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Good morning everyone on this episode of coding with Kate we are going to be dissecting an OP report or an operative report medical report this is the document you will be reading to figure out what procedures were done and what needs to be coded in the icd-10-pcs or procedural coding system code book it's going to be a lot of fun and I want it to do this type of setup, so you can see how I read through an OP report and highlight and make notes, so I know what information is pertinent to build my code, so I cover all my bases and make sure that I am coding to the highest degree of specificity and I don't miss any detail so enjoy a reading the very first opera port we'll be doing okay so here is our op report this is an example from one of my work books for one of my PCs coding courses and as you can see at the top of the note it says do not code intraoperative fluoroscopic guidance with this procedure we are going to ignore that because this is the same example that I use in a previous PC coding video and I will also make another video with this example of how we actually code within the book, so we're just going to ignore that, so it says the procedure placement of a dual chamber pacemaker, so this is information we can already highlight because it's telling us what device is being inserted and then the indications just give a little more information on the diagnosis we can skip over that now actually reading the procedure description it says after informed consent the patient is brought to the lab the procedure is done under conscious sedation fluoroscopic guidance we want to remember that information because there is fluoroscopic guidance being used which means we will need a code for that imaging assistance 1 lidocaine was used to anesthetize the skin under the left clavicle and subcutaneous pocket we need to remember this information because they are making an incision near the left clavicle in the subcutaneous tissue and fascia and was made for the pacemaker generator and leads, so that is where the pacemaker generator is going to be inserted and the leaves will connect to that generator the left, so clay in vain was cannulated twice using a micro puncture set the subclavian vein is giving us our approach of how they're going to get to the heart which was upsized to regular Oh three five wire the position of which was confirmed under floor so again confirming that they're using the fluoroscope in guidance to get from the left subclavian vein to the heart and as far as the information on the puncture set and the wire we don't need to know that information that is all information that is integral to the procedure, so that does not need a separate code the seven French sheath and a seven French right ventricular lead this is giving us a clue as to where they're going was used and placed in the right ventricular apex, so this is where they are bringing the leads to place them on the right ventricular apex originally and then more proximally in...
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