General endotracheal anesthesia cpt code

CHAPTER 26 r Endocrine and Nervous Systems

PRACTICAL

Using the CPT manual, code the following:

2l.Incisionanddrainageofaninfectedthyroglossalductcyst.

& cpr code(s):

lr. *"^ovar of a complete cerebrospinal fluid shunt system; without replacement.

& cpr code(s):

23. Suture of the posterior tibial nerve'

& cpr code(s):

T. w^bar sympathetic block (left)'

CPT Code:

25. Mioodissection, microrepair ulnar digital nerve teft middle frnger'

CPT Codes:

4u. n ur"*ent of a dorsal column stimulator with implanted generator, with stereotactic stimulation of spinal cord'

27. Epidual iniection of a steroid, caudal'

ur/g. aruniotomy for drainage of an intracranial abscess; infratentorial.

CPT Code:

due to leak of CSF29. Re-opetation, skull base surgery, repair of dura matel

of miOdte cranial fossa; myocutaneous flap graft'

.,a/0. ,.rr.r,ion of a cerebrospinal fluid ventriculoperitoneal shunt for

hydrocephalus.

CPT Code:

31. Hemilaminectomy, posterior approach, with decomqr-elsion of two

"- ;.-re;ooi, u"O #ittr excision bi herniated disc atLl-LZ and foraminotomy at L2-L3'

CPT Codes:

B ur." to decide number of codes necessary to correctly arrswer the question.

odd-numberedanswersarelocatedinAppendixB,whilethefullanswerkeylsonlyavailableintheTEACll Instructor Resources on Evolve'

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CHAPTER 26 r Endocrine and Nervous Systems

REPORTS

In Appendix A of this workbook you will find a section titled Repotts, which contains original reports. Read the rcports indicated below and supply the ilppropriate CPT and ICD-10-CM/ICD-9-CM codes on the following lines:

J32. Report 4t

CPT Codes: (arthrodesis with discectomy),

(arthrodesis with discectomy),

(instrumentation), (allograft),

(evoked potential)

ICD-10-CM Code:

(ICD-9-CM Code:

33. Report 43

& code(s):

& tco-ro-cM code(s):

(& ICD-o-cM code(s):

& U".. to declde number of codes necessary to correctly answer the questlon. Odd-numbered answers are located ln Appendlx B, while the full answer key is only available il the TEACH Instructor Resources on Evolve.

Copydght @ 2015 by Saunders, an impdnt of Elsevier Inc. All rights reserved.

APPENDIX A r RePorts

stapleL We imbricated the staple line with two Ethibond sutures, placed a wad of fat over the last to adhere the fat neal oul staple line. We tested the anastomosis with air with the bowel clamped, and there was no evidence of a leak. We then placed Hemaseel ovel this anastomosis, and then once again mobilized the mesentery. We then closed the mesenteric defect where the small bowel had gone in retrogastric fashion with the Ethicon Endo- suture. We once again placed Hemaseel on our small anastomosis. We placed L0 flat Jackson-Pratt drains near our GJ anastomosis, which came on out the Ieft side. We removed the trocal polts under direct vision. We then extended our umbilical incision and reduced the umbilical hernia. We closed the fascial defect with interrupted 0 Prolene sutures. We anesthetized the wounds at all aleas with a total of 60 cc of 0.50o/o Sensorcaine with epinephdne solution. We secured the drains in place with 0 silk sutures and then closed the skin with 3-0 Prolene sutures. Steri-Strips and sterile Band- Aids were applied. All sponge and needle counts were correct. We left the taut catheter and a Penrose drain in the left midclavicular line incision.

AtI sponge and needle counts were correct. She tolerated this well and was taken to recovery in stable condition.

PATHOLOGY RBPORT LATER INDICATED: See Report 63.

IIISTORY: This patient, who is unknown to me, reports working in the shop at his home grinding metal approximately 5 hours ago. He was wearing safety glasses, but he has noticed a foreign body in his right eye. He reports slight irritation to the eye. Denies blurred vision.

PHYSICAL EXAMINATION: PERLA, tundi without edema. There was no foreign body on lid eversion. Slit lamp shows a foreign body approximately 2 to 3 o'clock on the edge of the cornea. This foreign body appears metallic. There is very small area of rust around the site. Iris is intact. There are no cells in the anterior chamber. Fluorescein dye reveals uptake only over foreign body.

PROCEDURE: Two drops of Alcaine were used in the right eye. Foreign body was removed with an eye spud without difficulty. Slight orange discoloration at the base of cornea, but no definite rust ring visible.

IMPRESSION: Residual corneal abrasion.

DISPOSITION: Foreign body removed from right eye.

PREOPERATM DIAGNOSIS: Left cervical spondylosis, C5-6, C6-7, with cervical discs.

POSTOPERATM, DIAGNOSIS: Same.

PROCEDURE PERFORMED: Anterior discectomy and osteophytectomy for decompression at C5-6 and C6-7 , with allograft fusion and Zephyr plating.-

This case was monitored with sensory evoked potentials throughout the case. There were no changes.

PROCEDURE: Under general anesthesia, the patient was placed in the cervical outfigger. The neck was prepped and draped in the usual manner.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.

APPENDIX A r Reports

1.

2. 3.

An incision was made parallel to the sternocleidomastoid, and then we got onto the omohyoid and incised this. Then with sharp dissection we got onto the prevertebral fascia, put the Farley-Thompson retractor in, and then I was able to localize the C5-6 and C6-7 interspaces. The plan here was to decompress the nerve roots and get rid of the ridges, the disc, and to fuse and p1ate. The discectomies were done at C5-6 and C6-7. The ridges were removed, the discs were removed, and then the cartilaginous surfaces were prepared for reception of the bony fusion. At C6-7, a #8 trial was utilized and at C5-6 a #7 trial was utilized with bone. I took off the ridges, I took off the osteophytes, I removed the discs. I got down to the dura on both sides and was satisfied now that the nerve roots were decompressed and I could put the trial in and place the structural bone graft in. This was done at both Ievels. This having been done, they were countersunk and I then utilized a Zephyr plate from C5 down to C7 and put a screw into C6 as well. This done, a Hemovac drain was placed into the wound. Of course, the plate was locked, and we then closed the wound in layers utilizing 2-0 chromic on the platysma with 2-0 plain in the subcutaneous tissue and 3-0 nylon interrupted mattress sutures on the skin. A dressing was applied. The patient was to wear a collar in the postop period.

PATHOLOGY REPORT LATER INDICATED: Benign bone and tissue.

PREOPE,RATfVE DIAGNOSES:

Ptosis, right upper lid. Loss of superior visual field secondary to #1. Superior hemianopia secondary to #1, right eye.

POSTOPERATM DIAGNOSES: Same.

PROCEDURE, PERFORMED: Fasanella-Servat procedure, right upper lid.

ANESTHESIA: General endotracheal.

INDICATIONS: This S7-year-old white female has had progressively drooping lid on her right for many years which has now reduced her superior visual field in the right eye and has actually limited her vision. After the prior approval and the photos and documentation were obtained, it was noted that the patient did have a 3- to 4-mm ptosis of the right upper lid and we would approach this with a Fasanella-Servat procedure. The risk of infection, hemorrhage and reoperations were discussed.

PROCEDURE: After the patient was placed under suitable general endotracheal anesthesia; the superior tarsal border was then marked with a marking pen and a 15 Bard-Parker blade cut down through skin to the muscle area. The lid was then everted on a Desmarres retractor and two curved mosquitos were then placed with the point central and pointing superiorly when the lid was everted. A 6-0 gut rapid absorbing suture was then started through the skin incision at the superior tarsal border and then a purse string was then woven along the curve tips and then the 3 to 4 mm resection was then obtained and then the serpentine 6-0 gut suture was then approximated without cutting it and brought out through the skin and tied. It was allowed to retract into the knot. There was no bleeding and there was no cut suture. Maxitrol ointment, a Telfa pad, and patch was applied and the patient was sent to the recovery room. There were no complications.

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CHAPTER 27 . Eye, Ocular Adnexa, Auditory, and Operating Microscope

PRACTICAL

[Jsing the CPT and ICD-10-CM/ICD-9-CM manualg code the following:

/ 38. Incision and drainage of coniunctival cysts of left and right eyes.

& cpr code(s):

& tcp-ro-cM code(s):

1& tco-o-cM code(s):

39. Optic nerve decompression of the right eye.

& cpr code(s):

/ 40. Removal of an embedded foreign body of the upper left eyelid.

CPT Code:

ICD-IO-CM Code:

(ICD-9-CM Code:

41. Myringoplasty of the left ear.

& cpr code(s):

V +2. Single stage reconstruction of the right external auditory canal for congenital atresia.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

43. Left stapedectomy with footplate drill out.

& cpr code(s):

/nn. u*rrrion of a lacrimal sac, left eye.

& cpr code(s):

& Ur". to declde number of codes necessary to correctly answer the question. Odd-numbered answers are located in Appendlx B, while the full answ€r key is only avallable in the TEACE Instructor Resources on Evolve.

Copyright @ 2O15 by Saunders, an imprint of Elsevier Inc. AI1 rights reserved.

CHAI{ER 27 t Eye, Ocular Adnexa, Auditory, and Operating Microscope

REPORTS

InA?pendixAofthisworkbookyouwillfi"d!secfgn.titledReports-,w-hich ,oriiin, originai reports. Read the reports indicated below and supply the appropriateZPf aia ICD-10-CM/ICD-7-CM codes on the following lines:

45. Report 85

CPT Code:

ICD.1O-CM

(rcD-e-cM

Code:

Codes: )

d+e . xeport go

& cPr code(s):

47. Report 87

& cpr code(s):

,/ nr Report 88

& crrr code(s):

& u.., to decide number of codes necessafy to cofrectly answef the questlon. odd-numbered answers are located ln Appendix B, while the full alswer key ls only available

ta the TEACE

Instructor Resources on Evolve.

Copylright@2015bySarrnders,animprintofElsevierlnc.Allrightsreserved.

85.

APPENDIX A r RePorts

A prostatic block was then performed. Using an 83, 1B-gauge spinal

needie, the area between the "angle" of the prostate to seminal vesicle

lateraliy is identified. Needle is placed into position at that point under the rectum. 8 cc's of 2o/o Xylocarne are used to create the block'

The patient was then brought to the cystoscopic a1ea, fulher preparation includes viscous Xylocaine and liquid Xylocaine to the bladder. After a 15-minute wait, we proceedecl with the procedure as follows'

The scope was advanced down into the urethra through the sphincter and prostaiic urethra and into the bladder. A prominenttrladder neck is noteh. The length of the prostate is about 28 mm. The obstructing components are deflnitely the median lobe'

After introduction of the radiofrequency thermotherapy stylet, treatments

were performed utilizing a suggested needle-length of 16 mm' The treatments were ferformed 1 cm back from the bladder neck laterally'

one cm back from that positioning, the next tleatment halfway between

the original and the verr]montanum. This was performed-bilaterally' A11

target temperatures were reached without difflculty. The flfth tleatment ,.,ri" *u, the median lobe. We retracted the needles to 12 mm to do this' The patient tolerated the procedure well. Foley catheter was placed at the

conc'lusion of the procedure. Usual post procedure protocol to include

antibiotics and pain relief medications.

PREOPERATIVE DIAGNOSIS: Glaucoma, severe stage, open angle, right eye.

POSTOPERATM DIAGNOSIS: Same.

oPERATION PERFORMED: Sequential cyclocryotherapy, right eye.

INDICATION: This 74-year-oldwhite female has an out-of-control glaucoma in her right eye. She is pseudophakic and has been allergic to irultiple drops and"has had one sequential therapy before that worked quite well and then she stopped taking her drops. It is obvious that despite the cyclocryotherapy, she will need to continue on the Pilocarpine'

DESCRIPTION OF PROCEDURE: After the patient was placed on the oR

table, she was given a retrobulbar anesthesia of Xylocaine Zoh with 0.75olo Marcaine and wydase for a volume of 3.5 cc. After this, she was prepped

and draped in the usual sterile fashion for ophthalmic surgery and a wire lid

speculuin was used to separate the lids of the right eye. 3.5 mm from the

timuus was marked out with a marking pen in the superior temporal quadrant and the right inferior nasal quadrant of her eye. The cryoprobe was liquid nitrogen and nitrous oxide and was applied to -80 for a S-second treatm-ent in a fieeze-thaw-freeze triple row of cryotherapy laid down in both the defined quadrants. There were no complications. Maxitrol ointment, Telfa, and two pads were applied and the patient sent to the

Recovery Room.

PREOPERATIVE DIAGNOSES:

1. Blunt trauma with paint ball, right eye' 2. Hyphema, right eye, secondary to #1. 3. Recurrent hyphema, right eye, secondary to #1' 4. Corneal staining, right eye, secondary to #1'

Copl,right@2015bySaunders,animprintofElsevierlnc'Altrightsreserved'

APPENDIX A T RCPOTTS

5. Increased intraocular pressure, right eye, secondary to #1' 6. Dense cataract, right eye, secondary to #1'

POSTOPERATM DIAGNOSIS: Same'

pRocEDURE PERFORMED: Irrigation and aspiration of hyphema and

blood clot anterior chamber, right eye.

ANESTHESIA: General endotracheal anesthesia'

INDICATION: This 14-year-old white male has had persistent problems since he was hit with a paint ball in his right eye 2 weeks ago. It has not resolved. It has continuid to bleed and now it has formed a huge clot. Because of the increase in pain and obvious corneal staining, it was elected to irrigate the clot at this time. No guarantees were made to the mother for

vision.

DESCRIPTION OF PROCEDURE: After the patient was plepped and

draped in the usual sterile fashion for ophthalmic surgery under general endotracheal anesthesia, a wire lid speculum was used to separate the lids of the right eye. The Super knife was then used in the limba1 area to make a 2-mm-wide incision it tt " B-o'clock

meridian, and the chamber was filled

with BSS Plus. using the Simcoe I&A apparatus, gentle suction' and a push- pull method, the clot was removed and the blood was irrigated. There was iro damage done to the lens surface or to the iris and the pupil remained round. Healon was used to help dissolve the clot and make it easier for aspiration. At the end of the procedure, all the Healon and blood clot was

reinoved and the pupil remained round. There was a dense cataract well on its way to hlpermaturity already present, but no evidence of any vitleous or subluxation'of tne lens. The wound was closed with a 10-0 nylon suture, and the knot was buried. Healon was then placed over the cornea because the cornea showed some irregularity secondary to the paint ball explosion. Solu-Medrol was injected inferiorly Sub-Tenon's. Atropine 1olo was placed in the eye and Maxitrol ointment and a Telfa pad, patch, and shield applied. The patient was sent to the Recovery Room. There were no complications'

1. 2.

;o4. 5. 6. 7.

PREOPERATIVE DIAGNOSES:

Cataract, right eYe. P-seudophakia, left eye. Excess myopia, both eYes. Diabetes mellitus. Atrial f,brillation, controlled. Hypothyroidism. Pacemaker for history of bradycardia.

POSTOPERATM DIAGNOSIS: Same.

PROCEDURE PERFORMED: Extracapsular cataract extfaction, right eye, with insertion of intraocular lens implant, right eye.

ANESTHESIA: MAC anesthesia.

INDICATION: This 86-year-old white female has had progressively decreasing vision in her right eye secondary to a nuclear sclerotic cataract that has reduced her vision to 2Ol4OO, which can be corrected to 201100. she had successful cataract surgery in her left eye a yeal ago and has returned to 20140 vision without glasses. She was counseled again as to the

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APPENDIX A I REPOTTS

type of procedure' the need for medical cleatance' anticoagulation

rlgutation, and pacemaker regulation'

PRoCEDURE:AfterthepatientwasplacedontheoRtable,shewasgiven Nadbath and van Lint anesthesia on i zs-gauge-needle for a volume of

9 cc

oi-iyio.ui, e 2o/o wrtt- O.7 5o/o Marcaine and Wydas:: Tlt same mixture was

administered on a uiunt retronulbar Atkinson needle for a volume of 4 cc

without complications. After this, she was prepp-ed and dyped in the usual

sterile fashion for ophthalmic surgery, anaine ilottutt balloon was placed

for four minutes by th; clock at s.-5 mm Mercury. After this, the lid

speculum was used to s"parate ttt:1i9: of the right eye and a fornix-based

ii"p ;;, raised from g o,ilock to 3 o,clock and the wet-fieId cautery was used.Therewasno.,..''i".bleedingdespitetheuseoftheCoumadin.A 69_Beaver uraoe maJe u nur-tni.tness o,uarley groove

from 9:30 ro 2:30

and the Super knife was used to enter the "y" it 11 o'clock. The chamber

*u, mr.a with Healon, and a dry, nonirrigating anterior capsulotomy was

performed o, u U.riii€fu" needle. ThE woJnd was extended with left and right .orn"al-.rtt1.rg'i.iitots, and three 8-0 Vicryls were

post placed'

Usingalensvectis,thenucleuswasexpressedwithoutcapsularruptureor irisprolapse'ThepostplacedsutulesweretieddownandtheSimcoel&A ffi;il; *u, ,rr.'a to ilean up excess cortex. It was noted

that there was

veryweakzotnlarrrppo'tand-positive.vitreouspressure'Weelectedatthis point to filIthe crramuer with liealon, insert a lens glide, and a

14 diopter

L122tJV lens was inserted. Miochol was used to bring down the pupil and

eight 10-0 nylons *.r. ,t"A to close the wound' A peripheral iridectomy wasperformedatlo,clockandtherewasnoevidenceofanyvitreous.The Healonwasleftl,'tt'"eye.ThepupilwasroundandtwoS-0Vicrylsclosed the conjunctiva. Solu-v'earot wis isea sub-Tenon's inferiorly,

and Pilopine

gel, Maxitrof ointmeni,-fefa, two pads, and an eye shield were applied'

There were no .o-fii.uai*r, und itte heart rate was not out of ordinary since it was protected with a magnet'

PREOPERATIVE, DIAGNOSES:

1. History of corneoscleral laceration, right eye'

2. History of retained sutures, right eye'

POSTOPERATM, DIAGNOSIS: Same'

PROCEDUREPERFORME.D:RemovalofretainedSutures,anterior cornea, right eYe.

ANESTHESIA: General anesthesia'

INDICATIONS: This 17-year-old white male who suffered a severe iniury

to his eye with ,""I;;1. ticerations of his right cornea has.now recovered to

ifr" p"iir, that his vision is correctable with a contact lens to 20l25i

however, there is , i"rg" 'Inot"tt of suture material' and it was elected to

remove the sutures at this time'

PROCEDURE: After the patient was prepped and draped in the usual

stedlefashionforophthalmicsurgery"dhtwasundergeneralanesthesia' the tid speculum *i;;;;a to sepa"ratl the lids of the right eye. Healon was placed over the ,rrtrr.i, a supeiknlfe was used to cut them' and they

were

"p"ri"J *itt u .omnirraiio, o? ,truight tiers and o.l2 forceps. one suture remained deeply uuriea and was leit alone. None of the scleral

sutures were

removed.Therewerenocomplicationsandthechamberremainedintact.

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APPENDIX A T REPOITS

PREOPERATM DIAGNOSIS: Splenic hematoma'

POSTOPBRATM DIAGNOSIS: Same.

PROCEDURE PERFORMED: Splenectomy'

ANESTHESIA: General.

PROCEDURI,: A surgical technique was used to remove the spleen due to

rpt.ni. hematoma foiowing trauma in football game, kicked. The patient #as given general anesthesii. The anesthesiologist inserted a temporary tube

intoit e pa"tient,s stomach to empty it. This helped to decompress the stomachind prevent postoperative nausea. A catheter was inserted into the

bladder to drain the uiine. S.r.g..y was done with the patient lying flat on

his back. severai small incisions wele made into the abdomen. one was

used for the laparoscope, which was attached to a camera that sent images

to the video monitor. The other incisions were used to hold or manipulate

tissue in the abdomen. Carbon dioxide gas is insufflated into the abdominal cavity to allow room to work and to allow visualizing the area. Parts of the

rpr""'" were freed from surrounding tissue. Blood vessels to the stomach

aind spleen were visualized, clipped with metal clips, and divided. once the

spteen was dissected free of itJaltachments in the abdominal cavlty, it was piacea in a special surgical plastic bag- and removed through one of the imall abdominal incistns. At the end of the surgery, carbon dioxide gas was removed. The small incisions were closed with suture, the skin cleaned, and the incisions covered with a small dressing. Patient tolerated the procedure well.

He was patched with TobraDex ointment without Telfa for 24 hours, and we

wili make arrangements to see him within the week'

PREOPERATM DIAGNOSIS: Prostate cancer'

POSTOPERATM DIAGNOSIS: Same.

PROCEDURE PERFORMED: Cryoablation of prostate including

suprapubic catheter insertion, transrectal ultrasound for prostate volume

determination, placement of probes, and guidance of tissue ablation.

Suprapubic catheter insertion.

CLINICAL NOTE: This gentleman has had prostate cancef' He has elected

to proceed with crYoablation.

PROCEDURE NOTE: The patient was given a spinal anesthetic, prepped

and draped in the lithotomy position. The Foley catheter placed into the

bladder and transrectal ultrasound probe introduced. Prostate measurements

and volumes were determined. Using the cryoguide system, an 8 probe

freeze was selected. Probes were placed undei ultrasound guidance. Once all

temperature monitors and cryoprobes were placed the Foley catheter was

withdrawn and patient then iystoscoped using the flexible instrument' This

ensured the needles had not violated the urethra and the probes were in good position. A 12 French suprapubic catheter was then placed using a

irocaitechnique under endoscopic and ultrasound guidance into the

anterior watl of the bladder using a single pass technique. once probe

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