1. The patient is having cholelithiasis , chronic cholecystitis and acute pancreatitis which are the indications of cholecystectomy . It is the surgical removal of the gallbladder.
2. Procedure code of laparoscopic cholecystectomy with intra- operative fluoroscopic cholangiography - 47564
3. Steps to find out CPT code :-
1. determine the procedures and services performed during the encounter
2. locate the descriptor in the index and verify the code selection in the main text
3. determine the need for modifiers
Medical Record: I Preoperative Diagnosis: Cholelithiasis, Chronic Cholecystitis and acute pancreatitis Postoperative Diagnosis: Cholelithiasis, Chronic Cholecystitis...
1.210. Postoperative peritoneal adhesions ICD-10-CM Code(s): Cholelithiasis with acute and chronic cholecystitis ICD-10-CM Code(s): Chronic pancreatitis ICD-10-CM Code(s): 1.211. 1.212. 1.213. Pouchitis ICD-10-CM Code(s): Barrett's esophagus ICD-10-CM Code(s): Retained cholelithiasis following cholecystectomy ICD-10-CM Code(s): 1.214. 1.215.
PREOPERATIVE DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis. POSTOPERATIVE DIAGNOSIS: Chronic adenotonsillitis and chronic tonsillitis. PROCEDURE PERFORMED: Tonsillectomy and adenoidectomy. OPERATIVE NOTE: The patient is a 15-year-old woman who was seen in the office and diagnosed with the above condition. Decision was made in consultation with the patient to undergo the procedure. She was admitted through the same-day department and taken to the operating room, where she was administered general anesthetic by intravenous injection. She was then intubated endotracheally. The Jennings...
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...
cpt codes 5. Operative Report Preoperative Diagnosis: A 5mm stone in the right lower pole Postoperative Diagnosis: A 5mm stone in the right lower pole Operation Performed: Right extracorporeal shockwave lithotripsy Anesthesia: Intravenous sedation Indications for Procedure: This is a 32 year old young man who recently presented with right renal colic. An X-ray showed a stone in the proximal ureter. On June 1, 2012, he underwent cystourethroscopy, the stone was successfully flushed into the kidney, and a double-J stent...
The following documentation is from the health record of an 86-year-old female patient. Preoperative Diagnosis: Paraesophageal hernia Postoperative Diagnosis: Paraesophageal hernia Procedure: Laparoscopic reduction of paraesophageal hernia 256Indication The patient, a pleasant, 86-year-old female, previously presented with an acute onset of hematemesis. During this previous encounter an endoscopy was performed, which revealed a large portion of the patient’s stomach in her chest. The condition was discussed with the patient and her family. The options of open versus laparoscopic repair of...
What is the CPT code(s) for this case and if any modifier(s) if applicable? 2. PREOPERATIVE DIAGNOSIS: Elevated prostate-specific antigen (PSA). POSTOPERATIVE DIAGNOSIS: Benign prostatic hypertrophy (BPH). PROCEDURE: Transrectal ultrasound and biopsy. ANESTHESIA: Local. The patient was brought to the procedure room and placed on the procedure table in the dorsal lithotomy position. A transrectal ultrasound probe was placed in the rectum after digital rectal exam was performed. Local anesthesia was achieved by injecting 2.5 cc of 1% Xylocaine solution...
99.OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Recurrent carcinoma of the prostate POSTOPERATIVE DIAGNOSIS: Recurrent carcinoma of the prostate PROCEDURE PERFORMED: Cryoablation of the prostate CLINICAL NOTE: This is a 53 year old gentleman who has undergone radiation therapy for adenocarcinoma of the prostate. Unfortunately, he developed problems again and underwent a needle biopsy, and recurrence of his cancer was found. Options were discussed with the patient, and he has opted to proceed with cryoablation. He has been told of the risk of...
83. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of left cryptorchid testicle. POSTOPERATIVE DIAGNOSIS: Left ectopic testicle. PROCEDURE PERFORMED: Left groin exploration with orchiopexy. ANESTHESIA: General. Please see the preoperative note for indications of the procedure as well as full informed consent. This 14-year-old was recognized on a sports physical as having a nonpalpable testicle. Through his younger years, it had been palpable. The testicle on physical exam sat in the superficial inguinal canal next to the external ring. With...
81. OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. POSTOPERATIVE DIAGNOSIS: History of adenocarcinoma of the prostate. PROCEDURES PERFORMED: 1. Transrectal ultrasound performance with: 2. Volume study. 3. Needle localization. 4. Needle implantation. 5. Cystoscopy. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. PROCEDURE: Please see the preoperative note for indications of the procedure, as well as full informed consent. The patient underwent a general anesthetic and was put in the extended dorsal lithotomy position. The table was decanted or...
PREOPERATIVE DIAGNOSES: Right carotid stenosis POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Right carotid thromboendarterectomy. This patient was monitored with EEG. There were some depressions when we clamped, but this returned to normal after re-establishing circulation. ANESTHESIA: General DESCRIPTION OF PROCEDURE: Under general anesthesia, the patient’s right side of the neck was prepped and draped in the usual manner. An incision was made across the medial border of the sternocleidomastoid. The platysma was divided. The common carotid artery was localized. We then...