AAPC - Chapter 8 Practical Applications

CASE 1 Operative Report PREOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left proximal humerus fracture. (The postoperative diagnosis is used for coding.) OPERATIVE PROCEDURE: Open treatment of left proximal humerus.(The working procedure until the report is read.) ANESTHESIA: General.(General anesthesia is used.) IMPLANTS: DePuy GLOBAL® FX™, stem size 10 with a 48 x 15 humeral head.(This is an indication that a prosthesis was introduced into the joint.) INDICATIONS: The patient is a 66 year-old female who sustained a traumatic severe comminuted proximal humerus fracture. (This is confirmation of the diagnosis. The proximal end of the humerus is the shoulder area.) The risks and benefits of the surgical procedure were discussed. She stated that she understood and desired to proceed. DESCRIPTION OF PROCEDURE: On the day of the procedure, after obtaining inf - 23616-LT S42.202A