Mrs. 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 DetailsA 55-year-old patient had several episodes of fecal incontin…
A 55-year-old patient had several episodes of fecal incontinence. A colonoscopy had been performed one year ago with normal results. Anorectal manometry was performed to determine the pressure on the sphincter muscles. The test indicated a mild relaxation of the sphincter. Biofeedback training was prescribed. What CPT® and ICD-10-CM codes are reported?
Read DetailsA 26-year-old female with a one-year history of a left tympa…
A 26-year-old female with a one-year history of a left tympanic membrane perforation. She has extensive tympanosclerosis with a nonhealing perforation. Her options, including observation with water precautions or surgery, were discussed. The patient wished to proceed with surgery. With use of the operating microscope, the surgeon performs a left lateral graft tympanoplasty. What CPT® code is reported?
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