Auditory & Ocular System

1. 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.

2. DIAGNOSIS: Bilateral upper lid ptosis, by levator dehiscence.

ANESTHESIA: Local standby.

NAME OF OPERATION: Repair of ptosis, by repair of levator dehiscence, bilateral upper lids.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Less than 5 cc.

PROCEDURE: The patient was taken to the operating room and placed on the table in the supine position. Cardiac monitor and IV were established by anesthesia, who administered anesthesia standby. The patient was prepped and draped in the usual sterile fashion for oculoplastic surgery. Tetracaine ophthalmic drops were instilled into the eyes. Attention was directed to the upper lids where very little skin fold was noted, consistent with her levator dehiscence. At 12 mm above the lash line, a skin mark was made across the lid in a gentle arch. This was performed on both upper

lids and noted to be symmetrical. Lidocaine 2% with epinephrine was injected into the right upper lid along the skin-mark line, and the skin incision was made with a #15 blade. Dissection was carried down to the subcutaneous and orbicularis muscle, down to the orbital septum which was then opened superiorly, and orbital fat was encountered. With gentle dissection, the levator aponeurosis was noted. The dissection was carried to the tarsal plate and the anterior tarsal plate was cleared.

A 5-0 nylon suture was used to re-approximate the edge of the levator aponeurosis back to the tarsal plate, thereby elevating the lid, until the lid position was approximately 1 mm above the limbus. A second and third suture was placed, one medially and one laterally, with good arch of the lid.

Attention was then directed to the left upper lid where the exact, same procedure was done, after anesthetic was injected. Again, dissection through the skin and subcutaneous and orbicularis muscle down to the orbital septum, which was then incised. Orbital fat was encountered, and the levator aponeurosis was noted. The tarsal plate was cleared from the orbicularis muscle, and again three sutures were used to reapproximate the levator aponeurosis back to the tarsal plate. With a gentle arch to the lid, the lid now elevated about 1 mm above the limbus. Since this was symmetrical, all suture knots were then secured permanently. The skin was closed with interrupted 6-0 silk sutures.

Tobradex ointment was instilled over the incisions, and cold compresses and ice packs applied. The patient was sent to her room in good condition, to be followed in physician office next day.

3. 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.

4. Code the CPT and ICD-9 Procedural Codes for the Op Report Below:

DIAGNOSIS: Cataract, left eye.

ANESTHESIA: Topical

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.

5. 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 subretinall 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.

6. An infant born at 33 weeks underwent five photocoagulation treatments to both eyes due to retinopathy of prematurity at six months of age. The physician used an operating microscope during these procedures. These treatments occurred once per day for a defined treatment period of five days. How would you report all of these services?

7. Todd had a tumor removed from his left temporal bone. How would you report this service?

8. Jennifer was admitted to the hospital for an aspiration of two thyroid cysts. Her physician completed this procedure with CT guidance of the needle including interpretation and report. How would you report the professional services?

9. Max had a bilateral revision fenestration operation. How would you report this procedure?

10. John was hospitalized for a repair of a laceration to his left conjunctiva by mobilization and rearrangement. How should you report this procedure?

11. The region at the back of the eye where the optic nerve meets the retina is the ------

12. The normal adjustment of the lens to bring an object into focus for near vision on the retina is -----

13. A yellowish region on the retina lateral to the optic disc is the -----

14. In this condition there is destruction of the fovea centralis:

15. This is an infection that occurs in the middle ear cavity:

16. The point at which the fibers of the optic nerve cross in the brain is the --------

17. The photoreceptors cells in the retina that makes perception of color possible are the ------

18. The photoreceptor cells in the retina that make vision in dim light possible are the ------

19. The ----- is the area behind the cornea and in front of the lens and iris. It contains aqueous humor.

20. The posterior, inner part of the eye is the -------

21. Instrument to examine the ear

22. Removal of the third bone of the middle ear -------

23. Pertaining to the auditory tube and the throat is ------

24. Flow of pus from the ear is -----

25. Instrument to measure hearing is the -------

26. Surgical incision of the ear drum ------

27. Deafness due to old age ------

28. Small ear

29. Inflammation of the middle ear is -------

30. Repetitive rhythmic movements of one or both eyes ------

31. Combining form means eyelid:

32. Combining form means eye lens:

33. Abbreviation meaning the pupils are equal, round, and reactive to light and accommodation:

34. This condition can be acquired or congenital and results in an irregular curvature of the refractive surfaces of the eye:

35. In this condition the eyeball is shorter than normal and results in being able to see objects in the distance but not close up:

36. Rapid involuntary eye movement is the predominant symptom of this condition:

37. Age related farsightedness is:

38. Another name for a stye is:

39. An inflammation of the cornea that is caused by herpes simplex virus is:

40. In this condition there is destruction of the fovea centralis:

41. This is an infection that occurs in the middle ear cavity:

42. The covering of the front of sclera and lining of eyelid:

43. Which of the following is NOT a bone of the middle ear?

44. A 65-year-old patient presented with ectropion of the right lower eyelid. Repair with tarsal wedge excision is performed for correction. Attention was then directed to the left eye. The patient also had an ectropion of the left lower lid which was repaired by suture repair. Code this procedure.

45. A 63-year-old woman presented to the eye clinic as a new patient with symptoms of flashing lights and floaters in the right eye for two days duration. The ophthalmologist does a general evaluation of the complete visual system, including dilating her eyes and checking her with the indirect ophthalmoscope, revealing peripheral retinal tear. The physician explains to the patient that if left untreated, there is a high likelihood of retinal detachment. The patient agrees to the procedure. The physician lasers the retinal tear and tells the patient to come back in 24 hours for follow-up. Code this visit.

46. A four-year-old with chronic otitis media and fluid buildup in both ears was admitted by her otolaryngologist for a bilateral tympanostomy. The procedure was performed with placement of ventilating tubes. The procedure required general anesthetic due to the patient’s age. Select the procedure code for this procedure.

47. A patient presents to the emergency department with complaint of painful eye. The patient states that her right eye is constantly tearing and is sensitive to light. The physician performs an exam and identifies a corneal foreign body in the right eye. Utilizing a slit lamp, the foreign body is removed. Code the encounter.

48. The physician performs a right thyroid lobectomy. The patient was prepped and draped. After adequate general anesthesia, the neck was incised on the right side and sharp dissection was then used to cut down onto the strap muscles and sternodcleidomastoid muscles. The strap muscles were separated and transected on the right side. A small thyroid lobe was visualized and dissected free. There was no evidence of a tumor. The wound was closed with 3-0 interrupted Vicryl for the platysma, 4-0 Vicryl for the deep tissues and 6-0 fast absorbing gut for the skin. Code the encounter.

49. 2-year-old Hispanic male has a chalazion on both upper and lower lid of the right eye. He was placed under general anesthesia. With an #11 blade the chalazion was incised and a small curette was then used to retrieve any granulomatous material on both lids. What code should be used for this procedure?

50. An extracapsular cataract removal is performed on the right eye by manually using an iris expansion device to expand the pupil. A phacomulsicfication unit was used to remove the nucleus and irrigation and aspiration was used to remove the residual cortex allowing the insertion of the intraocular lens. What code should be used for this procedure?

51. An infant who has chronic otitis media was placed under general anesthesia and a radial incision was made in the posterior quadrant of the left tympanic membrane. A large amount of mucoid effusion was suctioned and then a ventilating tube was placed in both ears. What CPT and ICD-9-CM codes should be reported:

52. An entropian repair is performed on the left lower eyelid in which undermining was performed with scissors of the inferior lid and inferior temporal region. Deep sutures were used to separate the eyelid margin outwardly along with stripping the lateral tarsus to provide firm approximation of the lower lid to the globe. The correct CPT code is:

53. Which bone takes credit for being smallest in the body?

54. In which part of the body would you find the choroid?

55. Using your CPT codebook and looking up Strabismus in the Index, Strabismus surgery would be performed to correct which of the following eye disorders?

56. Which of the following organs has NO refractive properties?

57. Code69210 in your CPT codebook describes removal of impacted earwax from the external auditory canal. What type of conduction is interrupted by impacted earwax?

58. The incus bone is between the malleus and stapes. In which part of the ear does the incus reside?

59. Which of the following statements is true regarding the vitreous humor?

60. What is a blepharoplasty?