Question

Assign the CPT code for all 3 operative reports

Assignment #1

PREOPERATIVE DIAGNOSIS: Appendicitis.

POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated.

PROCEDURE PERFORMED: Appendectomy.

ANESTHESIA: General endotracheal.

PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner.

A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia. The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp. The internal oblique fascia was similarly incised and its muscular fibers were similarly spread. The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident. Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.

The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound. After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties. The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix. The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp. The stump of the appendix was cauterized and the cecum was returned to the abdomen.

The peritoneum was irrigated with warm sterile saline. The mesoappendix and cecum were examined for hemostasis which was present. The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers. The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion. The skin was prepped with benzoin, and Steri-Strips were applied. A dressing was placed on the wound. All surgical counts were reported as correct.

Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.

Assignment #2

PREOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma.

POSTOPERATIVE DIAGNOSIS: Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.

OPERATION PERFORMED: Cystoscopy, bladder biopsies, and fulguration.

ANESTHESIA: General.

INDICATION FOR OPERATION: This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy. He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules. He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months. Recent cystoscopy raises suspicion of another recurrence.

OPERATIVE FINDINGS: The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder. Scarring was noted along the base of the bladder from the patient's previous cysto TURBT. Ureteral orifice on the right side was not able to be identified. The left side was unremarkable.

DESCRIPTION OF OPERATION: The patient was taken to the operating room. He was placed on the operating table. General anesthesia was administered after which the patient was placed in the dorsal lithotomy position. The genitalia and lower abdomen were prepared with Betadine and draped subsequently. The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above. Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area. Each of these biopsy sites were fulgurated with Bugbee electrodes. Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear. The patient's bladder was then emptied. Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area. There were no apparent complications, and the patient appeared to tolerate the procedure well. Estimated blood loss was less than 15 mL.

Assignment #3

Description: Spontaneous controlled sterile vaginal delivery performed without episiotomy.

The patient is a 29-year-old, Caucasian, para 0, 40 weeks' pregnant who presented with contractions. Prenatal care has been in my office since the first trimester. Ultrasounds have been consistent with menstrual history. Factors identified for consideration during prenatal care included maternal history of Gilbert's syndrome.

The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilation, but 80% effacement by nurse examination. The patient was admitted. Expected management was utilized initially. Stadol was used for analgesia. Examination did not reveal vulvar lesions. Epidural was administered. Membranes ruptured spontaneously. Cervical dilation progressed. Acceleration-deceleration complexes were seen. Overall, fetal heart tones remained reassuring during the progress of labor. The patient was allowed to "labor down" during second stage. Early decelerations were seen as well as acceleration-deceleration complexes. Overall, fetal heart tones were reassuring. Good maternal pushing effort produced progressive descent.

Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. There was no loop or coil of cord. Infant was vigorous female sex. Oropharynx was aggressively aspirated. Cord blood was obtained. Placenta delivered spontaneously.

Following delivery, uterus was explored without findings of significant tissue. Examination of the cervix did not reveal lacerations. Upper vaginal lacerations were not seen. Multiple first-degree lacerations were present. Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried. Post-approximation examination of the rectum showed smooth, intact mucosa. Blood loss with the delivery was 400 mL.

Plans for postpartum care include routine postpartum orders. Nursing personnel will be notified of Gilbert's syndrome.

yndrome.

Answer 1

Assignment 1:
Appendectomy
Current procedural terminology (CPT code)- 44950
Assignment 2
Cystoscopy, bladder biopsy and fulguration(CPT code) -52234( This code is for fulguration or resection of a small bladder tumor..It includes cryosurgery or laser surgery)
Assignment 3
Spontaneous controlled sterile vaginal delivery performed without episiotomy(CPT code) - 59409(vaginal delivery with or without episiotomy)