnancy . She has had isolated episodes of this problem prior to pregnancy ; however this has become more of an issue over the last several weeks . She notes episodes of tachycardia at rest associated with some shortness of breath . Prior to this , she has been healthy , physically active . She has been obese , weighing approximately 220 pounds prior to her pregnancy . She has not been hypertensive . She has no chest pain . CORONARY RISK FACTORS 1. No hypertension 2. She is pregnant . 3. Nonsmoker . 4. Nondiabetic . 5. Glucose tolerance test performed at 28 weeks : Results not available . 6. Cholesterol level is not known .

99204 R00.0 Z33.1 E66.9

Patient Name : Sex : Female Age : 71 HISTORY OF PRESENT ILLNESS : The patient is a widowed woman who had been referred for cardiovascular management . She is 12 years S / P coronary artery bypass graft surgery . She states this was precipitated by developing chest pain . She was told she had two silent heart attacks previously CORONARY RISK FACTORS 1. History of hypertension for five years . 2. Noninsulin dependent diabetes mellitus for five years , which is well controlled with fasting glucose level in the 90s . 3. She has been treated for hyperlipidemia . 4. Fasting lipids ( 01 / 01 / 20XX ) : Total cholesterol 146 , triglycerides 187 , HDL 51 , LDL 58 .

99204/25 93010 I25.2 I10 E11.9 E78.5 Z82.49 Z95.1 Z79.84

PROGRESS NOTE Patient Name : Sex : Male AGE : 70 CHIEF COMPLAINT He is here for a six - month check . PROBLEM LIST 1. Patient with history of 10-15 + years of paroxysmal atrial fibrillation ( none since 20XX ) . 2. Hypertension . 3. Hyperlipidemia . 4. Sleep apnea , using oral device .

99213 G47.30 I10 E78.00 Z79.82

Progress note 62 year old, female Chief concerned, she is here for a one month to check A female who is six years as/P to vessel, coronary stent Progressive decline and exercise capacity with shortness of breath and chest pain. No evidence of ischemia per recent nuclear, cardiac stress test Six years s/P. DDD - are pacemaker for sick sinus syndrome Hypertension Obstructive sleep apnea compliant with CPAP

99213 I27.9 G47.33 F33.1 I10 Z95.5 Z99.89

Office visit established patient 52-year-old male Subjective the patient is seen back in clinic. Keep her sis with a component of edema in the right leg, however, it is markedly improved. An ultrasound ordered at a prior visit is review. The patient has been wearing his compression socks from Medi and they have been working well. He has not had an allergic reaction to them. Overall, he is pleased. He has been continue his pneumatic compression boot twice a day as well.

99213 R60.0

OPD7099 PROGRESS NOTE Patient Name : Smith , Wilma AGE : 94 CHIEF COMPLAINT : She is here for echocardiogram results . PROBLEM LIST 1.94 - year - old with pulmonary hypertension , most severe at 86 mmHg , now 45 mmHg on Letairis and Revatio . She remains oxygen dependent . 2. Hospitalized ( 01 / 20XX ) for anemia , transfused with 2 units of packed RBCs . 3. Hospitalized ( 01 / 20XX ) for pneumonia , pleural effusions requiring thoracentesis , and increased pulmonary hypertension . 4. Dual chamber pacemaker upgrade from VVI to DDD ( 01 / 20XX ) . 5. S / P community acquired pneumonia ( 01 / 20XX ) ; resolved with treatment . 6. Paroxysmal atrial flutter and atrial fibrillation with 2 : 1 A - V block . 7. Sick sinus syndrome , S / P single chamber VVI pacemaker ( 01 / 20XX ) . 8. History of coronary artery disease , S / P right coronary stent ( 8+ years ago ) . 9. Hypothyroidism , on replacement therapy . 10. Hypertension ; markedly labile and difficult to control secondary to left ventricular noncompliance and aortic inelasticity 11. History of gout . 12. History of osteoporosis .

99213 - Low/Md I10 - High blood pressure (hypertensive disease) I27.20 - Pulmonary Hypertension Z95.0 - Presence of cardiac pacemaker Z79.01 - Long term use of anticoagulants Z99.81 - Dependence on Oxygen

Office follow up 60 year old female Problem list 1.60 year old S/P Cabomedics, mechanical, aortic valve replacement for severe valve stenosis 2. Hypothyroidism on replacement therapy 3.hyperlipidemia. 4.iron deficiency anemia, secondary to menorrhagia now, resolved following hysterectomy 5.degenerative disc disease.

99214 E78.2 G47.33 Z95.2 Z79.01 Z99.89

Progress note, establish patient Patient name Smith, Jerri Reason for 1.67-year-old with cardiac murmur for evaluation. 2.incidental asymptomatic, hypercalcemia

99214 I42.1 I34.8

OFFICE - ESTABLISHED Patient Name : Sex : Female AGE : 79 CHIEF CONCERN : She is here for test results . PROBLEM LIST 1. Patient with chronically occluded proximal left anterior descending coronary artery , with extensive right LAD collaterals , with preserved left ventricular systolic function . 2. Idiopathic thrombocytopenic purpura , refractory to high - dose steroids requiring pr.n. platelet transfusions .

99214 J44.9 I34.0 Z86.73

Establish patient Cardiology 90 year old female Problem list One dot a female 14 years ago S/P door chamber, pacemaker for a complete heart block, generator replace for battery at end of life status three years ago 2.hypertension. 3.multivessel CABG. 4.chronic lumbosacral pain. 5.hyperkalemia, associated with renal tubular dysfunction. 6.hypothyroidism on replacement therapy. 7.mild COPD.

99214 J44.9 Z95.0 Z86.79

Office visit establish patient Patient name Smith, Victor 62 years old Problem list 1.patient with nonischemic cardiomyopathy, ejection fraction initially 25% now 55 to 60% 2.chronic atrial fibrillation with difficulty controlling ventricular rate. 3.history of persistent thrombosis in the left atrial appendage, already on warfarin for atrial fibrillation 4.3 years s/p AICD/VV,I pacemaker

99214 I51.7 I42.0 Z95.810 Z79.01

OPD7101 PROGRESS NOTE Patient Name : Smith , Dan AGE : 82 CHIEF COMPLAINT : Today he is here for six - month check and echocardiogram results . PROBLEM LIST 1.82 - year - old with history of early constrictive pericarditis , secondary to acute pericarditis , treated with prednisone . 2. History of progressive increase in white cell count increasing from pericardial effusion and thickening secondary to recent pericarditis : so far refractory to steroid therapy with left heart catheterization showing normal coronary arteriogram and left ventriculogram . Findings consistent with constrictive pericarditis . 3. Normal coronary arteriogram ( OX / 20XX ) . 4. Pulmonary infiltrates settling on recent CT scan . 5. S / P left anterior descending and diagonal branch stenting ( 20XX ) with residual diffuse circumflex disease . 6. Mild to moderate ischemic cardiomyopathy , ejection fraction initially 40 % , now 65 % . 7. 13+ year history of hypertension . 8. Hyperlipidemia . 9. Glaucoma .

99214 - Moderate MDM R60.0 - Hypertensive Heart Disease w/o Heart Failure I11.9 - Localized Edema

OPD7107 Progress note Patient's name Smith, Jennifer 75 years old Chief complaint, she is here for echo and medication check

99214 Moderate MDM I51.89 - other ill-defined heart diseases (hyperkinetic left ventricle) I10 - Primary hypertension J44.9 - Chronic COPD unspecified Z95.1 - Coronary artery bypass graft Z95.3 - Presence of prosthetic heart valve Z99.81 - Dependence on other enabling machine, oxygen

Professional fee services Establish patient Patient name Smith, Beatrice 84 years old Chief complaint, she is here for three month check up and pacemaker interrogation

99214/25 93288/26 dx link I48.20. Z45.018 I10 I48.20 R42 T44.7XA Z45.018 Z79.01

********* PROFESSIONAL FEE SERVICES ********** Robert Jones 101 Ridge Road Apple Creek , MI 42328 Patient Name : Smith , Abagail AGE : 91 CHIEF CONCERN : She is here for three - month check and pacer check . PROBLEM LIST 1. A female with hospitalization ( / 20XX ) for recurrent ventricular tachycardia , associated dizziness and syncope , managed with amiodarone . Normal left heart cath . 2. Severe ischemic cardiomyopathy , ejection fraction 15 % . 3.5 / P DDD / AICD pacemaker ( 20XX ) for sick sinus syndrome . 4. S / P generator replacement for battery ( 20000 5.S / P dual chamber pacemaker implant ( 2000 . 6. Complete proximal dominant RCA occlusion , 60 % mid - LAD stenosis , normal circumflex 7. Nonsustained ventricular tachycardia B. Hypothyroidism , on replacement therapy . 9.5 / P MI ( 19 ) 00

99214/25 93289/26 I47.2 E03.9 R21 Z45.02 Z79.02

Global services 61 years old, female Problem list 1.12 years S/P two vessel CABG 2.hypertension. 3.hyperlipidemia.

99214/25 93350 dx link I42.5 93325. Dx link I42.5 I42.5 G47.30 E78.5 I10 Z79.82 Z95.1

GLOBAL SERVICES *************** Patient is seen in the outpatient hospital setting . Robert Jones 101 Ridge Road Apple Creek , MI 42328 Patient Name : Smith , Bernie Date of Birth : 01/06/1938 Attending Physician : Referring Physician : Date : 01 / 01 / 20XX PROBLEM LIST 1.74 year old with history of marked left ventricular diastolic dysfunction , secondary to pulmonary hypertension . 2. Four years S / P coronary artery stent . 3. Chronic atrial fibrillation with history of uncontrolled rate intermittently . 4. Severe sleep apnea ; on CPAP and oxygen as Rx'd . 5. Type 2 diabetes , difficult to control . 6. Questionable history of COPD .

99214/25 all linked 93351/26 link 127.22. I48.20 Z95.5 I27.22 I48.20 G47.33 Z95.5 Z99.89 Z99.81

OPD7104 Report physician services Patient's name Smith, Bernie Date of birth, 01/06/1938 Problem list 1.74 year old with history of marked left, ventricular, diastolic dysfunction, secondary to pulmonary hypertension. 2.4 years S/P coronary artery stent. 3.chronic atrial fibrillation with history of uncontrolled rate, intermittently 4.severe obstructive sleep apnea; on CPAP and oxygen. 5.type two diabetes, difficult to control. 6.questional history of COPD.

99214/25. All 93351/26 - Stress EKG/Echo link I27.22 I48.20 Z95.5 I27.22 - Pulmonary Hypertension due to left heart disease I48.20 G47.33 - Obstructive Sleep Apnea Z95.5 - Presence of Coronary Artery Stent Z99.89 Z99.81 - Dependence on Supplemental Oxygen

Emergency Department Report Patient : AGE : 90 Male HISTORY OF PRESENT ILLNESS Chief Complaint - FALL Location of injuries ( Right Should Fell ( between his bed and wall . Lay there until Hip , Knee ) . The injury occurred yesterday . found this AM by Meals on Wheels Occurred at his private home The patient complains of mild pain . No blow to the head , neck pain , loss of consciousness or seizure . Not dazed .

99219/25 93042 S70.01XA S80.01XA R41.0 F03.90

Emergency Department Report - Admitted to Observation Patient : Sex Female Age 86 HISTORY OF PRESENT ILLNESS Chief Complaint : PITA FAST HEART RATE and DIZZINESS . This started today and is still present . It is described as a fast heart beat . The patient complains of dizziness and weakness . Modifying factors- worsened by walking and exertion . Relieved by rest . She has had difficulty breathing ( today ) . The patient has had dizziness . No chest pain or discomfort , sweating episodes , fainting episodes tingling . No muscle spasms .

99220/25 93010 R06.00 R55 R00.2 R09.02 I51.7 Z79.82 Z95.2

Emergency department visit 77-year-old female History of present illness Chief complaint single syncopal episode. It was abrupt in onset and has been constant. There's a car just prior to arrival. She has recovered. Event was witness. At time of event, she was standing for a brief time. She had preceding symptoms of lightheadedness and nausea. No proceeding symptoms of chest pain. She felt faint, lost consciousness was apnecic and collapse. The patient was incontinent of feces. No seizure activity. Had a single episode. The episode was brief.

99220/25 93010 93042/59

Emergency department report 62 year old, female Chief complaint, body fluid exposure

99281 F41.9

Emergency Department Report Patient : AGE : 61 Male CHIEF COMPLAINT : Left hip pain . HISTORY OF PRESENT ILLNESS : This is a male who had been jogging , on residential street , today and after jogging felt as if he had some denies diarrhea or constipation . He denies any hematochezia pain just superior to his left hip . He did not have any injury . The onset was gradual . He denies any abdominal pain , nausea or vomiting . He or melena . He denies any other acute complaints . He does have some he uses them more . He is right - handed and complains of some right elbow pain when complaints of some chronic pains in his joints when he is mopping and doing his usual activities . This has not been occurring currently or even in the last few days but does occasionally bother him .

99281 S39.013A M77.11

Emergency department visit 16-year-old male Chief Complaint, elbow pain History of present illness; this is a male who, in a baseball game was pitching a ball hard and heard a pop in his elbow with subsequence soreness with range of motion or palpation sense. He denies numbness or tingling. Denies any shoulder pain. Denies any prior similar problems. He has had somewhat some more pain in the past after the pictures too much of throws too hard. In fact, his father states he has been telling him about warming up properly.

99282 M77.1

Emergency Department Report Patient : AGE : 6 Male CHIEF COMPLAINT : Fever . intermittent raspy breathing , cough as well as a throat pain . Patient's mom states that he has been having generalized body aches and has been getting Motrin for his symptoms , last given at about 8:00 a.m. this HISTORY OF PRESENT ILLNESS : This is a male who comes in today with mom who developed a fever yesterday with associated getting a real clear focus of his complaints is difficult . He morning . He was seen here last night and diagnosed with a prescription for Tylenol and is concerned that his fevers have not been very well the Tylenol and thought she would come back by here for recheck . She well . He has had some decreased activity but is otherwise acting fairly urinary symptoms . Has not had any rashes . Has not had any sick contacts . He is up to date on his immunizations . probable viral syndrome . He returns today after mom did not fill the controlled . She was in the area to get the prescription for denies any vomiting or diarrhea . He has been eating and drinking normal without any sign of respiratory distress . He has not had any sick contacts.

99282 R50.9 R05.9 R09.89 J45.909 Z85.831

Emergency Department Report Patient AGE : 32 Male CHIEF COMPLAINT : Left arm pain . HPI : This is a male man who fell on his left arm . This happened about 2 hours ago . He was playing with his kids , at his single family private home , and tripped over one of them and fell . He has some numbness in his fingers at baseline due to a history of frostbite . However , he has no new paresthesias . He did not take any medication for it . He denies any other trauma including head trauma . He denies loss of consciousness .

99282 S50.812A S50.12XA

Emergency Department Report Patient : AGE : 4 - Female CHIEF COMPLAINT : Elbow pain . HISTORY OF PRESENT ILLNESS : This is a female injury while horsing around with her brother yesterday . Her brother , who who was seen over at one of our prompt cares after persistent left elbow pain from an wanted to move her arm since that time . She seemed to be quite tender last night and apparently is 7 , was twisting her arm last night and she has not bothered by it . Today she continues to not want to and had an x - ray done and was sent over here for further evaluation as there . The family makes comments that after the x - ray was done and the manipulative instantaneously . She since that time has had no signs of distress , use it . They apparently went to Prompt Care over at Hospital was some concern that she may have had a dislocation process of that the patient seemed to be remarkably improved almost has been using her arm normally , and without any discomfort . She has not taken any medication for this today . She was sent over here further evaluation . She did not have any other injuries . She has not had any other complaints .

99283 M25.522

Emergency Department Report Patient : Age : 56 Sex : Female PAST MEDICAL HX : Depression . Mild bacterial gastritis ( ON ABX LAST MONTH ) . Last normal menstrual period was 3 weeks ago . SURGERY HX : Colonoscopy ( LAST MONTH ) . SOCIAL HX : Occasional alcohol use . Nonsmoker . Functional assessment : no impairments noted . The nutritional risk assessment revealed no deficiencies . No report of abuse . No infectious disease exposure . MEDICATIONS : Birth Control Pills Zoloft Oral .

99283 R10.84 R11.2

Emergency department visit 90 year old female Patient arrive by private vehicle comes in my family, a female who complains of difficulty breathing and weakness. She also complains of chest pains on and off for the last three weeks. She has been seen in the past, but did not follow up with Dr. Kramer as recommended at that time.

99283 R53.1 R07.89 R00.2 I25.10 I25.2 Z79.02 Z79.82

Emergency department report 81-year-old male Chief complaint injury to the left hand and left some possible metal. FB. The injury happened possibly three months ago while the patient was in the hospital. This was not an incised wound. Thinks there is a broken needle in the thumb.

99283 Z18.10

OPD7083 Emergency department report 36 year old, female History of present illness chief complaint, allergic reaction and itching. They start about four days ago and is still present persistent. It was gradually Nonset and has been waxing/Waning PT was seen here for an allergic reaction and possible skin infection. She is unable to determine any exact trigger for the allergy and she has never had this before. There is no one else with a rash, every action at work or home, she lives in an apartment with three roommates. She was doing better after treatment three days ago, but tonight developed some itching in the mouth and throat.

99283 - Expanded/Moderate Complexity T78.40XA - Allergy, unspecified XA (initial encounter)

Emergency Department Report Patient : AGE : 31 Female HISTORY OF PRESENT ILLNESS Chief complaint - ABDOMINAL PAIN . This started 3 days ago and is still present . It was gradual in onset . It is not gone now . It is described as pain and it is described as located in the epigastric area . No radiation . At its E.D. , severity described as 8/10 . Modifying factors ( improved with lying in a ball ) . maximum , severity described as 8/10 . When seen in the The patient has an additional complaint of abdominal pain stinging low pelvic pain .

99284 R10.13 R10.2

Emergency department visit 31-year-old female History of present illness Chief complaint headache, this started three days ago. It was gradual in onset. It is now gone. Onset during cannot recall. It is still present. It is described as pain. Described as a global headache. And located in the frontal region. No neck pain. Not located in the facial region at its maximum severely described as eight out of 10.

99284 R51.9 R10.31 R42 R11.2 Z33.1

Emergency department visit 58 year old female Chief complaint fell and diarrhea This is a female she was shoveling snow a few days ago and slipped and fell on her private single residence. Driveway complains of pain over her right forearm, and left tibia, fibula and some scrapes

99284 S50.11XA S80.12XA S80.812A R19.7

OPD7073 Emergency Department Report Patient : AGE : 32 Male CHIEF COMPLAINT : Run over by car . HISTORY OF PRESENT ILLNESS : This is a male who states suffered abrasions to his hands , face , elbow and also mostly trauma to his that last night some car pulled out quick knocked him over , ran over his feet . He feet He states this happened last evening around 10:30 and this morning he cannot ambulate . He states that he woke up this morning and just cannot ambulate . His feet are too abdominal pain . It happened at a low rate of speed . No numbness states that after the injury he was able to ambulate , but he walked home , he went to bed , and he sore . He denies any neck pain , any chest pain , any or tingling in his extremities . No vision changes . No headache he stated

99284 - Moderate complexity S92.002A - unspecified fracture of left calcaneal, initial encounter S93.401A - Sprain of unspecified ligament of right ankle, initial encounter S60.511A - Abrasion of right hand S00.31XA - Abrasion of nose S00.81XA - Abrasion of chin S50.312A - Abrasion of left elbow

Emergency department visit Patient's name Smith, Christiane Chief complaint, chest pain, and discomfort

99284/25 93010 93042/59 R07.89 R10.12 Z33.1

Emergency department visit 63-year-old male History of present illness Chief complaint diarrhea this started today finished argument him and F/UD with Dr. Kramer a week ago and is still present. It was abrupt on onset and has been constant profuse diarrhea. He has had nausea, diarrhea, and abdominal pain. Has recently been on antibiotics. No vomiting, black stools, or bloody stools.

99284/25 93042 93042/76 K52.1 E86.0 T36.0XA

EMERGENCY DEPARTMENT Pt : Female Age : 83 CHIEF COMPLAINT : Vomiting . take of food and fluids and HISTORY OF PRESENT ILLNESS : Female brought by her son with history of nausea , vomiting , decreased worry about her being dehydrated . There was some question of small amount of loose or bloody stools or hematemesis , coffee grounds emesis . The patient was a poor historian . She has been increasingly confused and stool , diarrheal type today . No one has seen black fatigued appearing , according to the son progressively over the last 2 days ..

99285 K86.609 E86.0 R82.81 L89.152 Z85.038 Z80.9

Emergency department report 67-year-old female History of present illness. Chief complaint injury to Chazz location of injuries. Front left Chazz. The injury occurred yesterday. Fail; slept in walls. Balance. Slept getting out of the bathtub yesterday. Patient did not become dizzy or pass out. Occurred at their private home. The patient complains of moderate pain. The patient sustain a blow to the head.

99285 S20.212A S02.5XXA

Emergency Department Report Patient : AGE : 93 Female HISTORY OF PRESENT ILLNESS Chief Complaint - FALL . Location of injuries- head and right shoulder . The injury occurred just prior to arrival . Tripped and fell in the hallway . Occurred at her private residential home . The patient complains of severe pain . The patient sustained a blow to the head . No neck pain , loss of consciousness or seizure . Not dazed .

99285.57 23650/RT 12011/XS/RT S43.014A S01.111A N39.0

Emergency Department Report Patient : AGE : 74 Male HISTORY OF PRESENT ILLNESS : Chief Complaint - SINGLE nurse sent him to PMD Muse office , pt refused to take was witnessed . He had preceding symptoms of light - headedness . No preceding SYNCOPAL EPISODE . It was abrupt in onset . This occurred today ( home care walker , had to walk a long ways , tired in Dr's WR , fainted ) . He has recovered . Event symptoms of nausea , chest pain or abdominal pain . He activity , incontinence or apnea noted . Did not lose pulse . Had a single episode . The caught him on way down ) . No injuries noted . Currently he feels felt faint , lost consciousness , and collapsed . No seizure episode was brief . The episode lasted seconds . Location of injuries ( brother normal .

99285/25 90310 93042/59/ 93042/59/76 R55 I48.91 I50.9 E86.0 N39.0 R64 Z79.01 Z95.810

Emergency department visit 71-year-old female History of present illness chief complaint injury to face location of injuries knows them out the injury car just prior to arrival Fell walking across street after lunch and tripped on street fell hit face on street. Neighbor saw her on the ground and rushed out to help, called EMS and notified brother, occurred on the street.

99285/25 93010 S01.2XXA S02.81XA S00.511A R93.0

Emergency department visit 98 year old female Chief complaint, palpitations, tremor. This started last night, and is still present on site during rest. No history of caffeine use prior to onset, decongestants years prior to onset, cocaine use prior to the onset or anthem Phetamine years prior to the onset. It was graduate onset and has been constant. Is described as a fast, heartbeat and an irregular heartbeat. .

99285/25 93010 N39.0 I48.20 E11.649 R00.0 I10 Z79.84

EMERGENCY DEPARTMENT Patient : DOB : 1/1/1987 Female Private Payer ( Medicare rules for 65 and older ) HISTORY OF PRESENT ILLNESS Chief complaint ABDOMINAL PAIN . This started yesterday and is still present . It is not improving . It was abrupt in onset and has been Modifying factors - worsened by deep breaths . Not relieved by anything . At its constant . It is described as sharp and stabbing and it is described as located in the right chest and the right upper quadrant . No radiation . maximum , severity described as moderate . No nausea , loss of appetite , vomiting or diarrhea .

99285/25 93042 R10.11 R07.1 R91.8 Z33.1

Emergency Department Report Patient : AGE : 47 Male CHIEF COMPLAINT : Aching across front of chest . HISTORY OF PRESENT ILLNESS : This is a male who states about 1 o'clock today he started getting this aching across his chest and into his not think much of it , had no associated left shoulder . He states that it occurred when he was twisting to put his seatbelt on . He thought he just pulled a muscle or something , did symptoms . Kept doing his normal stuff , and exertion did not increase the symptoms . He had no associated shortness of breath , nausea , vomiting , diaphoresis . It seemed to be a little bit worse when he moved his left shoulder , but it was fairly quite nonspecific pain in his shoulder . It was in his chest , seemed to radiate into his posterior aspect of his left shoulder , he states basically like it is underneath the scapula . He states that he took some Advil and got rid of most of the pain . Initially he states he would move his left shoulder and it seemed to make the pain a lot worse . Said he did not really think much about it , but he states he just felt kind of off . Changes in his shoulder seemed to get a little bit worse with range of motion of his neck . He went to work , did his normal stuff . When he came back home told his wife about it , and she felt that the patient should probably be seen . He took an aspirin at home but this was one baby aspirin .

99291 I21.4

60 year old female Postoperative diagnosis degenerative primary osteoarthritis of right shoulder Procedure performed, arthroplasty, glenohumeral joint; Hemiarthroplasty

23470/RT M19.011

46 year old, female Postoperative diagnosis, right shoulder, chronic impingement, AC joint primary arthritis Name a procedure, right shoulder examination under anesthesia arthroscopy ,acrimioplasty, distal clavicle excision

29824/RT 29826/RT M75.41 M19.011

OPD6972 PATIENT NAME : AGE : 70 SEX : FEMALE PROCEDURE PERFORMED : Implantable loop recorder . INDICATIONS : Syncope

33285 - Insertion, subcutaneous cardiac rhythm monitor R55 - Syncope

AGE : 53 SEX : MALE PREOPERATIVE DIAGNOSIS : ANAL CONDYLOMATAS PROCEDURES : FULGURATION OF ANAL CONDYLOMATAS - ANOSCOPY POSTOPERATIVE DIAGNOSIS : ANAL CONDYLOMATAS

46612 99152 A63.0 Z21

Age : 82 Sex : FEMALE This is a Commercial Payer ( Follow Medicare rules . External causes are NOT required ) Date of Service : 1 / 1 / 20XX Service Department : Orthopedic Group General Provider : Dr. OPERATIVE NOTE : PREOPERATIVE DIAGNOSIS : Pathological fracture approximately T - 5 . Possible Malignant neoplasm of vertebral column POSTOPERATIVE DIAGNOSIS : NAME OF PROCEDURE : Percutaneous vertebral augmentation with cavity creation , mechanical device one vertebral body , thoracic

22513/53 M84.48XA

Age : 71 SEX : FEMALE Private Payer Use Medicare rules for 65 and older ) OPERATIVE NOTE : OPERATIVE DIAGNOSIS : Right shoulder partial biceps tendon tearing with full - thickness supraspinatus tear 1 cm NAME OF PROCEDURE : Right shoulder examination under anesthesia , arthroscopy , biceps tendon debridement , Open rotator cuff repair

23412/RT 29824/59/RT M75.121

PATIENT : SEX : MALE AGE : 35 PREOPERATIVE DIAGNOSIS : LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED . PROCEDURES : LEFT CLAVICLE ORIF WITH FLUOROSCOPY . POSTOPERATIVE DIAGNOSIS : LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED . FLUOROSCOPY ( Included in Procedure )

23515/LT S42.022A

Operative note 20-year-old male Postoperative diagnosis left proximal humerus, two-part fracture, growth plate fracture, Salter - Harris type 2 Closed reduction with percutaneous pinning of the left proximal humerus fracture

23605 22-LT S92.022A Modifier 22 is reported for the extra time

EMERGENCY DEPARTMENT - SURGERY Patient : Sex : Male Age : 26 yrs Private Payer ( Medicare rules for 65 and older ) RAD SHOULDER 2 + V LT HISTORY : Fall from Snowboarding , injury . Post reduction . TECHNIQUE : 2 views of the FINDINGS : no significant bone or articular abnormality . IMPRESSION : Negative shoulder MD Radiologist Electronically signed by ( Radiologist ) : MD 01 / 01 / 20XX Reported and Signed by : MD

23655/LT S43.005A

58-year-old female Preoperative diagnosis chronic lateral epicondylitis Name of procedure, lateral tennis, elbow release, left elbow

24359/LT M77.12

Patient 48-year-old male Postoperative diagnosis, non-displaced, right medial column, intra-articular distal humerus fracture Procedure performed right elbow ORIF/medial call him in intra-articular portion with anterior ulnar nerve transposition

24579/RT S42.464A

PATIENT : SEX : MALE AGE : 33 This is a Commercial Payer ( Follow Medicare rules and DO NOT report external causes ) PREOPERATIVE DIAGNOSIS : RIGHT DISTAL RADIUS COMMINUTED INTRAARTICULAR FRACTURE . PROCEDURES : ORIF RIGHT WRIST . POSTOPERATIVE DIAGNOSIS : RIGHT DISTAL RADIUS COMMINUTED INTRAARTICULAR FRACTURE .

25608/RT S52.571A

72-year-old male Postoperative diagnosis left distal radius, intra-articular fracture Name of procedure Open reduction, internal fixation of left distal radius, intra-articular fracture Intraoperative use of fluoroscope

25609/LT S52.572A

PATIENT : Age : 56 Sex : FEMALE PREOPERATIVE : Left Fourth , Third , and Second finger displaced proximal phalanx fractures . POSTOPERATIVE : Left Fourth , Third , and Second finger displaced proximal phalanx fractures . OPERATIVE PROCEDURE : 1. Closed reduction and percutaneous pin fixation left Fourth finger proximal phalanx base fracture . 2. Closed reduction and percutaneous pin fixation left Third finger proximal phalanx fracture . 3. Closed reduction and percutaneous pin fixation left Second finger proximal phalanx fracture

26727/F4 26727/F3 26727/F2 S62.617A S62.615A S62.613A

Age : 81 SEX : MALE PREOPERATIVE DIAGNOSIS : Severe Primary osteoarthritis of the right hip . POSTOPERATIVE DIAGNOSIS : Severe Primary osteoarthritis of the right hip . NAME OF PROCEDURE : Right AML press - fit metal on metal total hip arthroplasty .

27130/RT M16.11

Emergency Department Report Patient : Female AGE : 97 years HISTORY OF PRESENT ILLNESS Chief Complaint - LEFT HIP INJURY . The injury occurred yesterday . Occurred at a nursing home . Patient reportedly had dislocation while having her Depends changed . The patient complains of moderate pain . No blow to the head , neck pain , loss of consciousness or seizure . Not dazed . REVIEW OF SYSTEMS The patient has had fever No numbness , hearing loss , headache , loss of vision or chest pain . No depression , weakness , nausea , bladder dysfunction or laceration . No vomiting . All systems otherwise negative except as recorded above .

27265/LT 99285/57 99152 99153 T84.021A T81.41XA E86.0 Y92.129 Y93.E8

82-year-old male Postoperative diagnosis primary osteoarthritis, right hip Name of sexy girl, right AML pressfit metal on metal total hip arthroplasty

27310/RT M16.11

Operative note 66 year old, female Postoperative diagnosis left knee, lateral bucket handle, meniscal, tear with chondromalacia of knee Procedure performed left knee arthroscopy, Synovectomy, chrondroplasty with open lateral mensical repair

27403/LT 29877/51-LT 29877/LT S83.252A M94.262 Z53.33

PATIENT : SEX : MALE AGE : 63 Private Payer ( Medicare rules for 65 and older ) DATE OF OPERATION : 1 / 1 / 20XX PREOPERATIVE DIAGNOSIS : PRIMARY DEGENERATIVE JOINT DISEASE - RIGHT KNEE Procedures: RIGHT TOTAL KNEE ARTHROPLASTY ( ZIMMER ) . 1. FEMORAL SIZE - SIZE E ; RIGHT . 2. TIBIAL SIZE 6 . 3. ARTICULAR SURFACE - SIZE E - RIGHT ; 10 - MM HEIGHT . 4. TAPER STEM PLUG AND STEM EXTENSION SCREW . POSTOPERATIVE DIAGNOSIS : PRIMARY DEGENERATIVE JOINT DISEASE - RIGHT KNEE .

27447/RT M17.11

Patient 70 year old female Postoperative diagnosis advance, primary degenerative joint - right knee; vagus deformity Procedure performed right total knee arthroplasty

27447/RT M17.11 M21.061

PATIENT : SEX : MALE DOB : 1/1/1967 PREOPERATIVE DIAGNOSIS : LEFT FEMUR FRACTURE PROCEDURES : LEFT FEMUR INTERMEDULLARY NAILING , POSTOPERATIVE DIAGNOSIS : DISPLACED COMMUNITED LEFT FEMORAL SHAFT FRACTURE .

27506/LT S72.352A

PATIENT : AGE : 63 Sex : FEMALE PREOPERATIVE DIAGNOSIS : Arthrofibrosis , both knees . POSTOPERATIVE DIAGNOSIS : Arthrofibrosis , both knees . OPERATIVE PROCEDURE : Manipulation under anesthesia , bilateral knees .

27570/50 - Manipulation of knee joint/gen anesthesia - modifier bilateral M24.662 - Ankylosis - Left knee M24.661 - Ankylosis - Right ,nee Z96.653 - Presence of artificial knee joint bilateral

PATIENT : SEX : MALE Age : 38 PREOPERATIVE DIAGNOSIS : COMMINUTED AND DISPLACED FRACTURE OF THE RIGHT TIBIA - MID SHAFT . PROCEDURES : LOCKING , INTRAMEDULLARY ROD FIXATION - FRACTURED RIGHT TIBIA ; STRYKER . 1. ROD - 375 X 9 - MM . 2. PROXIMAL SCREW - 40 AND 45 X 5 - MM . 3. DISTAL SCREW 35 X 5 - MM . POSTOPERATIVE DIAGNOSIS : COMMINUTED AND DISPLACED FRACTURE OF THE RIGHT TIBIA - MID SHAFT .

27759/RT S82.251A

PATIENT : SEX : FEMALE AGE : 48 This is a Commercial Payer ( Follow Medicare rules . ) PREOPERATIVE DIAGNOSIS : DISPLACED RIGHT LATERAL MALLEOUS ( DISTAL FIBULA ) AND RIGHT ANKLE WITH MORTISE INSTABILITY PROCEDURES : OPEN REDUCTION AND INTERNAL FIXATION RIGHT ANKLE ; LATERAL APPROACH . 1. SEVEN - HOLE SEMITUBULAR PLATE 2. TIMES 4 FULL THREADED CORTICAL SCREWS . 3. TIMES 2 FULL THREADED CANCELLOUS SCREWS . 4. POSTERIOR SPLINT AND MOBILIZATION . 5. TOURNIQUETPNEUMATIC 6 : IMAGE INTENSIFIER CONTROL POSTOPERATIVE DIAGNOSIS : DISPLACED RIGHT LATERAL MALLEOUS ( DISTAL FIBULA ) AND RIGHT ANKLE WITH MORTISE INSTABILITY

27792/RT S82.61XA M25.371

PATIENT : SEX : MALE AGE : 26 This is a Commercial Payer ( Follow Medicare rules . External causes are NOT required . ) DATE OF OPERATION : 1 / 1 / 20XX PREOPERATIVE DIAGNOSIS : DISPLACED LEFT ANKLE BIMALLEOLAR EQUIVALENT FRACTURE . PROCEDURES : LEFT ANKLE ORIF , LATERAL MALLEOLUS . POSTOPERATIVE DIAGNOSIS : LEFT ANKLE DISPLACED FRACTURE OF LATERAL MALLEOLUS OF LEFT FIBULA WITH DISRUPTION OF SYNDEMOSIS

27829/LT 27792/LT S93.432A S82.62XA

82-year-old male Postoperative diagnosis, chronic methicillin- resistant staphylococcus aureus infected, right total knee replacement, arthroplasty Name of procedure, irrigation, Dabrye meant, washing out, and Betadine and drainage of wound

29871/RT T84.53XA B95.62

Age : 57 SEX : FEMALE OPERATIVE DIAGNOSIS : Right knee symptomatic medial plica , with medial femoral condyle chondromalacia . NAME OF PROCEDURE : Right knee examination under anesthesia , arthroscopy , medial plica excision , and medial femoral condyle chondroplasty .

29875/RT M67.51 M94.261

PATIENT : AGE : 61 SEX : Female PREOPERATIVE DIAGNOSIS : Torn lateral meniscus , right knee . POSTOPERATIVE DIAGNOSIS : Grade 2 and 3 degenerative joint disease , Primary knee . OPERATIVE PROCEDURE : Arthroscopy , right knee , with tricompartmental articular debridement

29877/RT M17.11

PATIENT : AGE : 47 Sex : FEMALE PREOPERATIVE DIAGNOSES : Torn lateral meniscus Degenerative . POSTOPERATIVE DIAGNOSES : Torn lateral meniscus and tear of medial meniscus right knee degenerative . OPERATIVE PROCEDURES : Arthroscopic partial medial and lateral meniscectomies and degenerative joint debridement .

29880/RT M23.251 M23.211 M23.261

OPERATIVE NOTE PATIENT : AGE : 56 Sex : FEMALE PREOPERATIVE DIAGNOSES : Torn medial meniscus right knee . POSTOPERATIVE DIAGNOSES : Complex Tear medial meniscus right knee plus Bucket Handle Tear of lateral meniscus and grade 4 chondrosis medial femoral condyle , medial tibial plateau , and retropatellar surface . OPERATIVE PROCEDURES : Medial and lateral meniscectories and chondroplasty of medial compartment and patellofemoral joint .

29880/RT M94.261 S83.231A S83.251A

PATIENT : Age : 51 Sex : FEMALE PREOPERATIVE DIAGNOSIS : Left knee lateral meniscal old tear . POSTOPERATIVE DIAGNOSIS : Left knee lateral meniscal old tear . OPERATIVE PROCEDURE : Left knee arthroscopic lateral meniscal repair

29882/LT M23.252

OPD6936 AGE : 41 SEX : MALE Private Payer ( Medicare rules for 65 and older ) OPERATIVE NOTE NAME OF PROCEDURE : Left knee examination under anesthesia , arthroscopy , and anterior cruciate ligament reconstruction , of an old disruption of the ACL with chronic instability .

29888/LT - Arthroscopically aided anterior cruciate ligament (ACL) repair/augmentation or reconstruction (EXAM IS INCLUDED) M23.52 - Chronic instability of left knee

PATIENT : SEX : Male AGE : 34 PREOPERATIVE DIAGNOSIS : RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT , TORN MEDIAL MENISCUS . PROCEDURES : RIGHT KNEE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH ACHILLES TENDON ALLOGRAFT ALL SOFT TISSUE AND PARTIAL MEDIAL MENISCECTOMY . POSTOPERATIVE DIAGNOSIS : RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT , TORN MEDIAL MENISCUS .

29888/RT link S83.511A 29881/RT. Link S83.241A

CARDIOPLUMONARY REPORT : PATIENT NAME : AGE : 64 SEX : Male INDICATIONS : Sick sinus syndrome with sinus arrest . ANESTHESIA : Conscious Sedation - Time : 60 mins . administered by MD PROCEDURES PERFORMED : Dual - chamber pacemaker with A and B lead insertion , and an axillary venogram

33208 99152 99153 3 units I49.5 I45.5

OPERATIVE REPORT CARDIOPULMONARY PATIENT NAME SEX Female INDICATIONS : Atrioventricular block , second degree PROCDURES PERFORMED 1. Dual - chamber pacemaker implantation 2. Axillary venogram

33208 99152 99153 with 2 units I44.1

Scenario CARDIOPULMONARY REPORT PATIENT NAME : AGE : 80 SEX : Female SIGNING PHYSICIAN : MD ELECTROPHYSIOLOGY PROCEDURE REFERRING PHYSICIAN : MD FLUOROSCOPY TIME : 0 minutes PROCEDURE PERFORMED : Pacemaker generator change and pocket revision . INDICATIONS : AV block with device at ERI OPERATOR : MD

33228 33222 Z45.010 I44.30

101 Ridge Road Apple Creek , MI 42328 DOS : 1 / 1 / 20XX Private payer ( Medicare rules for 65 and older ) ENCOUNTER INFORMATION Cardiac Catheterization Angiography Report / Diagnostic Report PATIENT INFORMATION Patient : Patient ID : 527XXXX Study Date : 1 / 1 / 20XX Performing : Referring : Age : 79 Gender : Male Height : 193 cm Account # : 427XXX BSA : 2.10 m2 Weight : 88.9 kg Performing : ANESTHESIA : Conscious Sedation - Time : 30 minutes

33228 99152 99153 Z45.010 I25.2

****** GLOBAL SERVICES ******* CARDIOPULMONARY REPORT : PATIENT NAME : AGE : 70 SEX : Male ADMISSION DATE : 01 / 01 / 20XX Private payer ( Medicare rules for 65 and older ) DISCHARGE DATE : DATE OF SERVICE : 01 / 01 / 20XX SIGNING PHYSICIAN : MD REFERRING PHYSICIAN : MD FLUOROSCOPY TIME : 6.8 minutes . PROCEDURES PERFORMED : Aborted EP study ; the patient did undergo dual - chamber ICD implantation and DFT testing . INDICATIONS . Typical Atrial flutter and CHF OPERATOR : MD

33249 99653/53 99152 99153 4 units 93641 I50.9 I48.3 I87.1

PATIENT : AGE : 44 Y SEX : FEMALE PREOPERATIVE DIAGNOSIS RIGHT UPPER EXTREMITY PROCEDURES : RIGHT UPPER EXTREMITY BRACHIAL AND AXILLARY THROMBECTOMY . POSTOPERATIVE DIAGNOSIS : RIGHT UPPER EXTREMITY THROMBOSIS

34101/RT I74.2

PATIENT : AGE : 69 Y SEX : FEMALE PREOPERATIVE DIAGNOSIS : SYMPTOMATIC RIGHT CAROTID STENOSIS . PROCEDURES : RIGHT EXTERNAL CAROTID ARTERY ENDARTERECTOMY LIGATION OF INTERNAL CAROTID ARTERY . POSTOPERATIVE DIAGNOSIS : SYMPTOMATIC RIGHT CAROTID STENOSIS , RIGHT ICA OCCLUSION .

35301/RT 37601/Rt I63.231 Z86.73

PATIENT : AGE : 53 SEX : MALE This is a Commercial Payer ( Follow Medicare rules ) DATE OF OPERATION : 01 / 01 / 20XX PREOPERATIVE DIAGNOSIS : ATHEROSCLEROSIS CRITICAL ISCHEMIA OF RIGHT LOWER EXTREMITY WITH GANGRENE PROCEDURES : RIGHT BELOW KNEE POPLITEAL TO DORSALIS PEDIS ARTERY BYPASS WITH REVERSED GREATER SAPHENOUS TO ATHEROSCLEROSIS POSTOPERATIVE DIAGNOSIS : ATHEROSCLEROSIS CRITICAL ISCHEMIA OF RIGHT LOWER EXTREMITY WITH GANGRENE

35571/RT I70.261

Referring : AGE : 81 Gender : Female Height : 162.6 cm Account # : BSA : 1.75 m2 Weight : 67.1 kg Performing : ANESTHESIA : Conscious Sedation - Time : 45 mins Procedures performed : Left heart catheterization . Procedure : Left heart cath , LV gm coronary angio & bilateral renal angio , R external iliac angio . Allergies : Indomethacin , aml

36252 93458 99152 99153 I25.10 I10 R94.39 Z95.820

OPERATION REPORT PATIENT : AGE : 4 mos . SEX : MALE PREOPERATIVE DIAGNOSIS : LOCAL INFECTION OF BROVIAC CATHETER . PROCEDURES : REMOVAL OF TUNNELED BROVIAC CATHETER . POSTOPERATIVE DIAGNOSIS : LOCAL INFECTION OF BROVIAC CATHETER .

36589 T80.212A

General Surgery Report PATIENT : AGE : 52 Y SEX : MALE PREOPERATIVE DIAGNOSIS : LEFT ILIAC VEIN THROMBOSIS END - STAGE AIDS DISEASE WITH NEUROLOGIC DEFICIT . POSTOPERATIVE DIAGNOSIS : ACUTE LEFT ILIAC VEIN THROMBOSIS END - STAGE AIDS DISEASE WITH NEUROLOGIC DEFICIT . PROCEDURES : CAVOGRAM AND INSERTION OF FILTER .

37191 I82.422 B20

ENT Specialists 1017 Rose Garden Ln . Burley , ID 83768 PATIENT : SEX : Male AGE : 38 DATE OF SERVICE : 01 / 01 / 20XX This is a Commercial Payer ( Follow Medicare rules if 65 and older ) DIAGNOSIS : Chronic Tonsillitis ANESTHESIA : GENERAL DESCRIPTION OF PROCEDURE : The patient was brought into the operating room and placed supine on the operating room table . General anesthesia was administered . An left 90 degrees and the patient's head and neck region was prepped and draped orotracheal tube was placed by the anesthesiologist . The operating room table was then turned to the in the usual fashion for bilateral tonsillectomy

42826 J35.01

Gastroenterology Associates 101 Ridge Road Apple Creek , MI 42328 NAME : SEX : FEMALE AGE : 65 ADMIT TYPE : Outpatient Digestive Care Center Procedure : Upper Gl endoscopy . Indications : Nausea and vomiting . Referring Physician : Dr. Bradshaw Complications : No immediate complications . Medicines : Monitored Anesthesia Care . ( MAC )

43235 R11.2

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : Age : 74 PREOPERATIVE DIAGNOSIS : Gastroesophageal reflux disease . POSTOPERATIVE DIAGNOSIS : Adult hypertrophic pyloric stenosis , acute gastritis without bleeding , hiatus hernia . OPERATIVE PROCEDURE : Esophagogastroscopy . ANESTHESIA : Conscious Sedation - Time 21 minutes

43235/52 G0500 K31.1 K29.00 K44.9

PATIENT : Age : 81 PREOPERATIVE DIAGNOSIS : Anemia . POSTOPERATIVE DIAGNOSIS : Prepyloric gastric ulcer , Hiatus hernia , Chronic antral gastritis . OPERATIVE PROCEDURE : Esophagogastroduodenoscopy , CLO test biopsy of gastric ulcer , conscious sedation .

43239 99152/59 99153 K25.9 K44.9 K29.50

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : Age : 55 This is a Commercial Payer ( Follow Medicare rules . External causes are NOT required ) Use a HCPCS Level Il code for moderate sedation for Medicare for the first 15 minutes Follow instructions . DOS : 1 / 1 / 20XX PHYSICIAN : MD OPERATIVE PROCEDURE : Colonoscopy and 1st degree internal hemorrhoids and External Hemorrhoids . SURGEON : MD ANESTHESIA Conscious Sedation : 33 mins

43835 G0500 99153 K64.0 K64.4 K63.5 D17.79 K59.00 Z85.038 Z90.49 Z98.0

OPERATION REPORT PATIENT : AGE : 47 SEX : FEMALE PREOPERATIVE DIAGNOSIS : Post Op Peritoneal Adhesions PROCEDURES : EXPLORATORY LAPAROTOMY , LYSIS OF ADHESIONS POSTOPERATIVE DIAGNOSIS : POST OP PERITONEAL ADHESIONS

44005 K66.0

PATIENT : SEX : MALE AGE : 62 DATE OF OPERATION : 01 / 1 / 20XX PREOPERATIVE DIAGNOSIS : SMALL BOWEL OBSTRUCTION . PROCEDURES : EXPLORATORY LAPAROTOMY , SMALL BOWEL ENTEROTOMY , REMOVAL OF FOREIGN OBIECT AND CLOSURE POSTOPERATIVE DIAGNOSIS : BEZOAR OBSTRUCTING THE ILEOCECAL VALVE .

44020 T18.3XXA

OPERATION REPORT PATIENT : AGE : 71 SEX : FEMALE PREOPERATIVE DIAGNOSIS : COLOVAGINAL FISTULA . PROCEDURES : 1. EXAMINATION UNDER ANESTHESIA PROCTOSIGMOIDOSCOPY . 2. EXPLORATORY LAPAROTOMY , TAKEDOWN OF COLOVAGINAL FISTULA , SIGMOID RESECTION AND PRIMARY COLORECTAL ANASTOMOSIS . POSTOPERATIVE DIAGNOSIS : RECTOVAGINAL FISTULA

44145 57305/51 45300/59 N82.3

OPERATIVE REPORT PATIENT : Age : 33 SEX : MALE PREOPERATIVE DIAGNOSIS : GUNSHOT WOUND TO THE RIGHT LOWER QUADRANT PROCEDURES : EXPLORATORY LAPAROTOMY , REMOVAL OF TERMINAL ILEUM AND CECUM , ILEOCOLOSTOMY AND PRIMARY ANASTOMOSIS . POSTOPERATIVE DIAGNOSIS : THRU AND THRU GSW PERFORATION OF THE CECUM

44160 S31.643A

PATIENT : SEX : MALE AGE : 41 Commercial PREOPERATIVE DIAGNOSIS SIGMOID DIVERTICULITIS . PROCEDURES : LAPAROSCOPIC SIGMOID COLECTOMY . POSTOPERATIVE DIAGNOSIS : SIGMOID DIVERTICULITIS .

44207 K57.32

OPERATION REPORT PATIENT : AGE : 17 SEX : FEMALE PREOPERATIVE DIAGNOSIS : RUPTURED APPENDICITIS WITH OMENTAL INVOLVEMENT AND PURULENT ABSCESS COLLECTION , ANTERIOR AND POSTERIOR CUL - DE - SAC PROCEDURES : DIAGNOSTIC LAPAROSCOPY FAILED , EXPLORATORY LAPAROTOMY , LYSIS OF ADHESIONS , REMOVAL OF ABSCESS WALL , APPENDECTOMY , IRRIGATION AND PLACEMENT OF JP DRAIN AND PARTIAL OMENTECTOMY . POSTOPERATIVE DIAGNOSIS : RUPTURED ACUTE APPENDICITIS WITH OMENTAL INVOLVEMENT AND PURULENT ABSCESS COLLECTION ANTERIOR AND POSTERIOR CUL - DE - SAC .

44960 K35.33 Z53.31

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : SEX : Male AGE : 55 PREOPERATIVE DIAGNOSIS : Colon cancer screening . POSTOPERATIVE DIAGNOSIS : Hemorrhoids . OPERATIVE PROCEDURE : Colonoscopy , conscious sedation . Time : 21 min

45378 99152/59 Z12.11 K64.0 Q43.8

Gastroenterology Associates 101 Ridge Road Apple Creek , MI 42328 NAME : Age : 68 DATE : 1 / 1 / 20XX ADMIT TYPE : Outpatient Procedure : Colonoscopy . Indications : Iron deficiency anemia . Referring Physician : Complications : No immediate complications . Medicines : Monitored Anesthesia Care .

45378/53 D50.9 Z53.09

OPERATIVE NOTE PATIENT : SEX : Male AGE 84 PREOPERATIVE DIAGNOSIS : History of colon polyps . POSTOPERATIVE DIAGNOSIS : Colon polyps , rectal polyps , diverticulosis of the colon , hemorrhoids . OPERATIVE PROCEDURE : Colonoscopy , snare polypectomy , Conscious Sedation Time 31 min .

45385 99152/59 99153 K63.5 K57.30 K62.1 K64.8 Z86.010

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : SEX MALE Age : 79 PREOPERATIVE DIAGNOSIS : History of colon polyp . POSTOPERATIVE DIAGNOSIS : Colon polyp , diverticulosis , hemorrhoids . OPERATIVE PROCEDURE : Colonoscopy , snare polypectomy , conscious sedation . Conscious Sedation - Time : 23 Minutes

45385-33 99152-33 99153-33 Z12.11 K63.5 - Cecum Polyp K64.4 - External hemorrhoids K57.30 - Diverticulosis of large intestine without perforation or abscess without bleeding Z86.010 - Personal history of colonic polyps

OPERATIVE NOTE PATIENT : AGE : 65 SEX : Male PREOPERATIVE DIAGNOSIS : History of colon polyps . POSTOPERATIVE DIAGNOSIS : Colon polyps , internal hemorrhoids . OPERATIVE PROCEDURE : Colonoscopy with cold biopsy polypectomy . SURGEON : MD ANESTHESIA Conscious Sedation : 30 mins

45385/33 45380/59/33 99152/33 99153/33 Z12.11 K63.5 K64.8 K62.1 Z86.010

OPERATIVE NOTE PATIENT Age 64 Sex Female This is a Commercial Payer ( Follow Medicare nules External causes are NOT required ) PREOPERATIVE DIAGNOSIS : Colon cancer screening POSTOPERATIVE DIAGNOSIS : Diverticulosis . Polyp . 1st degree Internal Hemorrhoids and External Hemorrhoids Conscious Sedation Time ; 25 minutes

45385/33 99152 99153 Z12.11 K57.30 K63.5 K64.0 K64.4

OPERATIVE REPORT PATIENT : Age : 17 SEX : MALE PREOPERATIVE DIAGNOSIS : ANAL ABSCESS . 5 O'CLOCK ON ANODERM ( LITHOTOMY POSITION ) PROCEDURES : EXAM UNDER ANESTHESIA RIDGID PROCTOSIGMOIDOSCOPY INCISION AND DRAINAGE OF ANAL ABSCESS POSTOPERATIVE DIAGNOSIS : ANAL ABSCESS .

46045 45300 K61.0

PATIENT : AGE : 28 YRS SEX : MALE PREOPERATIVE DIAGNOSIS : CHRONIC ANAL FISSURE . PROCEDURES : EXAM UNDER ANESTHESIA , RIGID PROCTOSCOPY , FISTULOTOMY POSTOPERATIVE DIAGNOSIS : CHRONIC ANAL FISSURE AND ANAL FISTULA

46270 K60.1 K60.3

PATIENT : DOB : 1/1/1989 SEX : MALE PREOPERATIVE DIAGNOSIS : ACUTE CHOLECYSTITIS STATUS POST CHOLECYSTOSTOMY TUBE . PROCEDURES : EXPLORATORY LAPAROSCOPY AND OPEN PARTIAL CHOLECYSTECTOMY WITH INTRAOPERATIVE CHOLANGIOGRAM POSTOPERATIVE DIAGNOSIS : ACUTE CHOLECYSTITIS STATUS POST CHOLECYSTOSTOMY TUBE CONTAINED PERFORATED CHOLECYSTITIS .

47605 K80.0 K82.2 Z53.31 Z97.8

OPERATION REPORT PATIENT : AGE : 21 SEX : MALE PREOPERATIVE DIAGNOSIS : SMALL BOWEL INTUSSUSCEPTION . PROCEDURES : DIAGNOSTIC LAPAROSCOPY EXPLORATORY LAPAROTOMY AND MESENTERIC LYMPH NODE BIOPSY . POSTOPERATIVE DIAGNOSIS : LOCALIZED MESENTERIC LYMPHADENOPATHY AND NO INTUSSUSCEPTION

49000 R59.0

OPERATION REPORT PATIENT : Age : 31 SEX : MALE PREOPERATIVE DIAGNOSIS : STATUS POST BLUNT TRAUMA TO THE ABDOMEN WITH SMALL AND LARGE BOWEL RESECTION RULE OUT BOWEL ISCHEMIA PROCEDURES EXPLORATORY LAPAROTOMY AND ABDOMINAL WASHOUT . POSTOPERATIVE DIAGNOSIS ACIDOSIS STATUS POST BOWEL RESECTION . RULE OUT BOWEL ISCHEMIA CONSCIOUS SEDATION Time 35 minutes

49002/78 99152 99153 E87.2 Z98.890 Z90.49

PATIENT : SEX : FEMALE Age 24 PREOPERATIVE DIAGNOSIS : CHRONIC PELVIC PERITONITIS ABSCESS . PROCEDURES : EXPLORATORY LAPAROTOMY WITH DRAINAGE OF PERITONEAL ABSCESS , ABDOMINAL WASHINGS . POSTOPERATIVE DIAGNOSIS : CHRONIC PELVIC PERITONITIS ABSCESS .

49020 N73.4

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : Age : 60 PREOPERATIVE DIAGNOSIS : Left inguinal hernia . POSTOPERATIVE DIAGNOSIS : Left inguinal hernia ( direct ) . OPERATIVE PROCEDURE : Open left inguinal hernia with mesh ( PHSL ) .

49505/LT K40.90

PATIENT : AGE : 37 SEX : MALE PREOPERATIVE DIAGNOSIS : Right inguinal hernia . POSTOPERATIVE DIAGNOSES : 1. Right inguinal hernia ( indirect ) . 2. Small cord lipoma . OPERATIVE PROCEDURE : 1. Open right inguinal hernia repair with mesh . 2. Resection of cord lipoma .

49505/RT K40.9 D17.6

OPERATIVE NOTE PATIENT : AGE : 30 SEX : Male PREOPERATIVE DIAGNOSIS : Symptomatic right inguinal hernia . POSTOPERATIVE DIAGNOSIS : Right inguinal hernia . OPERATIVE PROCEDURE : Open right inguinal hernia repair with mesh ( PHSL ) .

49505/RT K40.90

OPERATIVE NOTE SURGICAL CENTER WEST VALLEY CITY , UTAH PATIENT : AGE : 52 SEX Female PREOPERATIVE DIAGNOSES : 1. Biliary colic . 2. Symptomatic incisional hernia . POSTOPERATIVE DIAGNOSES : 1. Biliary colic . 2. Symptomatic incisional hernia . OPERATIVE PROCEDURE : 1. Laparoscopic cholecystectomy . 2. Repair of incarcerated incisional hernia ( mesh = Ventralex 6.4 cm ) .

49561/59 link k43.0 47562 link k80.50 49568 link K43.0 K43.0 K80.50