LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was involved in a car fire and suffered an inhalation injury and 25% body surface area burns. These burns involved his face, posterior neck, back, bilateral upper extremities, and left foot and ankle. He was initially treated with debridement and Biobrane. He was managed in the intensive care unit with intubation and support on the ventilator because of his inhalation injury. Approximately 10 days ago, he was extubated. He has been undergoing whirlpool therapy and all of the Biobrane has been removed. Significant portions of his burn injuries have healed. However, he has persistent deep partial-thickness and full-thickness areas of injury over the dorsum of both hands, a small area on the lateral aspect of the left ankle, and patchy deep partial and full-thickness areas over the left side of his upper back. He was therefore brought to the operating room at this time for full-thickness skin graft into the dorsum of both hands by Dr. Sanchez. After this was completed, we proceeded to graft the child's back and left ankle. DESCRIPTION OF PROCEDURE: The child was taken to the operating room and under general anesthesia he underwent full-thickness skin grafting with harvesting from his groin to the dorsum of both his hands by Dr. Sanchez. He was then placed in an upper extremity cast. We then placed the child in the right lateral decubitus position. His back and the left lower extremity hip and buttock were; prepped and draped. We began by debriding the non-healed areas on the back, which extended over an area that measured 14 x 6 cm. These were irregular in shape and not in continuity. We also debrided a 6 x 2 cm area in the lateral aspect of the left ankle. Hemostasis of the recipient sites was then achieved with epinephrine-soaked sponges. We harvested grafts from the left lateral and posterior thigh using the dermatome set at 10/1000th of an inch. The graft of the lateral aspect of the left ankle was placed as sheath graft and sutured in place with 5-0 chronic. It was pie-crusted. Bulky occlusive bandage was applied as well as a posterior plaster splint to keep the ankle at 90 degrees. The donor sites had epinephrine-soaked sponges for hemostasis. Subsequently, the donor site of the left thigh was dressed with Acticoat and a bulky gauze occlusive bandage. We took the graft that had been harvested for the back and meshed it 1.5 to 1. This meshed graft was then placed over the left upper back and secured in place with staples. The area grafted was not in continuity and extended over an irregular surface shape. Interphase, Polysporin and Adaptic and then a VAC dressing was applied over the graft on the back. The Granulofoam silver impregnated sponge was used. This was extended down over the left hip to the suction device that was connected to 125 of intensity and 50 of pressure. The extent of the VAC dressing was to cover the area grafted, which was 14 x 6 cm. The patient was then placed supine and the upper extremities casts were revised by Plastic Surgery. The child was then awakened, extubated, and transferred to the recovery room in stable condition. What are the codes for CPT, ICD-10-CM and HCPCS?
ICD -10-CM code is the tenth classification of diagnosis and is used by the healthcare workers to code a diagnosis . It is also used by the insurance company to code for reimbursement purpose .
ICD -10-CM code for third degree burn is T31.20
CPT code is the current procedural terminology . It is used to code a procedure . Healthcare workers and insurance company uses thess codes to represent the procedure .
CPT code for :-
Split-thickness skin graft, left upper back 14 x 6 cm and Sheath split-thickness skin graft, left ankle 6 x 2 cm is 15100.
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE...
LOCATION: Inpatient, Hospital PATIENT: Thomas Wilder PHYSICIAN: Loren White, M.D. ANESTHESIOLOGIST: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURES: 1. Split-thickness skin graft, left upper back 14 x 6 cm. 2. Sheath split-thickness skin graft, left ankle 6 x 2 cm. ANESTHESIA: General. INDICATIONS: This 3-year-old was...
LOCATION: Inpatient, Hospital PATIENT: Karla Stevens SURGEON: John Hodgson, M.D. PREOPERATIVE DIAGNOSES: 1. Spinal stenosis, without neurogenic claudication. 2. Spondylolisthesis, L4-L5. 3. Right radicular pain L5 root. INDICATIONS: Karla is a 52-year-old woman who is a baker and stands on her feet for many hours a day. She was diagnosed with spinal stenosis and spondylolisthesis and continues to have low back pain. She understands the risks and potential complications and problems that may occur from the surgery and wishes to...
LOCATION: Inpatient, Hospital PATIENT: Charlene Tipton SURGEON: Loren White, M.D. PRE/POSTOPERATIVE DIAGNOSIS: Right breast mass. PROCEDURE(S) PERFORMED: Right breast open biopsy. ANESTHESIA: General endotracheal. INDICATIONS: Charlene is a 66-year-old female who presented with a palpable right breast mass. A biopsy was done which showed atypical cells and was felt to be suspicious for cancer. She also had a highly suspicious lesion on ultrasound in the same area. An open biopsy was recommended. Possible definitive treatment with simple mastectomy was also...
LOCATION: Hospital Emergency Department PATIENT: Dillon Watkins PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: 13-year-old white male, no ongoing medical problems, takes no medications, and no known allergies. He presents to the Emergency Room with a jamming injury (catching football) to his left third finger he sustained while playing football. Complains of pain at the PIP joint. NEUROMUSCULOSKELETAL REVIEW OF SYSTEMS: No paresthesias. OBJECTIVE: He has slight swelling and tenderness of the PIP joint. He has full range of motion and the...
SURGEON: Loren White, M.D. PREOPERATIVE DIAGNOSES: 1. Sacral decubitus ulcer. 2. Osteomyelitis of sacrum/coccyx. POSTOPERATIVE DIAGNOSES: Same. PROCEDURES PERFORMED: 1. Excision of sacral ulcer. 2. Excision of coccyx. SURGICAL FINDINGS: There was about a 4 cm deep ulcer that went all the way down to the coccyx. The coccyx was separated from the sacrum and had very sclerotic bone in it. It was very vascular around the coccyx. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: 150 cc. DRAINS: #10 Jackson-Pratt. PROCEDURE:...
LOCATION: Inpatient, Hospital PATIENT: SURGEON: PREOPERATIVE.DIAGNOSES: 1. Septal deviation. 2. Bilateral sinonasal polyposis. 3. Pansinusitis, chronic 4. Bilateral inferior turbinate hypertrophy. 5. Nasal obstruction. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: 1.Bilateral endoscopic total ethmoidectomy. 2. Bilateral endoscopic maxillary antrostomy with removal of polyps from maxillary sinus. 3. Bilateral endoscopic sphenoidotomy. 4. Septoplasty. 5. Bilateral inferior turbinate overfracture. ANESTHESIA: Endotracheal. INDICATIONS: A 43-year-old male with history of nasal trauma that resulted in a septal deviation. He also has a history of bilateral...
LOCATION: Inpatient, Hospital PATIENT: Tim Luther ATTENDING/ADMIT PHYSICIAN: Frank Gaul, MD SURGEON: David Barton, MD PREOPERATIVE DIAGNOSIS: Fluid overload state, no urine output, acute renal failure. POSTOPERATIVE DIAGNOSIS: Fluid overload state, no urine output, acute renal failure. PROCEDURE PERFORMED: Temporary dialysis catheter placement. PROCEDURE: This 77-year-old patient was brought to the emergency room. The right femoral vein was selected. This was tried with the left IJ vein earlier without success. I reserved the right IJ for a central line that...
What are the Service and ICD-10 Codes for this scenario? LOCATION: Inpatient, Hospital PATIENT: Art Schear PHYSICIAN: Gregory Dawson, MD PREOPERATIVE DIAGNOSES: Obstructive sleep apnea Nasal obstruction Septal deviation Bilateral inferior turbinate hypertrophy Hypertrophic tonsils POSTOPERATIVE DIAGNOSES: Obstructive sleep apnea Nasal obstruction Septal deviation Bilateral inferior turbinate hypertrophy Hypertrophic tonsils PROCEDURES PERFORMED: 1. Septoplasty 2. Bilateral inferior turbinate mucosal reduction with radiofrequency 3. Tonsillectomy ANESTHESIA: General endotracheal anesthesia INDICATION: The patient is a 16-year-old male with documented obstructive sleep apnea....
Case 1-2 LOCATION: Inpatient, Hospital PATIENT: Sorrento Hernandez PHYSICIAN: Rolando Ortez, MD CHIEF COMPLAINT: Prematurity with respiratory difficulty. HISTORY: This is a 30 weeks, 1 day gestation female infant with birth weight of 1808 grams. Mom is a 26-year-old gravida 2, now para 2 mom. Her blood type is O positive, antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, HIV negative, GC negative, chlamydia negative, Group B Strep status unknown. Mom’s MSAFP was elevated at 14.2 with...
assign the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Left tibial tubercle avulsion fracture. POSTOPERATIVE DIAGNOSIS: Comminuted left distal end of the tibia PROCEDURE: Open reduction and internal fixation of left tibia. ANESTHESIA: General. The patient received 10 ml of 0.5% Marcaine local anesthetic. TOURNIQUET TIME: 80 minutes. ESTIMATED BLOOD LOSS: Minimal. DRAINS: One JP drain was placed. COMPLICATIONS: No intraoperative complications or specimens. Hardware consisted of two 4-5 K-wires, One 6.5, 60 mm partially threaded cancellous screw...