A patient with chronic obstructive pulmonary disease is issued a medically necessary nebulizer with a compressor and humidifier for extensive use with oxygen delivery.
A patient presents for trimming of 10 dystrophic toe nails.
A 54-year-old patient with primary lung cancer of the upper lobe is receiving his first radiation treatment in the oncology clinic. What is the diagnosis code selection for this encounter?
When adding multiple repair sites:
Which of the following is “NOT” part of the standard “surgical package” for all procedures?
Which of the following is NOT a valid auditory surgical procedure?
------ are procedures or services that are commonly carried out as an integral component of a total service or procedure and should not be reported in addition to the total procedure or service of which it is considered an integral component.
The following is not a main section of the CPT:
Specific information about coding for each CPT section is located in the:
Which part of Medicare is also known as Medicare Advantage Program?
-------- refers to legislation regarding financial kickbacks between hospitals and providers for referrals.
The covered entities include,
EMERGENCY DEPARTMENT REPORT CHIEF COMPLAINT: Nasal Bridge Laceration SUBJECTIVE: The patient is 74-year-old male who presents to the emergency department with a laceration to the bridge of his nose. He fell in the bathroom tonight. He recalls the incident. He just sort of lost his balance. He denies any vertigo. He denies any chest pain or shortness of breath. He denies any head pain or neck pain. There was no loss of consciousness. He slipped on a wet floor in the bathroom and lost his balance; that is how it happened. He has not has any blood from the nose or mouth. PAST MEDICAL HISTORY: 1. Parkinson’s 2. Back pain 3. Constipation MEDICATIONS: See the patient record for a complete list of medications ALLERGIES: NKDA REVIEW OF SYSTEMS: Per HPI. Otherwise negative. PHYSICAL EXAMINATION: The exam showed a 74-year-old male in no acute distress. Examination of the HEAD showed no obvious trauma other than the bridge of the nose, where there is approximately a 1.5 to 2 cm laceration. He had no bony tenderness under this. Pupils were equal, round, and reactive. EARS, NOSE and OROPHARYNX was unremarkable. NECK was soft and supple. HEART was regular. LUNGS were clear but slightly diminished in the bases. PROCEDURE: The wound was draped in a sterile fashion and anesthetized with 1% Xylocaine with sodium bicarbonate. It was cleansed with sterile saline and then repaired using interrupted 6-0 Ethilon sutures (Dr. Barney Teller, first year resident, assisted with the suturing) ASSESSMENT: Nasal bridge laceration, status post fall. Plan: Keep clean, Sutures out in 5 to 7 days. Watch for signs of infection.
DIAGNOSIS: Scaphoid nonunion, right. NAME OF OPERATION: Open reduction and internal fixation of right scaphoid fracture nonunion with autogenous bone graft from the distal radius; filling of bone graft donor site with coralline bone graft substitute. FINDINGS AT OPERATION: The distal pole of the scaphoid at the level of the tuberosity was fractured and had failed to heal. The distal pole had resorbed partially, leaving a shell of bone which did not allow screw fixation. The proximal pole appeared to be viable, as did the distal pole. The distal radioscaphoid joint appeared normal. The scaphocapitate joint appeared normal. PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. He underwent satisfactory uneventful induction of general inhalation anesthesia. The right upper extremity was scrubbed with Betadine scrub solution, prepared with Betadine prep solution, and sterile drapes were applied to expose the right upper extremity. The limb was exsanguinated with an elastic wrap, and an incision was made along the radiovolar side of the thumb metacarpal base extending across the carpometacarpal joint and the scaphotrapezial joint and the radioscaphoid joint. At the flexor carpi radialis sheath, the incision extended proximally, approximately 6-8 cm. The subcutaneous tissues were dissected sharply. Care was taken to avoid injury to the terminal branches of the superficial radial nerve and to the radial artery. Care was taken to avoid injury to the median nerve. The flexor carpi radialis sheath was opened, and the flexor carpi radialis tendon was reflected ulnarward. The sheath was opened dorsally and the distal radius was exposed, and the radiocarpal joint was exposed, as was the radioscaphoid and scaphotrapezial joint. The crossing vessels from the radial artery were cauterized and suctioned. Care was taken to avoid injury to the terminal branches of the superficial radial nerve. Care was taken to avoid injury to the major trunk of the radial artery. The capsule of the wrist joint was opened. The scaphoid nonunion was identified. The .062-inch Kirschner wires were used as manipulating handles to control the proximal and distal fragments while the nonunion was cleaned of fibrous tissue and scarred, dense bone. A satisfactory, though nonanatomic reduction could be achieved, and it appeared that there was slight flexion of the scaphoid. The pronator quadratus was reflected from the distal radius and a window measuring approximately 1 x 2 cm was opened in the transverse axis of the distal radius. The margins of the window were rounded with Kirschner-wire drill holes to diminish stress-rising effect. Ample, good, viable cancellous bone was removed from the distal radius. The wound was irrigated with saline and packed with coralline bone graft substitute (Interpore). The bone graft was placed in the exposed raw surfaces of the proximal and distal fragments of the scaphoid bone. A corticocancellous bone graft was placed slightly to the volar side to prevent further volar collapse. Using the image intensifier video monitor after placement of .062-inch Kirschner wires across the fracture site, the Kirschner wires appeared to be satisfactory, after they were repositioned. The image intensifier AP and lateral projection revealed satisfactory, though nonanatomic reduction of the carposcaphoid. The radioscaphoid articulation did not appear to be threatened. The fracture was stably fixed with no motion evident on radial or ulnar deviation. The wound was irrigated with saline, infiltrated with 0.25% Marcaine, and the tourniquet was deflated. Hemostasis was ascertained, and the capsular structures were closed with interrupted 4-0 Vicryl suture, so that the capsule-ligamentous portion of the volar wrist capsule was restored. The wound was irrigated with saline. Hemostasis was ascertained and the subcutaneous tissues were closed with interrupted 4-0 Vicryl suture.
Diagnosis: Cardiac Tamponande Ten-year-old boy was admitted with cardiac tamponade. initial pericardiocentasis yielded pus. Procedure: A subxiphoid tube-pericardiostomy was done with partial resection of pericardium and thick, purulent material was drained out. Subsequently, pericardiectomy was undertaken as features of pericardial constriction persisted. At surgery, however, an intrapericardial mass was discovered. Successful excision was performed and the patient made an uneventful recovery. histopathology of the mass revealed features of an intrapericardial teratoma.
Diagnosis: Diverticular disease of the sigmoid colon and appendix with resolving diverticulitis of the sigmoid colon Operation: resection of the sigmoid colon, Appendectomy Findings at surgery: The patient was found to have the sigmoid colon showing the evidence of resolved diverticular disease. This involved only the mid-portion of the sigmoid colon with this area being thickened and showing evidence of inflammatory reaction around the colon. There were numerous diverticula noted. The sigmoid colon was adherent to the lateral peritoneum as well as to the bladder with inflammatory adhesions. These were easily taken down. The appendix showed evidence of past scarring and appendicitis. Numerous diverticula were noted. Under general anesthesia, after routine prepping and draping the abdomen was entered through a low midline abdominal incision. After limited exploration, the pelvis was exposed and the involved area of the sigmoid colon was identified. The blood supply to the sigmoid colon was taken and the sigmoid colon was resected between clamps. The distal descending colon was then brought down to the rectosigmoid area, and an end-to-end anastomosis was accomplished. This provided a good lumen and a watertight closure. The mesentery over the bowel was closed using a running 3-0 Vicryl suture. The operative area was thoroughly irrigated. The bowel was all returned to a normal position. Sponge and needle counts were all correct. The abdominal wall was closed in layers routinely. No intraoperative complications were encountered. Dressings were applied. The patient returned to the recovery room in satisfactory condition.
Diagnosis: Persistent ovarian cyst, right ovary, unresponsive to contraceptive pills Operation: Laparotomy with cystectomy of right ovarian cyst Anesthesia: General Procedure: The patient was placed in the dorsal position. She underwent general anesthesia without incident. She was converted to the dorsal lithotomy position, and prepped and draped abdominally and vaginally. We attempted to use a HUMI and Sargis tenaculum, but her uterus was too small to retain these. A single-tooth tenaculum was placed. A transverse suprapubic, small mini-laparotomy incision was made through skin and subcutaneous tissue and fascia. The fascia was separated, the rectus muscles were separated, and the peritoneum was entered. We identified pelvic anatomy. We packed bowel away with two lap pads. After this was done, we were able to elevate the right ovary into the incision. It was clamped along the utero-ovarian ligament with a Babcock. Using traction with this, we were able to hold into the ovary with the operator’s hand and then an incision was made on the antimesenteric border of the ovary. We then used small dissecting scissors to dissect out the ovary cyst. We secured the base and observed for hemostasis. We closed the incision with 3-0 Vicryl suture.After this was done, it was observed for hemostasis and removed the two lap pads. All counts were correct. The muscle was reapproximated in the midline. The fascia was closed with running interlocking #1 Vicryl suture. The subcutaneous tissue was reapproximated with interrupted 3-0 Vicryl. Skin edges were brought together with subcuticular closure using a Keith needle and 3-0 Vicryl. A sterile bandage was placed above the Steri-Strips. The Foley catheter was left in. The patient was transported to the recovery room with stable vital signs. Her estimated blood loss was less than 50 cc.
DIAGNOSES: 1. Foreign body in right middle ear. 2. Right tympanic membrane perforation. NAME OF OPERATION: 1. Myringoplasty with fat patch graft. 2. Removal of right middle ear foreign body. INDICATIONS: The patient is a 7-year-old who has had three sets of PE tubes placed in the past. Tubes which were placed by myself approximately two years ago have since extruded. He recently developed a middle ear infection with rupture of the tympanic membrane on the right. He has a tympanic membrane perforation on the left which has been stable. After several weeks of drop usage and antibiotics and visualization with the operating microscope (it should be noted the patient is quite difficult to examine because of his lack of cooperation in the office), it appeared he had a foreign body in the middle ear space, which was consistent with an old tube, a type that I do not use, probably from a previous PE tube placement. It was located in the middle ear space with a substantial amount of granulation and inflammation surrounding it. PROCEDURE: The patient was taken to the operating room and placed in the supine position. After adequate endotracheal anesthesia was obtained, the patient was prepped and draped in a sterile fashion. A post lobular incision was made on the right side to harvest fat from the posterior lobule area of the right ear. This was obtained, and then closure was performed with a 4-0 Monocryl subcutaneous and subcuticular closure. Attention was then directed toward the right ear where the right ear was cleaned of purulent material which was quite evident. There was an anterior perforation, and deep into the middle ear space could be visualized an old tube lying in the middle ear space anteriorly. This was removed using an alligator forceps. The edges of the tympanic membrane perforation were freshened with a Rosen needle. The middle ear space was then thoroughly irrigated with Cortisporin drops. The Gelfoam was placed into the middle ear space medially, and the fat was placed with fat exuding from the middle ear space and filling up the perforation site. Then, Gelfoam was placed lateral to the myringoplasty site. The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.
A 54-year-old female presented several moths ago with Stage III right breast cancer, infiltrating ductal carcinoma and is 94 days post-total mastectomy. Postoperative wound seromas have been aspirated several times and she is currently undergoing adjuvant chemotherapy. Today she presents with a complaint of recurrent seroma under her right breast scar (expanded problem focused history). Physical examination: Vital signs are stable and the patient is a febrile. Examination of her left breast reveals no masses. Examination of her right breast area reveals a fluctuant mass beneath the incision site with some surrounding erythema and tenderness (expanded problem focused exam). Impression: Recurrent seroma of the right chest area. Plan: Drained the seroma to submit for culture and pathology and return in three days at patient’s request and discussed options including open procedure (moderate level).
What is the basis of the anesthesia time reporting period for multiple surgical procedures?
A transperineal permanent interstitial Palladium-103 implantation of the prostate was performed on a 68-year-old patient with cancer of the prostate of using 15 ribbons. A postimplant cystogram was performed by the urologist and revealed the seeds to be in excellent position. The patient went to the recovery room in stable condition. Follow-up dosimetry is arranged. Code for the facility.
A non-Medicare patient is seen in the outpatient clinic for fever, flank pain, and blood in the urine. The patient has a comprehensive history and physical examination. A moderate complex medical decision making is required by the physician. The diagnosis made is urosepsis and bacteremia. The patient is given an IM antibiotic of Rocephin 250 mg. What codes are used to report the facility services?
DIAGNOSIS: Scar lesion of the left mandibular line times two. HISTORY: This patient has two scar lesions from an attack last year that has left on her left jaw line with "dog-ears" on either end, and she desires removal of these lesions for more normal anatomic reconstruction site. She, therefore, presents today for removal of these scars. PROCEDURE: With the patient in the supine position under intravenous sedation, 1% lidocaine with 1:100,000 epinephrine buffered with sodium bicarbonate was injected into the two scars in question along the left jaw line. Each scar measured approximately 1.5 cm in length. Having waited 10 minutes for vasoconstriction to occur, each scar was excised under loupe magnification with a #15 Bard-Parker. Hemostasis was obtained with the Bovie. The closure was performed with two layers of 5-0 Vicryl, followed by running, fine, 6-0 black nylon, again under loupe magnification. The patient tolerated the procedure well. Sponge and needle counts were reported as correct times two. She was brought to the recovery room in stable condition.
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Macromastia. ANESTHESIA: General OPERATION: McKissock reduction mammoplasty, inferior pedicle only. PROCEDURE: Under adequate general anesthesia, the breasts were prepped and draped in a routine fashion and injected with 0.5% Xylocaine with 1:200,000 epinephrine to aid in hemostasis. The patient's breasts had been marked for standard McKissock reduction mammoplasty preoperatively with the patient in the sitting position.The right breast was operated upon first, and a standard McKissock reduction mammoplasty was carried out, creating medial and lateral flaps and excising medial and lateral triangles. The nipple was supported with an inferior pedicle approximately 10 cm. in width. Good viability of the nipple was present at the termination of dissection. Approximately 1,000 grams of breast tissue was removed from the left breast, and 1,000 grams from the right breast. The patient's wounds were closed with clear and black nylon fine sutures. Sterile dressings were applied, and the patient returned to the recovery room in satisfactory condition with a bra in place. Both breasts were operated upon in equal fashion. No drains were placed. There were no complications.
DIAGNOSIS: Full-thickness nasal defect, skin of right alar. ANESTHESIA: Local NAME OF OPERATION: Full-thickness skin graft of right preauricular area to right nose, 1 x 1 x 1 cm. PROCEDURE: The patient had undergone Mohs' micrographic skin cancer surgery by another physician. I was asked to perform a skin graft to close the defect. She had an alar defect 1 x 1 x 1 cm, and this was fairly deep. She had previous basal cell carcinoma surgery just above that, preventing a nasolabial flap. The preauricular area was selected as site of the skin graft. This was marked and infiltrated with lidocaine with epinephrine, as was the nose. The preauricular skin graft was harvested in a hairless area just in front of the tragus, and the skin closed with 5-0 PDS and running 5-0 plain. Steri-Strips were applied. The skin graft was then defatted, trimmed to fit exactly into the defect and sutured into place with interrupted 5-0 plain and quilting sutures of 5-0 plain. The dressing was then applied. The patient was taken to the outpatient unit in satisfactory condition with stable vital signs
Preoperative Diagnosis: Right breast mass Postoperative Diagnosis: Same Operation: Right subcutaneous mastectomy Indications for Surgery: Operative findings included benign-appearing breast tissue. Frozen section reports as benign breast tissue consistent with gynecomastia. The patient is a 51-year-old male who presented to the clinic complaining of swelling in his right breast under his nipple and areola. He complained that this area was tender and was concerned about possible cancer. The patient was scheduled for outpatient procedure, breast biopsy versus subcutaneous mastectomy. Procedure: After obtaining signed consent, the patient was taken to the operating room and placed in comfortable supine position. After placing all proper anesthesia monitoring devices, EKG, blood pressure and saturation monitors, the patient's right breast was prepped and draped in the usual sterile fashion. Once this was completed, 1% lidocaine was used to infiltrate the inferior aspect circumareolarly and a #15 blade was then used to make an incision circumareolar from 3 o'clock and 6 o'clock to 9 o'clock on the nipple and small extending incisions were created laterally and medially at 3 o'clock and 5 o'clock. This incision was carried down through the skin and into the subcutaneous tissue. Skin flaps were then created using Metzenbaum scissors. Allis clamps were used to secure the mass and the mass was dissected out using electrocautery Bovie. After excision the mass, the lateral border of the mass was marked with long silk, the superior aspect of the mass was marked with a short stitch. This was then passed off to pathology for frozen section. Inspecting the wound, the wound was dry. It was irrigated copiously with normal saline. A 3-0 Vicryl was used to reapproximate the subcutaneous tissue to obliterate the dead space and a 4-0 Vicryl suture was used to reapproximate the skin edges using a subcuticular stitch. Steri-strips were then applied over the wound. A sterile dressing was placed over the wound. The patient tolerated the procedure well and there were no complications. A total of 7 cc of 1% lidocaine were used during the case. The estimated blood loss was less than 10 cc. There were no drains.
Operative Procedure: Excision of back lesion Indications for surgery: The patient has an enlarging lesion on the upper midback Findings at surgery: There was a 5 cm upper midback. Operative surgery: With the patient prone, the back was prepped and draped in the usual sterile fashion. The skin and underlying tissues were anesthetized with 30 ml of lidocaine with epinephrine. Through a 5-cm transverse skin incision, the lesion was excised. Hemostasis was ensured. The incision was closed using 3-0 Vicryl for the deep layers and running 3-0 Prolene subcuticular stitch with Steri-Strips for the skin. The patient was returned to the same-day surgery center in stable postoperative condition. All sponge, needle, and instrument counts were correct. Estimated blood loss is 0 ml. Pathology report late indicated: Follicular cyst, infundibular type, skin of back.
This patient returns today for palliative care to her feet. Her toenails have become elongated and thickened, and she is unable to trim them on her own. She states that she has had no problems and no acute signs of any infection or otherwise to her feet. She returns today strictly for nail debridement to her feet. EXAMINATION: Her pedal pulses are palpable bilaterally. The nails are mycotic, 1 through 4 on the left, and 1 through 3 on the right. ASSESSMENT: Onychomycosis, 1 through 4 on the left and 1 through 3 on the right. PLAN: Mild debridement of mycotic nails x 7.This patient is to return to the clinic in 3 to 4 months for follow-up palliative care.
A patient underwent an anterior interbody arthrodesis with discectomy, osteophytectomy, fusion, and decompression of nerve roots at level C3, C4, and C5. The fusion was explored and stabilized with application of anterior instrumentation placed from C3 to C5. Which codes would you use to report this procedure?
Code the CPT and the ICD-10 Procedural Code for the following procedure(s): DIAGNOSIS: Dorsal ganglion cyst, left wrist. NAME OF OPERATION: Excision of dorsal ganglion cyst. FINDINGS AT OPERATION: This patient had one of these thick, very firm cysts in the classic location beneath the extensor tendon. PROCEDURE: The patient was given a general anesthetic, and the arm was prepped and draped in a sterile fashion, with a well-padded tourniquet around the arm. The tourniquet was inflated to 250 mmHg after exsanguination with an Esmarch. A transverse incision was made over the cyst, carried down through subcutaneous tissue. The extensor retinaculum was incised, and tendons were protected with retractors. The cyst was then surrounded and lifted up off the carpus, taking a portion of the dorsal ligament. Irrigation was then carried out. The incision was closed with nylon and Steri-Strips. A sterile dressing was applied. The patient appeared to tolerate the procedure well.
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Recurrent dislocation, right shoulder. FINDINGS AT OPERATION: Preoperatively, the patient had instability of the shoulder anteriorly. He did not have any posterior or inferior instability. At surgery, he was found to have a large Hill-Sach lesion, as well as very thorough Bankart lesion (link). The inferior part of the labrum was calcified, and this could be seen on preoperative x-rays. The glenohumeral surface was relatively clean. There was no rotator cuff tear or biceps tendon damage. PROCEDURE: He was given a general anesthetic and put in the beach-chair position, and prepped and draped in a sterile fashion. The shoulder was instilled with fluid, followed by diagnostic arthroscopy with the arthroscope in the posterior portal, with findings as noted above. The bursal area was examined, also, and no abnormalities were found. The scope was then removed, and the patient was put back in the semi-reclining position. A deltopectoral incision was made, carried down through the subcutaneous tissue, and the vein was retracted laterally. The deep structures were approached, and clavipectoral fascia incised. The arm was externally rotated, and the subscapularis reflected off the capsule. The capsule was entered, and debridement of the calcified inferior labrum was carried out. The labral tissue was in relatively good condition, and it was freed up by using a knife to allow it to come up over the edge of the glenoid better, and then the edge of the glenoid was roughened. Three Mitek sutures were then placed right at the edge of the glenoid, and these were used to repair the labrum. Copious irrigation was carried out. The arm was then reduced into position, and the lateral capsule tightened down to the labrum, allowing about 15 degrees of external rotation. These sutures were tied and were felt to be quite satisfactory. Again, irrigation was performed. The subscapularis was anatomically closed. The subcutaneous tissue and skin were closed in layers, and a sterile dressing was applied. All the capsular redundancy seemed to be negated by the procedure, and he seemed to be quite stable. Sponge and needle counts were correct. The patient tolerated the procedure well.
DIAGNOSIS: Left knee medial meniscus tear. NAME OF OPERATION: Partial medial menisectomy with limited debridement. ANESTHESIA: General. PROCEDURE: In the preoperative holding area the site and side and the procedure were confirmed with the patient. The risks, benefits, and alternatives were discussed. He voiced understanding regarding the limitations of arthroscopic treatment, particularly if there is arthritis involved. The patient was taken to the operating room, and after adequate general anesthesia the left leg was carefully fitted with a tourniquet over a snugly-fitted Webril and placed in the left leg holder. The leg was prepped and draped in sterile fashion. Portals were carefully established using landmarks as a guide. The anterior-medial portal was established using a spinal needle as a guide. Sequential examination of the joint was performed.Generalized arthritis was noted throughout except no full-thickness cartilaginous tears were noted. There was an unstable medial meniscus tear which was carefully debrided. The anterior cruciate ligament was a little bit incompetent with some fraying fibers, but no evidence of gross instability detected as pivot shift was equivocal. Hence this was left intact. The posterior cruciate ligament was normal. The patellofemoral joint tracked well. There were grade III articular changes throughout the knee. A few loose bodies were removed from some of the cartilaginous surfaces. The worst areas were smoothed, but otherwise it was left intact. Final inspection was made for loose bodies. These were removed. The last inspection found none.The joint was irrigated and back-bled. The knee was injected with Xylocaine and Marcaine for pre- and postoperative pain. A sterile dressing was applied. The patient was aroused from anesthesia and taken to the recovery room in stable condition having tolerated the procedure well.
Operative Report: Preoperative Diagnosis: Open fracture, left humerus, with possible loss of left radial pulse. Procedure performed: Open reduction internal fixation, left open humerus fracture. Procedure: While under a general anesthetic, the patient’s left arm was prepped with Betadine and draped in sterile fashion. We then created a longitudinal incision over the anterolateral aspect of his left arm and carried the dissection through the subcutaneous tissue. We attempted to identify the lateral intermuscular septum, and progressed to the fracture site, which was actually fairly easily to do because there was some significant tearing and rupturing of the biceps and brachialis muscles.These were partial ruptures, but the bone was relatively easy to expose through this We then identified the fracture site and thoroughly irrigated it wit several liters of saline. We also noted that the radial nerve was easily visible, crossing along the posterolateral aspect of the fracture site. It was intact. We carefully detected it throughout the remainder of the procedure. We then were able to strip the periosteum away from the lateral side of the shaft of the humerus both proximally and distally from the fracture site. We did this just enough to apply a 6-hole plate, which we eventually held in place with six cortical screws. We did attempt to compress the fracture site. Due to some communition, the fracture was not quite anatomically aligned, but certainly it was felt to be very acceptable. Once we had applied the plate, we then checked the radial pulse with a Doppler. We found that the radial pulse was present using the Doppler, but not with palpation. We then applied Xeroform dressings to the wounds and the incision. After padding the arm thoroughly, we applied a long arm splint with the elbow flexed about 75 degrees. He tolerated the procedure well, and the radial pulse was again present on the Doppler examination at the end of the procedure.
The physician applies a Minerva-type fiberglass body cast from the hips to the shoulder and to the head. Before application, a stockinette is stretched over the patient’s torso and further padding of the bony areas with felt padding was done.
DIAGNOSIS: Cardiac tamponade OPERATIVE PROCEDURE: Pericardial Window, Relief of Cardiac Tamponade; FINDINGS: Proximally, the pericardium was noted to be under a large amount of pressure. There was approximately 800 cc of straw-colored fluid withdrawn. The pericardium did not appear thickened. There did appear to be a diffuse fibrinous exudate covering the epicardium. PROCEDURE: With the patient in a semi-Fowler position, the abdomen and chest were prepped and draped in the usual sterile fashion. The abdominal midline from just above the xiphoid distally was infiltrated with 1% plain Xylocaine. An approximately 6-cm midline incision was made, begun just above the xiphoid. The incision was carried down through subcutaneous tissues. Hemostasis was obtained with electrocoagulation. The linea alba was incised and the xiphoid identified. The xiphoid was then excised. One large arterial pumper from the side of the xiphoid was controlled with a hemoclip. The pericardium was exposed beneath the sternum and grasped with a clamp. The pericardium was noted to be tense. It was incised with Metzenbaum scissors with a large rush of fluid appreciated. Fluid was obtained and sent for aerobic, anaerobic, acid-fast bacillus and fungal cultures, cytology and chemistries. Approximately a 3 x 3-cm portion of pericardium was then excised and also sent for cultures and pathology. The pericardium was felt and did not appear to be nodular. The pericardial fluid was suctioned free. A large drain was then inserted through a separate stab wound, and then cut and placed in the pericardial sac inferiorly and secured to the skin with a 1-Ethibond suture. The linea alba was reapproximated then using a running 0 Vicryl suture. The subcutaneous tissues were reapproximated using running 2-0 Vicryl sutures, and the skin was reapproximated using a running 3-0 Vicryl subcuticular suture. Mastisol and Steri-Strips were then applied. Sponge and instrument count were correct at the conclusion of the procedure. It was noted that the patient's blood pressure rose and the pulse dropped with relief of the tamponade.
Marvin a 51-year-old patient , required a conversion of a single chamber pacemeaker system to a dual chamber system. The previously placed electrode was removed transvenously. The skin pocket was opened and the pulse generator was removed. The skin pocket was then relocated and a dual system was placed with transvenous electrodes in both the right atrial abd ventricular chambers. The system was tested and the new skin pocket was then closed. The patient tolerated the procedure well. How should you report these services?
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: Diagnosis: Multiple Myeloma Operation: Placement of P.A.S. Port, left arm. Indications: The patient, age 48, is currently under therapy for multiple myeloma and will require chronic venous access for continued treatment. She was referred for placement of a P.A.S. port device in the left arm. The risks, benefits and options associated with this procedure are understood by the patient and she has elected to proceed with surgery under local anesthesia as described. Procedure: This patient was placed on the operating room table in the supine position with appropriate warming and monitoring devices in place. The left arm was circumferentially prepped with Betadine and sterilely draped. 1% plain Xylocaine was used to infiltrate the tissue of the antecubital fossa and good anesthesia was obtained. A transverse incision was fashioned through which a branch of the basilic vein was identified. A 5.6 French catheter and sensing wire assembly was inserted into the vein and its tip was advanced to the caval atrial junction. Catheter position was confirmed electromagnetically. The sensing wire was removed and the catheter was attached to a miniature port which was anchored in a subcutaneous space of the forearm. The system was flushed with heparinized saline, and dynamics were found to be excellent. With hemostasis intact and sponge and needle counts being correct the wound was irrigated with saline and closed in layers using 3-0 Vicryl on the subcutaneous tissues and 4-0 Vicryl subcuticular sutures in the skin. Sterile dressing was applied and the patient was transported to the AKU in good condition.
A patient suffering from chronic inflammation of the maxillary sinus underwent a surgical endoscopic transnasal balloon dilation procedure to restore normal sinus function. During this procedure, maxillary antrostomy with removal of tissue was completed. How should you report these procedures?
Operative Procedure: Preoperative diagnosis: 68-year-old male in coma Postoperative diagnosis: 68-year-old male in coma Procedure performed: Placement of a triple lumen central line in right subclavian vein. With the usual Betadine scrub to the right subclavian vein area and with a second attempt, the subclavian vein was cannulated and the wire was threaded. The first time the wire did not thread right, and so attempt was aborted to make sure we had good identification of structures. Once the wire was in place the needle was removed and a tissue dilator was pushed into position over the wire. Once that was removed, then the central lumen catheter was pushed into position at 17 cm and the wire removed. All three ports were flushed. The catheter was sewn into position, and a dressing applied.
Operative report: Preoperative diagnosis: Atherosclerotic heart disease Postoperative diagnosis: Atherosclerotic heart disease Operative procedure: Coronary bypass grafts x 2 with a single graft from the aorta to the distal left anterior descending and from the aorta to the distal right coronary artery. Procedure: The patient was brought to the operating room and placed in a supine position. Under general intubation anesthesia, the anterior chest and legs were prepped and draped in the usual manner. A segment of greater saphenous vein was harvested from the left thigh, utilizing the endoscopic vein harvesting technique, and prepared for grafting. The sternum was opened in the usual fashion, and the left internal mammary artery was taken down and prepared for grafting. The flow through the internal mammary artery was very poor. The patient did have a 25-mm difference in arterial pressure between the right and left arms the right arm being higher. The left internal mammary artery was therefore not used. The pericardium was incised sharply and a pericardial well created. The patient was systemically heparinized and placed on bicaval to aortic cardiopulmonary bypass with the sump in the main pulmonary artery for cardiac decompression. The patient was cooled to 26, and on fibrillation an aortic cross clamp was applied and potassium-rich cold crystalline cardioplegic solution was administered through the aortic root with satisfactory cardiac arrest. Subsequent doses were given down the vein grafts as the anastomoses were completed and via the coronary sinus in a retrograde fashion. Attention was directed to the right coronary artery. The end of the greater saphenous vein was then anastomosed thereto with 7-0 continuous Prolene distally. The remaining graft material was then grafted to the left anterior descending at the junction of the middle and distal third. The aortic cross clamp was removed after 149 minutes with spontaneous cardioversion. The usual maneuvers to remove air from the left heart were then carried out using transesophageal echocardiographic technique. After all the air was removed and the patient had returned to a satisfactory temperature, he was weaned from cardiopulmonary bypass after 213 minutes utilizing 5 g per kilogram per minute of dopamine. The chest was closed in the usual fashion. A sterile compression dressing was plied, and the patient returned to the surgical intensive care unit in satisfactory condition.
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Diverticular disease of the sigmoid colon and appendix with resolving diverticulitis of the sigmoid colon OPERATION 1. Resection of sigmoid colon 2. Appendectomy FINDINGS AT SURGERY: The patient was found to have the sigmoid colon showing the evidence of resolved diverticular disease. This involved only the mid-portion of the sigmoid colon with this area being thickened and showing evidence of inflammatory reaction around the colon. There were numerous diverticula noted. The sigmoid colon was adherent to the lateral peritoneum as well as to the bladder with inflammatory adhesions. These were easily taken down. The appendix showed evidence of past scarring. Numerous diverticula were noted and it was taken down. Under general anesthesia, after routine prepping and draping, the abdomen was entered through a low midline abdominal incision. After limited exploration, the pelvis was exposed and the involved area of sigmoid colon was identified. The blood supply to the sigmoid colon was taken, and the sigmoid colon was resected between clamps. The distal descending colon was then brought down to the rectosigmoid area, and an end-to-end anastomosis was accomplished. This provided a good lumen and a watertight closure. The mesentery over the bowel was closed using a running 3-0 Vicryl suture. The operative area was thoroughly irrigated. The bowel was all returned to a normal position. Sponge and needle counts were all correct. The abdominal wall was closed in layers routinely. No intraoperative complications were encountered. Dressings were applied. The patient returned to the recovery room in satisfactory condition.
PROCEDURE: Sigmoidoscopy INDICATIONS: Performed for evaluation of anemia, gastrointestinal Bleeding. MEDICATIONS: Fentanyl (Sublazine) .1 mg IV Versed (midazolam) 1 mg IV BIOPSIES: No BRUSHINGS: No PROCEDURE: A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications. FINDINGS: Was unable to pass scope beyond 25 cm because of stricture was very short bends secondary to multiple previous surgeries. Retroflexed examination of the rectum revealed small hemorrhoids. External hemorrhoids were found. Other than the findings noted above, the visualized colonic segments were normal. IMPRESSION: Internal hemorrhoids. External hemorrhoids Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy. Otherwise Normal Sigmoidoscopy to 25 cm. External hemorrhoids were found.
DIAGNOSIS: Left inguinal hernia. ANESTHESIA: General; 0.25% Marcaine at trocar sites. TITLE OF PROCEDURE: Laparoscopic left inguinal hernia repair. A skin incision was placed at the umbilicus where the left rectus fascia was incised anteriorly. The rectus muscle was retracted laterally. Balloon dissector was passed below the muscle and above the peritoneum. Insufflation and deinsufflation were done with the balloon removed. The structural balloon was placed in the preperitoneal space and insufflated to 10 mmHg carbon dioxide. The other trocars were placed in the lower midline times two. The hernia sac was easily identified and was well defined. It was dissected off the cord anteromedially. It was an indirect sac. It was taken back down and reduced into the peritoneal cavity. Mesh was then tailored and placed overlying the defect, covering the femoral, indirect, and direct spaces, tacked into place. After this was completed, there was good hemostasis. The cord, structures, and vas were left intact. The trocars were removed. The wounds were closed with 0 Vicryl for the fascia, 4-0 for the skin. Steri-Strips were applied. The patient was awakened and carried to the recovery room in good condition, having tolerated the procedure well.
DIAGNOSIS: Peritonitis OPERATION: Removal of Tenckhoff catheter DRAINS: None. All counts recorded as correct. INDICATIONS: The patient is a 56-year-old with peritoneal dialysis catheter in place and with peritonitis, gram-negative rods in peritoneal fluid. She is currently on hemodialysis. DESCRIPTION OF PROCEDURE: After satisfactory positioning, the patient's abdomen was prepped and draped in the usual fashion. Intravenous sedation was administered and local anesthesia was infiltrated around the Tenckhoff catheter. An incision was made over the palpable cuff of the catheter and then the catheter was brought into the wound. It was clamped and was divided. The catheter was divided at the skin edges and removed through the incision. The surrounding capsule was dissected to the cuff within the fascia and this was divided and the catheter was removed from the peritoneum. The fluid was cloudy, but not grossly purulent. There was no foul smell to it. The fascial defect was closed with 0-Vicryl. The wound was irrigated. The skin was closed with 4-0 Vicryl subcuticular and Steri-Strips were applied. The exit site of the catheter was debrided and left open. Sterile dressings were applied and the patient was taken to recovery in satisfactory condition, having tolerated the procedure without complication.
DIAGNOSIS: 1. Chronic cholecystitis. 2. Chronic cholelithiasis. OPERATION: Laprascopic cholecystectomy. ANESTHESIA: General, tube balanced. PROCEDURE: This healthy 42-year-old gentleman was taken to surgery with symptomatic gallbladder disease. In the operating room in the supine position after induction of adequate general anesthesia without event, the anterior abdominal wall was prepped with Hibiclens and alcohol and shaved. Drapes were applied. A routine umbilical port cut down was performed with direct visualization of the peritoneal cavity. A blunt trocar was inserted. Insufflation was carried out. The abdominal contents were examined. There were no gross abnormalities. The gallbladder was tense and thick-walled, but there were no other findings in the pelvis or upper abdominal regions. The remaining three trocars were inserted, and a routine laparoscopic cholecystectomy was performed, identifying the cystic duct, cystic artery, and the top of the common bile duct. Once said structures were identified, the cystic duct and artery were doubly clipped distally and singly proximally and divided. The gallbladder was dissected from the fossa in a retrograde fashion. The specimen was opened on the back table after it had been extracted through the epigastric port with removal of two large cholesterol stones. The mucosa was intact. The wall was definitely thickened with indications of chronic scarring. Re-inspection of the gallbladder fossa showed excellent hemostasis. No bile leakage. The clips were intact. The area was irrigated and suctioned dry. This concluded the procedure. Routine abdominal wall midline closures were carried out. Band-aid dressings were applied, and the patient was sent to the recovery room in satisfactory condition. Sponge count, needle count, and instrument counts were correct times three.
PROCEDURE: Colonoscopy with polypectomy. INDICATIONS: Iron deficiency anemia with low iron saturation. Positive fecal occult blood test per digital rectal exam. ANESTHESIA: Demerol & Versed. FINDINGS: Examination of the entire rectum & sigmoid colon is perfomed. DIVERTICULOSIS: Sigmoid Colon, Not bleeding; few small diverticulum POLYP: Sigmoid Colon, 5 mm, 45 cm from Anus, pedunculated. Procedure: Bipolor Cautery, Polyp removed; polyp retrieved. Polyp sent to pathology. HEMORRHOIDS: Internal, Size: Medium. DISPOSITION: After procedure, patient sent to recovery. After recovery, patient sent back to hospital ward.
Code the CPT and ICD-10 CM Codes for the Op Report Below: DIAGNOSIS: 1. Hematuria. 2. Chronic Prostatitis. 3. Right ureteral stricture. NAME OF OPERATION: 1. Cystoscopy. 2. Bilateral Retrogrades. 3. Ureteroscopy. ANESTHESIA: General. HISTORY: Patient is a 69-year-old male with persistent microscopic hematuria. PROCEDURE: After satisfactory general anesthesia was achieved, the patient was placed in the lithotomy position. A 21-French scope with a 30-degree lens was utilized. A survey of the bladder revealed some moderate hematuria and blood oozing from the enlarged median lobe of the prostate. The trigone area itself was elevated secondary to this enlargement. The right ureteral orifice was cannulated with a #8 cone-tipped catheter, and a retrograde was performed. This revealed a small distal ureteral stricture. Otherwise, no abnormalities were noted. Similarly, a left retrograde was obtained. No abnormality was noted. An ureteroscopy was performed to the level of the stricture on the right side using the #7 mini scope. This appeared to be a soft inflammatory stricture, as if there had been a small stone pass through there recently. Otherwise no abnormalities were noted. This was not balloon dilated. The bladder was drained, and he was awakened and transferred to the recovery room in stable condition.
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Abnormal uterine bleeding PROCEDURE: The patient was transferred to the operating room where she was placed on the operating table, and underwent induction of general anesthesia in the usual technique without difficulty. She was placed in the vaginal surgery stirrups and examined. She was found to have a midposition, normal uterus, and benign adnexa. She was prepped and draped in the usual fashion for the operation. The cervix was grasped with a single-tooth tenaculum. The cervix was progressively dilated to admit the hysteroscope. The uterine cavity was sounded to 2-3/4 inches. The hysteroscope was introduced. The endometrial cavity was noted to have some irregular thickening along the posterior uterine wall, consistent with hyperplasia. This was also consistent with the office biopsy taken preoperatively. No polyp formation was seen definitively. The endometrium was thoroughly curetted and submitted to pathology. The patient was awakened from anesthesia and transferred to the recovery room in satisfactory status.
Code the CPT and ICD-10 Procedural Codes for the following Op Report. DIAGNOSIS: Bladder outlet obstruction OPERATION: Cystoscopy with transurethral incision of the prostate and transurethral resection of the prostate INDICATIONS: This is a 61-year-old black male with a history of renal transplant. He had a history of bladder outlet obstruction symptoms prior to his transplant. He was in urinary retention and has been maintained on an indwelling Foley catheter. DESCRIPTION OF PROCEDURE: The patient was taken to the Operating Room and placed supine on the operating table after undergoing spinal anesthesia without difficulty. He was placed in the dorsal lithotomy position and the area of his genitalia and perineum were prepped and draped in standard sterile fashion. The #21 French cystoscope with the 30-degree lens was then placed through the patient's urethra and into his bladder. It was noted upon entering his prostate that there was a minimal amount of prostatic tissue obstructing the neck. In the prostate the neo-ureterocystotomy was noted to be in the upper right side dome of the bladder. There was a stent present. The ureteral orifice was not patent. The left ureteral orifice was patent. There were no mucosal abnormalities seen in the bladder, however, there were several cellules. His bladder was trabeculated and there was a cellule. The cystoscope was withdrawn then and the bladder emptied. The Van Buren sounds were then used to calibrate the urethra to 28 French, then and #24 French resectoscope sheath was placed into the patient's bladder. The scope was placed thorough the sheath with a Collings knife attached. A transurethral incision of the prostate was then made, first on the patient's right side form just proximal to his right ureteral orifice to the level of the verumontanum. This was then repeated on the left side without difficulty. That accomplished and the resectoscope was removed and #24 French loop was then placed on the resectoscope and it was placed back into the bladder. The median lobe was then resected with very few bites taken. Then the patient's left lobe of the prostate was resected without difficulty. We then resected the patient's right lobe of the prostate. Approximately four grams of prostatic tissue were resected, the resectoscope was withdrawn and the Ellik was used to evacuate these chips from the bladder. The resectoscope sheath was withdrawn and a three way #22 French Foley catheter was placed into the bladder and started on continuous irrigation. The patient was taken out of the dorsal lithotomy position. He was then transferred to the stretcher and taken to the postoperative holding area in stable condition. There were no complications during the case, estimated blood loss was 50 cc.
DIAGNOSIS: 1. Primary adenocarcinoma descending colon 2. Hydronephrosis, bilateral OPERATION: 1. Cystoscopy 2. Bilateral insertion of Double J stents FINDINGS AT OPERATION: Endoscopic examination of the urinary bladder showed no significant abnormalities. Double-J stent insertion as accomplished bilaterally with minimal difficulty in the patient's left side. PROCEDURE: With the patient in the lithotomy position and under satisfactory general anesthesia, the genitalia were prepped and draped in a routine sterile manner. The McCarthy panendoscope was inserted, and 24-cm, 6-French, silastic, Double J stents inserted bilaterally with ease. The patient was then sent to the recovery room in satisfactory condition.
DIAGNOSES: 1. Hydrocele, right. 2. Epididymitis, right, chronic. ANESTHESIA: General OPERATION: 1. Scrotal exploration. 2. Epididymectomy, right. 3. Hydrocelectomy, right. FINDINGS: Examination prior to, as well as at this procedure revealed the presence of enlargement of the right epididymis with associated hydrocele containing approximately 120 cc of straw-colored fluid. PROCEDURE: With the patient in the supine position and under satisfactory general anesthesia, the genitalia were prepped and draped in a routine sterile manner. A vertical incision was made in the right hemiscrotum, and the testicle and associated tunic delivered into the wound. Utilizing careful sharp and blunt dissection, the hydrocele sac was opened, aspirated, and dissected, as was the epididymis. The vas deferens was transected and ligated in the procedure. The patient's hemiscrotum was then drained with a small Penrose drain placed in a dependent position, followed by serial closure with 3-0 Vicryl. Sterile compressive dressing was applied. Blood loss was negligible. The patient was sent to the recovery room in satisfactory condition.
DIAGNOSIS: Recurrent right Bartholin gland abscess NAME OF OPERATION: Marsupialization of right Bartholin gland PROCEDURE: With the patient in the lithotomy position under satisfactory general anesthesia, the perineum and vagina were prepped and draped in the usual manner. The knife was used to incise an area of skin and exterior portion of the Bartholin gland, which was finished using Metzenbaum scissors. The specimen was sent for pathologic diagnosis. The lining of the gland was then sewn to the external part of the labia using a 3-0 Vicryl running locked suture. Estimated blood loss was 25 cc. The patient tolerated the procedure and anesthesia well and was taken to the recovery area in good condition with no packs or drains in place.
Code the CPT procedure(s): Diagnosis: Proliferative vitreal retinopathy, retinal detachment right eye. Status post trauma. Aphakia. Operative Procedures: Scleral buckle revision, pars plana vitrectomy, membrane peeling, removal of silicone oil, PFO, fluid gas exchange, endolaser and reinjection of silicone oil right eye. Indications: The patient is a 11-year-old boy who suffered a screwdriver injury to the right eye previously. He had undergone intersegment surgery by Dr. Smith for anterior segment reconstruction. Following this, he was noted to have a retinal detachment with a cataract approximately four months ago. At that time, he underwent pars plana lensectomy, vitrectomy, membrane peeling, endolaser, fluid gas exchange and injection of silicone oil with a scleral buckle to the right eye.he developed recurrent proliferation superiorly with a superior detachment. He is taken to the operating room now for repair of the superior detachment. Procedure: He underwent general anesthesia and intubation without difficulty. He was prepped and draped in a sterile fashion. A lid speculum was inserted straight in the right eye lid 2.5 mm inferotemporally a 5-0 Mersilene suture was passed in a mattress fashion and a 20 gauge sclerotomy created into the suture. A 4 mm infusion cannula space sclerotomy verified pin position inserted into place. Then the infusion was then turned on. The nasal sclerotomies were similarly created, a 2.5 mm posterior to the limbus. The superior detachment was noted to be anterior to the equator, between the equator and ora serrata superiorly. There were extensive preretinal fibrotic bands as well as subretinal fibrotic bands noted. The silicone oil was then removed form the eye. Following this, a Michel's pick was used to take off the preretinal proliferative membrane. The Dean forceps examination with the Michel's pick and vitrector were used. Specimens were sent to pathology. Attention was also turned to the retrocorneal fibrotic band, which was present nasally from 12 o'clock towards 3 o'clock with a dense fibrovascular white band. Using a Michel's pick and vertical scissors the band was cut away from the corneal endothelium. Dewar pick forceps were used to peel off the fibrotic tissue. It was noted that there was a fibrotic band extending from the cornea onto the ciliary body and onto the retinal surface itself, which was responsible for tenting of the retina nasally. These specimens were also sent to pathology. Following this, the view improved through the now more clear cornea in that location. There were still in the area of the corneal wound, fibrotic tissue which could not be removed. Following this, it was elected to pull up the scleral buckle. Plugs were placed into the eye, the Wtazke sleeve and the ends of the 287 were identified superonasally. The ends of the 287 were trimmed an additional 3 mm. The Watzke sleeve was placed and the 240-band was tightened and trimmed. There was now a nice high buckling effect at 60 degrees. The plugs were removed from the eye.The retinal tear was seen at 12 o'clock, which was felt to be the causative break. The previous break superotemporally still was attached and an additional laser reinforcement was placed to it. PFO was injected into the eye and all the subretinal fluid was drained out through the superior causative tear. Extensive endolaser was placed just around the tear superiorly as well as 360 degrees on the buckle. Following this the PRO was washed out with a fluid air exchange. Saline was injected into the eye to rinse out any residual PFO which may be remaining. The sclerotomy superonasally was closed. Silicone oil was injected into the eye for a good fill. Already present was an inferior peripheral iridotomy. The other sclerotomy was closed with 7-0 Vicryl suture. The infusion cannula was cut and removed from that eye and that sclerotomy closed with 7-0 Vicryl suture. Five milliliters of 0.75% Marcaine was then injected using a blunt cannula into the retrobulbar space for postoperative analgesia. The conjunctiva was then closed with 6-0 plain sutures. Ancef 150 mg and 4 mg of Decadron were given in a subconjunctival fashion. Erythromycin ointment and atropine drops were instilled into the right eye. The lid speculum was removed from the right eye and a patch and shield was placed. The patient underwent general anesthesia extubation without difficulty.
Code the CPT and ICD-10 Procedural Codes for the Op Report Below: DIAGNOSIS: Cataract, left eye.al OPERATION: Phacoemulsification with intraocular lens implantation, left eye. BRIEF HISTORY: This patient complains of progressive loss of vision and progressive cataract, admitted for phacoemulsification with implant. The patient is taken to surgery at this time for the above procedure. Technique is as follows. PROCEDURE: The patient was prepped and draped in the usual sterile fashion. Following peribulbar and topical anesthesia with preservative-free lidocaine, a wire lid speculum was placed and the superotemporal conjunctiva was approached with a fornix-based conjunctival flap. A groove was placed 2 mm posterior to the limbus with a #64 Beaver blade and carried into clear cornea with an angled Beaver. A 3.0 keratome was used to enter the anterior chamber after a paracentesis was performed on the opposite side at the limbus. Viscoelastic was used to fill the anterior chamber and a capsulorrhexis was started in the center with a triangular flap, torn circularly in a counterclockwise fashion to complete a 360 degree anterior capsulorrhexis tear. Irrigation under the anterior capsule was then performed with Balanced Salt Solution to perform hydrodissection, separating the nucleus from peripheral cortical attachments, spinning the nucleus free. The nucleus was then bisected with the phacoemulsification tip and rotated. These hemispheres were then sectioned into quadrants and splitting was performed with the cyclodialysis spatula, and the cannula for the viscoelastic. The aspiration was turned up on the phacoemulsification machine into position #2 with higher suction. The remaining nuclear quadrants were aspirated and phacoemulsification completed without difficulty. The irrigation and aspiration machine was then used to clean up the peripheral cortex and polish the posterior capsule. An 11 diopter lens was then rotated into position over the capsular bag. The inferior haptic was rotated into the bag and the superior haptic dialed into the bag. Miostat was used to constrict the pupil. The viscoelastic was removed under irrigation and aspiration control. One-half cc of Tobramycin and Decadron, 20 mg vancomycin were injected subconjunctivally at the end of the case. Maxitrol ointment and pressure patch were applied. The patient returned to the recovery room in good condition, to be discharged as an outpatient.
Diagnosis: Bilateral carpal tunnel syndrome, left greater than right Operation: Release of left carpal tunnel After successful axillary block was placed, the patient's left arm was prepared and draped in the usual sterile manner. A linear incision was made in the second crease in the left hand, after a local had been injected, and this was taken down through that area, then curved slightly medially toward the hypothenar eminence, until approximately 1 cm proximal to the wrist crease. Once this was done, the incision was taken with a knife through the skin and subcutaneous tissue. Hemostasis was achieved with bipolar cautery. The ligament was then identified, and this was cut through with a scissors, starting proximally and working distally, until the whole ligament was freed up. The nerve was identified, and this was noted to be in continuity all the way through. The nerve was freed up, along the bands from this ligament. Once this was done and hemostasis was achieved, a few 2-0 Dexon stitches were placed in the subcutaneous tissue, and the skin was closed with interrupted 4-0 nylon.
DIAGNOSIS: Conductive deafness, left ear. NAME OF OPERATION: Tympanoplasty with ossicular chain reconstruction. PROCEDURE: Under general endotracheal plus 2% Xylocaine endaural block anesthesia, the ear was inspected. The patient had several surgical procedures performed on this ear over the years, the last one being approximately three months ago, at which time the tympanic membrane was totally reconstructed, and the ossicular chain reconstructed using a hydroxyapatite prosthesis from the stapes head to the underside of the cartilage-reinforced drumhead. At the time of this present operation, the drum head was intact and slightly lateralized. The middle ear was entered through a posterior tympanomeatal incision, and it was found that the hydroxyapatite prosthesis was lying free in the inferior part of the middle ear with the shaft still touching the stapes head, but the head attached to the medial wall of the middle ear. This prosthesis was carefully dissected away. The medial aspect of the cartilage cap was scraped with a sharp right angle, and the reverse elevator, and then inspected with a Buckingham mirror to make certain that it was denuded of mucosa. Next, the middle ear was partly filled with moist Gelfoam. Another offset hydroxyapatite partial prosthesis was sculptured with diamond burs with approximately 0.5 mm extra length from the old prosthesis, with a groove cut for the stapedius tendon. This was placed in position with the chorda tympani touching this shaft at the medial aspect of the prosthesis. Using glue, the attachment with the stapedius tendon and the stapes head was glued in place. Then, the middle ear was completely filled with moist Gelfoam to stabilize the prosthesis. The chorda tympani was also glued to the superior portion of the shaft of the prosthesis. Next, the head of the prosthesis was covered with glue and the drumhead with the cartilage cap was replaced in position. The tympanomeatal flap was secured in place with compressed, moist Gelfoam. External auditory canal was filled with Polysporin ointment. It was anticipated this ossicular reconstruction will stay in the proper position, and the patient will have a significant improvement in the hearing. The patient tolerated the procedure well and returned to the recovery room in good condition.
Diagnosis: Left cervical radiculopathy at C5, C6. Operation: Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root. After informed consent was obtained from the patient, he was taken to the OR. After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted. At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position. The patient's posterior cervical area was then prepped and draped in the usual sterile fashion. At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine. A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated. After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken. This showed the spinous process to be at the C4 level. Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified. After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken. This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time. At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina. The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe. This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur. However, progress was limited because of thickness of the bone.Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area. After the bone had been thinned out, further bone was removed using the Kerrison rongeur. At this point the nerve root was visually inspected and observed to be decompressed. However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade. Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery. After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin. Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches. The subcutaneous layer was then reapproximated using 000 Dexon. The skin was reapproximated using a running 000 nylon. Sterile dressings were applied. The patient was then extubated in the OR and transferred to the Recovery room in stable condition.
DIAGNOSIS: Lumbar radicular pain syndrome. NAME OF OPERATION: Selective root (nerve) sleeve injection on the left at L5-S1 with fluoroscopy. PROCEDURE: The patient is taken to the block room, placed in the prone position on the x-ray table. Sterile prep and drape is applied. Local is with 3 cc of 1% plain lidocaine. Using fluoroscopic guidance, the neural foramen is obtained on the left at the L5-S1 level, confirmed with three views and the injection of contrast. The patient does note transient paresthesia on initial needle positioning, however, is not present on injection. Negative aspiration is followed with the injection of 0.5 cc of 1% plain lidocaine. This results in total resolution of the patient's pain complaint. She also notes some numbness in the left lower extremity which was in a similar location to that when it is experienced; however, this has not been continuously present. This is followed with repeat negative aspiration and the injection of 40 mg Depo-Medrol, 3 mg Celestone, 0.5 cc Wydase, and 0.5 cc of 0.5% ropivacaine. The needle is removed intact. There is no blood loss. There are no apparent complications. The patient is without complaints.
A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select the appropriate code(s) for this visit.
Mr. Johnson, a 38-year-old established patient is being seen for management of his hypertension, diabetes, and weight control. On his last visit, he was told he had a diabetic foot ulcer and needed to be hospitalized for this condition. He decided to get a second opinion and went to see Dr. Myers. This was the first time Dr. Myers had seen Mr. Johnson. Dr. Myers documented a comprehensive history, comprehensive examination, and decision-making of high complexity. He concurred with hospitalization for the foot ulcer and sent a report back to Mr. Johnson’s primary care doctor. How would you report Dr. Myers visit?
Dr. Jane admitted a 67-year-old woman to the coronary care unit for an acute myocardial infarction. The admission included a comprehensive history, comprehensive examination, and high complexity decision-making. Dr. Jane visited the patient on days two and three and documented (each day) an expanded problem focused examination and decision-making of moderate complexity. On day four, Dr. Jane moved the patient to the medical floor and documented a problem focused examination and straightforward decision-making. Day five, Dr. Jane discharged the patient to home. The discharge took over an hour. How would you report the services from day one to day five?
42-year-old woman is being discharged today, 2/5/XX. She was admitted to the hospital 2/2/XX for acute diverticulitis. Refer to dictated notes for a detailed description of the history, exam, and assessment and treatment protocol. Patient was also seen in consultation by Dr Z. She was placed on intravenous antibiotics and has made slow steady progress. Today has no abdominal pain. Labs are normal and CT of the abdomen and pelvis showed changes consistent with diverticulitis in the left side of colon. She was given follow up instructions of her medications, what diet to have and to follow up with PCP in 10 to 14 days or return if pain resumes. Total time spent with patient 40 minutes. What CPT® code(s) should be reported?
A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that arrived with multiple facial fractures that may need surgery. Patient was in an automobile accident and an opinion is needed for reconstructive surgery. Dr.Kevin arrives at the ED, obtains detailed history and performs a detailed exam. Dr. Kevin performs a moderate medical decision making, in deciding that the patient needs major surgery to repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with findings in the ED chart. The E/M service reported by Dr.Kevin:
A patient is brought to the ED with a broken collar bone. The injury was sustained from a fall while rock climbing in the mountains. The doctor performs a detailed history and exam, and moderate complexity decision-making. The bone is splinted with a figure 8 splint and the patient is sent home with a prescription of Lortab 7.5 and directions to restrict activity for 8-10 weeks. What are the correct E/M and ICD-10-CM codes for the encounter?
A 98-year-old Medicare patient diagnosed with prostate cancer is seen in the OR for a retropubic radical prostatectomy. What are the correct procedure, anesthesia, and diagnosis codes for this scenario?
Which of the following three anesthesia types are considered “regional” anesthesia? (Choose three)
A 38-week-pregnant woman presents to the hospital in labor. She is dilated four centimeters, is 50 percent effaced, and wants to have the baby vaginally. The woman is given an epidural for the pain. Twenty hours later she is still only dilated to six centimeters. The physician decides that a cesarean delivery is now necessary. She is taken to the OR, given anesthesia for the cesarean, and delivers a healthy baby boy. Which CPT code(s) should be reported for the anesthesia administered?
Using anesthesia procedure codes (00100-01999), code general anesthesia for repair of a ruptured aortic aneurysm graft. The patient was noted to have severe systemic disease at the time of anesthesia, and a pump oxygenator was used during the procedure.
A patient received 32 radiation oncology treatments. How should this series of treatment sessions be coded?
Select the appropriate code for a computerized axial tomography of the lumbar spine with contrast.
Jim received 2 fractions of high dose electronic brachytherapy by dermal application at a free standing oncology center. What code(s) report this service?
A patient suffering from lower back pain presented to the emergency department. The physician performed a physical examination on the patient and ordered a lumbar myelography for a suspected herniated disc. The patient was sent to the hospital where the radiologist injected contrast material into the subarachnoid space through a percutaneously placed spinal needle. Films of the lumbar area were obtained and interpreted by the radiologist. Select the appropriate codes for the radiologist services.
A CT study of the cervical spine (C2-C4) was performed with IV contrast in the hospital outpatient radiology department. How should the services be reported?
A 68 year old male presents with renal cell carcinoma for preoperative and metastatic evaluation prior to tumor resection. A CT of the abdomen “without contrast” followed by a CT “with contrast” was performed. Code the procedure and diagnosis codes.
A drug screen (multiple classes, one procedure) was performed on a comatose patient presenting at the ED. The presence of opiates and barbiturates was noted using dip stick method. Confirmatory test for each of these drug classes were run using liquid chromatography and mass spectrometry (2 procedures). Code all procedures performed.
A qualitative test found traces of benzodiazepines. The hospital did a quantitative examination to find out the quantity for benzodiazepines in the specimen. Code for the quantitative examination.
A patient presented to her hospital clinic physician for a routine general physical examination. The physician ordered the following test: an automated hemogram and platelet count; an automated complete differential WBC count (CBC); glucose; urea nitrogen (BUN); carbon dioxide; creatinine; uric acid; calcium; potassium; sodium; chloride; transferase, aspartate amino (AST) (SGOT); phosphatase, alkaline; total bilirubin; total protein; albumin; TSH; and transferase, alanine amino transferase (ALT) (SGPT). What are the procedure and diagnostic codes?
An established patient comes in the outpatient hospital clinic for a follow-up visit for chronic hepatitis. After being examined, the physician ordered the patient to have a hepatic function panel drawn. The panel includes the following elements: bilirubin, total and direct; SGPT; and SGOT. Code for the procedures and diagnosis.
Code for six body regions involved in osteopathic manipulative treatment.
Code for comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording. His bundle recording, including insertion and repositioning of multiple electrode catheters with attempted induction and repositioning of arrhythmia, despite failure of including arrhythmia.
A patient brings a child in for the first time to the outpatient pediatric clinic for an oral adenovirus’ Type IV vaccine. The physician’s assistant evaluates the child and administers the vaccine orally to the child. What procedure and diagnosis codes would be reported for the vaccination services?
Left heart catheterization retrograde from the femoral artery with injection procedures for selective coronary angiography and selective left ventriculography, including imaging supervision and interpretation with report, are performed. The cardiologist performed all of the services at the hospital. The CPT codes are:
A patient completed a diagnostic computerized ophthalmic scan of the retina on both eyes. The physician’s interpretation and report included changes to the retinal in the right eye from a previous stdy. The left retina looked stable with no changes noted. The patient is scheduled for a follow-up study in three weeks to assess any new changes and treatment is needed. How should the physician report her services?
A three-year-old patient, with accidental ingestion of iron pills, is treated with gastric lavage in the emergency department of the hospital. The patient is experiencing severe generalized abdominal pain. What codes are reported for this procedure?
Which organ has both exocrine and endocrine parts?
Identify the two structures that comprise the hair
Deoxygenated blood collects in which major veins during the process of circulation?
Which bone takes credit for being smallest in the body?
A 14-year-old male is brought to the emergency room by his parents after injuring his left knee while sliding into base during a tournament baseball game. X-rays reveal a sprain to the knee. The patient is instructed to keep his leg elevated and to keep off it as much as possible for the next two weeks. What diagnosis code(s) would be reported for this encounter?
A nine year old is brought to the emergency room by his parents. The child has been running a fever for the past 14 hours, with the highest reaching 103.5 degrees. Vomiting is also a complaint. After examination renal x-rays, and lab tests, which were positive for E-coli, the physician documented acute pyelonephritis. The patient was discharged to his parents with a prescription for Bactrim. What are the correct diagnosis codes for this visit?
A homebound patient with an indwelling catheter is treated in the emergency room for a urinary tract infection due to E.coli caused by the catheter. Aggressive antibiotic therapy was started in the ER. What are the correct diagnosis codes for this encounter?
A female is treated for a closed fracture of the right hand. The shaft and neck of the metacarpal bones are treated using closed reduction. The fracture was sustained at a baseball field. What are the correct diagnosis codes for this patient’s encounter?
A patient is issued a wedge cushion for his wheel chair
