1.
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
bepalpated. 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
Kerrisonrongeur 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 Kerrisonrongeur after the ligaments had
been freed by using a Woodson probe. This was then extended laterally to
perform a medial facetectomy also using theKerrisonrongeur. 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 Kerrisonrongeur.
At this point the nerve root was visually inspected and observed to
bedecompressed. 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 bipolarelectrocautery.
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. Thesubcutaneous layer was then reapproximated
using 000 Dexon. The skin was reapproximated using arunning 000 nylon. Sterile
dressings were applied. The patient was then extubated in the OR andtransferred
to the Recovery room in stable condition.
a.
63020
b.
63020,
69990
c.
63015
d.
63015,
69990
2.
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 withthe 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.
a.
69632-LT
b.
69633-LT
c.
69635-LT
d.
69636-LT
3.
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 bein
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.
a.
64721
b.
64721-LT
c.
64726
d.
64726-LT
4.
Code
the CPT and ICD- 10 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 keratomewas 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 Solutionto 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.
a.
66982
b.
66982-LT
c.
66984-LT
d.
None
of the above
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 ofsilicone 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 planalensectomy, vitrectomy, membrane peeling, endolaser, fluid
gas exchange andinjection of silicone oil with a scleral buckle to the right
eye. he developed recurrent proliferation superiorlywith 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 drapedin a sterile fashion. A lid speculum was inserted straight in the
right eye lid 2.5 mm inferotemporally a 5-0Mersilene suture was passed in a
mattress fashion and a 20 gauge sclerotomy created into the suture. A 4mm
infusion cannula space sclerotomy verified pin position inserted into place.
Then the infusion was thenturned on. The nasal sclerotomies were similarly
created, a 2.5 mm posterior to the limbus. The superiordetachment was noted to
be anterior to the equator, between the equator and oraserrata superiorly.There
were extensive preretinal fibrotic bands as well as subretinal fibrotic bands
noted. The silicone oilwas then removed form the eye. Following this, a
Michel’s pick was used to take off the preretinalproliferative 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 waspresent nasally from 12 o’clock towards 3
o’clock with a dense fibrovascular white band. Using a Michel’spick and
vertical scissors the band was cut away from the corneal endothelium. Dewar
pick forceps wereused to peel off the fibrotic tissue. It was noted that there
was a fibrotic band extending from the corneaonto the ciliary body and onto the
retinal surface itself, which was responsible for tenting of the retinanasally.
These specimens were also sent to pathology. Following this, the view improved
through the nowmore clear cornea in that location. There were still in the area
of the corneal wound, fibrotic tissue whichcould not be removed. Following
this, it was elected to pull up the scleral buckle. Plugs were placed intothe
eye, the Wtazke sleeve and the ends of the 287 were identified superonasally.
The ends of the 287were trimmed an additional 3 mm. The Watzke sleeve was
placed and the 240-band was tightened andtrimmed. 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 breaksuperotemporally still was attached and an additional laser
reinforcement was placed to it. PFO wasinjected into the eye and all the
subretinall fluid was drained out through the superior causative
tear.Extensiveendolaser 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 rinseout any residual PFO
which may be remaining. The sclerotomysuperonasally was closed. Silicone oil
wasinjected into the eye for a good fill. Already present was an inferior
peripheral iridotomy. The othersclerotomy was closed with 7-0 Vicryl suture.
The infusion cannula was cut and removed from that eye andthat sclerotomy closed
with 7-0 Vicryl suture. Five milliliters of 0.75% Marcaine was then injected
using ablunt cannula into the retrobulbar space for postoperative analgesia.
The conjunctiva was then closed with6-0 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
removedfrom the right eye and a patch and shield was placed. The patient
underwent general anesthesiaextubation without difficulty.
a.
67107,
67015-51
b.
67110,
67015-51
c.
67108,
67015-51
d.
67113,
67015-51
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?
a.
67229
-50
b.
67229
x 5
c.
67229,
69990
d.
67229
7.
Todd
had a tumor removed from his left temporal bone. How would you report this
service?
a.
61563
b.
61500
c.
69979,
69990-51
d.
69970
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?
a.
60300-26,
76942-26
b.
60300
x 2, 77012-26
c.
10021,
60300-51, 77012-26
d.
60300
9.
Baby
Smith was diagnosed with meningitis. His physician placed a needle through the
fontanel at the suture line to obtain a spinal fluid sample on Monday. The
needle was withdrawn and the area bandaged. The baby required another subdural
tap bilaterally on Wednesday. How would you report Wednesday’s service?
a.
61001
b.
61000,
61001
c.
61070
d.
61001-50
10.
Michael has bilateral lazy eyes and undergoes
strabismus surgery of the superior oblique muscle for both eyes. What CPT® code
is reported?
a.
67318-50
b.
67345
c.
67311-50
d.
67318
11.
Dr.
Martin performed an excision at the middle cranial fossa for a vascular lesion.
This procedure was completed in an intradural fashion with dural repair and
graft. His partner, Dr. Sutter, performed an infratemporal approach with
decompression of the auditory canal. How should Dr. Martin report her services?
a.
61590,
61606-51
b.
61606-62
c.
61606
d.
61601
12.
After
a snow skiing accident, Barry had a cervical laminoplasty to four vertebral
segments. How should you report this procedure?
a.
63050
x 4
b.
22600,
63051-51
c.
22842,
63045, 63050
d.
63050
13.
Phyllis
fell down on the ice and fractured her leg. The fall also caused severe injury
to the muscles and tore several nerves. Her physician completed suturing of two
major peripheral nerves in her leg without transposition and shortened the
bone. After the surgery she was seen by a physical therapist for ongoing
treatment and gait training. How would you report the surgical procedure?
a.
64857,
64859-51, 64876-51
b.
64856,
64857
c.
64857,
64859, 64876
d.
64858,
64857, 64859, 64876
14.
John
was hospitalized for a repair of a laceration to his left conjunctiva by
mobilization and rearrangement. How should you report this procedure?
a.
65273-LT
b.
67930
c.
65272
d.
67930-LT
15.
The
patient was taken to the procedure room and placed prone and the L4–L5
interspace was identified using fluoroscopy to determine the injection site.
The patient was prepped in routine sterile fashion with Betadine and covered in
sterile drape. 1% lidocaine was used to anesthetize the skin, subcutaneous
tissue, and muscle. Once the proper anesthesia was obtained, a 3 inch, 20 gauge
Tuohy needle was inserted and slowly advanced towards the L4-L5 interspace.
Using a 6 cc glass syringe and the loss-of-resistance technique the epidural
space was identified. After aspiration revealed no blood or cerebrospinal fluid
return, the syringes were then changed and 80 mg/ml preservative-free Depo
Medrol and 2 cc of 1% methylparaben free lidocaine were injected in slow
incremental fashion. After aspiration, all needles were removed intact, the
skin was cleaned and a Band-Aid was applied. Code this encounter.
a.
62322
b.
62322,
77003-26
c.
62320,
77003-26
d.
62326,
77003-26
16.
DIAGNOSIS:
Post dural puncture headache.
ANESTHESIA:
Intravenous sedation
OPERATION:
Epidural blood patch.
PROCEDURE:
After satisfactory explanation of the risks and benefits of the procedure,
patient was placed in the sitting position. His back was prepped with Betadine
in a sterile fashion. A lidocaine skin wheal was made in approximately the L2-3
interspace. This site was approximately 2-3 cm above the superior aspect of a
midline lumbar scar. A 17-gauge epidural needle was directed into the epidural
space using loss of resistance-to-air technique. Negative aspiration for blood
or cerebrospinal fluid was obtained. Twenty cc of blood was drawn sterilely
from the right antecubital fossa. This was then injected slowly into the
epidural space. Patient received 2 mg Versed during this procedure. He was
taken to the condition. He had good, though not complete resolution of his
headache.
a.
62273
b.
62273-26
c.
62281
d.
62284
17.
DIAGNOSIS:
Degenerative arthritis of lumbosacral spine with bilateral lumbar facet
syndrome.
OPERATION:
1. L3-4 facet injection, bilateral. 2. L4-5 facet injection, bilateral. 3.
L5-S1 facet injection, bilateral. 4. Monitored intravenous Versed sedation.
PROCEDURE:
The patient was taken to the block room. She was placed prone on the
fluoroscopy table.She was monitored appropriately. She was administered Versed,
a total of 4 mg IV. Her back was prepped and draped. Her O2 saturation remained
greater than 90%. The C-arm was brought in and was rotated obliquely to the
right. The facets at L3-4, L4-5, and L5-S1 on the right were visualized. After
adequate
local
anesthesia, 22-gauge, 5-inch spinal needles were inserted. One-half cc of
contrast was injected into each joint verifying intra-articular needle
placement. Depo-Medrol10 mg plus 1 cc of 0.5% preservative-free Marcaine was
injected into each joint. The needles were removed. I then rotated the C-arm
obliquely to the left. The facets on the left side were visualized. After
adequate local anesthesia, 22-gauge, 5-inch spinal needles were inserted into
each of these joints. Correct needle placement was confirmed with fluoroscopy,
and each joint was injected with 10 mg Depo-Medrol plus 1 cc of 0.5%
preservative-free Marcaine. The patient was placed supine. Her back and leg
pain were both much improved. She continued to have some pain in her upper back,
but otherwise had no complaints.
a.
64493,
64494
b.
64493-50,
64494-50-51
c.
64493-50,
64494-50, 64495-50
d.
64493-50,
64494-50, 64495-50, 77003-26
18.
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 myringoplastysite.The patient tolerated the procedure well and
returned to the recovery room awake and in stable condition.
a.
69200
b.
69205
c.
69205,
69620-51
d.
69620
19.
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 patientwas sent
to her room in good condition, to be followed in physician office next day.
a.
67906-50
b.
67904-50
c.
67903-50
d.
67902-50
20.
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, 0.5cc 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.
64493
b.
64483,
77003
c.
64483,
72100 and 77003-25
d.
64483
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