I need help with the diagnosis code and CPT code with this outpatient case: Case is...
I need help with the diagnosis code and CPT code with
this outpatient case: Case is in pdf format that is why just
copying the procedure. Let me know how to copy pdf format
too.
Case:410021 (VLab)
Sex:Female
Female Patient
Age:65
DATE OF SERVICE: 05/30/2014
PREOPERATIVEDIAGNOSIS:
POSTOPERATIVEDIAGNOSIS: Intractable epilepsy.
OPERATIONPERFORMED: Replacement of a VNS generator for vagal nerve
stimulator with
intraoperative interrogation of device.
SURGEON: The attending and surgeon is Dr.
ASSISTANTSURGEON:
ANESTHESIOLOGIST:
ASSISTANTANESTHESIOLOGIST:
ANESTHESIA:
POSTOPERATIVEDIAGNOSIS: Intractable epilepsy.
INDICATIONS: The patient is a woman with a long history of
intractable epilepsy with a vagal nerve
stimulator implant in place. The generator was nearing the end of
its lifespan and she was
recommended to undergo replacement of generator.
FINDINGSAT SURGERY: No abnormalities other than expected postop
changes.
DESCRIPTIONOF PROCEDURE: The patient was brought to the Operative
Suite. General
anesthesia was induced. An endotracheal tube was placed . Lines
were placed. The left chest was
sterilely prepped and draped. The old incision was infiltrated with
local anesthetic. A skin incision was
made with a #1 0blade. Bovie hemocautery was used to dissect
through subcutaneous fat and to
open the fibrotic capsule around the old generator. The generator
was brought out of the chest area .
The Allen wrench was used to remove the leads from the old
generator. The new generator was
obtained . Itwas a model 104, and it was attached to the leads with
the Allen wrench. The new
generator was then placed in the subcutaneous pouch and anchored
with a 2-0silk suture. The
wound was irrigated with bacitracin irrigation. The computer wand
was placed in a sterile sleeve and
the generator was interrogated and programmed with the patient code
and date. Lead impedance was
tested and found to be okay. The wound was closed with 3-0Vicryl
suture and runni ng subcuticular 4-
0 Monocryl suture with Steri-Stripsand a sterile dressing over th
at. The patient was transported to the
recovery area in stable condition .
Homework Answers
The ICD -10 code for unspecified intractable epilepsy is G40.919 .
The CPT code for Replacement of a VNS generator is 61885 .
61885 is used describe any insertion or replacement of cranial neurostimulator pulse generator or receiver .
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