Margaret has a cholecystoenterostomy with a Roux-en-Y. Five…
Margaret has a cholecystoenterostomy with a Roux-en-Y. Five hours later, she has an enormous amount of pain, abdominal swelling and a spike in her temperature. She is returned to the OR for an exploratory laparotomy and subsequent removal of a sponge that remained behind from surgery earlier that day. The area had become inflamed and was demonstrating early signs of peritonitis. What is the correct coding for the subsequent services on this date of service? (The same surgeon took her back to the OR as the one who performed the original operation.)
Read DetailsMrs. Jones is a 90-year-old female having laparoscopic gallb…
Mrs. Jones is a 90-year-old female having laparoscopic gallbladder surgery. Dr. Lot, the anesthesiologist for this case, documents she is a normal healthy person and begins to prepare the patient for surgery at 07:30 am. Surgery begins at 08:00 am. The surgery is concluded at 09:30 am. The anesthesiologist releases the patient to the PACU nurses at 09:45 am. How many minutes of anesthesia time transpired and what is the appropriate anesthesia code?
Read DetailsA 66-year-old sustained a left proximal humerus fracture. St…
A 66-year-old sustained a left proximal humerus fracture. Standard deltopectoral approach was used and dissection was carried down to the fracture site. The fracture site was identified and fragments were mobilized and the humeral head fragments removed. Once this was done, the stem was prepared up to a size 10. A trial reduction was carried out with the DePuy trial stem and implant head. Sutures were placed in key positions for closure of the tuberosities down to the shaft including sutures through the shaft. The shaft was then prepared and cement was injected into the shaft. The implant was placed. Once the cement was hardened, the head was placed on Morse taper and reduced. A bone graft was placed around the area where the tuberosities were being brought down. The tuberosities were then tied down with a suture previously positioned. This gave excellent closure and coverage of the significant motion at the repair sites. The wound was thoroughly irrigated. The skin was closed with Vicryl over a drain and also staples in the epidermis. A sterile dressing and sling was applied. The patient was taken to recovery in stable condition. No immediate complications. What CPT® code is reported?
Read DetailsA 65-year-old is seen by her cardiologist for preoperative e…
A 65-year-old is seen by her cardiologist for preoperative evaluation for clearance for removal of her gallbladder due to gallstones. The cardiologist notes that she has hypertension. Medication is given to control her hypertension. What diagnosis codes are reported?
Read Details