Question

Surgical Case #74

Diagnosis:	Unacceptable cosmetic appearance of the breast
Procedure Performed:	Bilateral breast augmentation with silicone implants
Indications:	A 42-year-old female was seen in consultation for breast augmentation and is a good candidate; therefore, she will be having the procedure.
Description of Procedure:	Patient was taken to the operating room and placed in supine position where general anesthesia was established. Chest was prepped and draped via standard surgical fashion.
	My attention was turned to the breasts where an inframammary fold incision was made to open pockets were then developed. Sizers in the range of 550 were placed. It was decided to move forward with 500 mL implants. The pockets were irrigated with triple antibiotic solution. 0.25% Marcaine with epinephrine was infiltrated. The permanent prostheses were placed in the inframammary folds and were secured with 2-0 PDS. The incisions were closed with 3-0 Vicryl, 4-0 Vicryl, followed by 4-0 Monocryl. The patient tolerated the procedure well.
Code(s):_____________________________________________________________________________________________

Surgical Case #75

Operative Report

Preoperative Diagnosis:	Retained right ureteral double J stent
Postoperative Diagnosis:	Retained right ureteral double J stent
Procedure:	Cystoscopy and removal of right double J stent
Summary:	Under anesthesia, the patient’s genitalia was prepped and draped in the usual manner.
	A 19.5 French cystourethroscope was inserted into the bladder without difficulty. An oblique lens was used to identify the retained right ureteral double J sent. The forceps instrument was inserted through the scope to grasp the stent. It was removed without difficulty.

Surgical Case #76

Operative Report

Preoperative Diagnosis:	Bilateral inclusion cysts of the cheeks
Postoperative Diagnosis:	Same
Procedure:	Excision of 1 cm inclusion cyst of the right cheek and 1.5 cm inclusion cyst of the left cheek.
Anesthesia:	Local
Brief History:	The patient had persistent recurrent cystic lesions of both cheeks and a history of previous cystic acne. After explanation of the risks, benefits, and alternatives, the patient agreed to the excision.
Details of Procedure:	The patient was taken to the outpatient- operating suite. The areas of the cheek were carefully marked and infiltrated with local anesthesia and prepared with Betadine paint. The lesions were elliptically excised (excised diameters of 1 cm of the right and 1.5 cm of the left.). Both lesions required layered closure of the deeper subcutaneous and epidermis with 4-0 Vicryl and 6-0 nylon. The patient tolerated the procedure well.
Code(s):_____________________________________________________________________________________________

Answer 1

The answer is given below  

Surgical case 74 - Z41.1

19325 with modifier 50

00402

Surgical case 75 - Z96.0

52310

Surgical case 76 - 11441 (RT)

11442(Lt)

12051