Question

CODE WITH ICD-10-PCS

Operative Report PREOPERATIVE DIAGNOSIS: Chronic Epistaxis

POSTOPERATIVE DIAGNOSIS: Chronic Epistaxis

NAME OF PROCEDURE: Cautery of both sides of nose

ANESTHESIA: General

INDICATIONS: This is a patient with severe chronic epistaxis, which has resulted in his bleeding to the point of a hemoglobin of 6.5, hematocrit of 19. Preoperative coagulation studies revealed a PT 13.9 with normal PTT at bleeding time. Because of the significance of his anemia, we brought him to the operating room for cautery.

DESCRIPTION OF OPERATION: Under adequate general anesthesia, the nose was decongested with Afrin preoperatively and intraoperatively. The bleeding site on the left side of his nose was identified. It was primarily anterior, and there was a varicosity along the inferior floor of the nose primarily caudally. Because of the fact that the cautery was directed primarily along the floor of the nose, I thought that it would be safe to cauterize the right side of the nose. The bleeding site on the right side of the nose was in a similar location, although it did come up just onto the caudal portion of the septum. Since there was no cautery of both sides of the septum, I felt it would be safe to cauterize both sides, which I felt was appropriate in a patient who has had this significant a drop in his hemoglobin and hematocrit. After that was performed then the nose was reexamined. There was no further bleeding from the cautery sites. Estimated blood loss was negligible, and he was awakened and taken to the recovery room in stable condition.

Answer 1

Answer: ICD 10 PCS is the international classification of the procedures that has been performed during the treatment. In this case the procedure was performed is Cautery of both sides of nose. The ICD 10 PCS code : 095KXZZ, 095KXZZ