The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was a -P1. 2-4 OPERATIVE REPORT, INCISION AND DRAINAGE LOCATION: Outpatient, Hospital PATIENT: Gabby Brown PHYSICIAN: Loren White, M.D. ANESTHESIOLGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSIS: Right perineal abscess. POSTOPERATIVE DIAGNOSIS: Right perineal abscess x2. PROCEDURE: Incision and drainage of right perineal abscess. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Less than 3 ml. COMPLICATIONS: None. INDICATIONS: This is a 14-year-old African-American female who has a 1-week history of a tender mass in right labial region. Per history, the mass has begun to bleed and drained over the past 24 hours. The patient was noted to be on Bactrim prior to admission. FINDINGS: as below DESCRIPTION OF PROCEDURE: After informed consent, we proceeded to the operating room. A general mask anesthesia was noted for the patient. A time out was made prior to the procedure beginning. The patient currently was receiving intravenous clindamycin. The prep was performed and sterile towels and drapes were placed over the perineum. A 1-cm stab incision was made near the edge of the right labia and into the buttocks region. Copious amount of purulence was noted with gentle expression of the cavity. The cavity was then irrigated with normal saline solution, approximately 80 ml. The cavity was then packed with quarter-inch iodoform gauze and covered by 4 x 4.
ICD-10-CM code is the tenth version of international classification of diagnosis . It is used by the healthcare workers and insurance company to code a diagnosis .
CPT is current procedural terminology and is used to code procedures .
ICD -10-CM code for right perineal abscess is L02.215
CPT code for incision and drainage of right perineal abscess is 56405
The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 2 concurrent cases....
LOCATION: Outpatient, Hospital PATIENT: Kaitlyn Carlton SURGEON: Loren White, M.D. ANESTHESIA: CRNA is Karen Demers PREOPERATIVE DIAGNOSIS: Epiphora, both eyes Nasolacrimal duct obstruction, both eyes POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes ANESTHESIA: General INDICATIONS: This healthy 3-year-old toddler was referred after an allergy workup to investigate her chronic otitis media, PE tubes times two, and the chronic epiphora that she has had in both eyes. The mother was counselled as to the success of probing at...
A CRNA provided the anesthesia service and placed a TEE probe for monitoring. Dr. Larson was medically directing this case only. Dr. Larson inserted an arterial line in the left radial artery and a central line in the RIJ after the patient was anesthetized. This patient is assigned a status of -P3. LOCATION: Inpatient, Hospital PATIENT: Madeline Spencerson CRNA performed with anesthesiologist PHYSICIAN: David Barton, M.D. ANESTHESIOLOGIST: Janice E. Larson, M.D. PREOPERATIVE DIAGNOSES: 1. History of coarctation, status post repair....
PREOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage. POSTOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage. PROCEDURE PERFORMED: Tracheostomy. ANESTHESIA TYPE: General. ESTIMATED BLOOD LOSS: 10 mL HISTORY: This is a 58-year-old female who presented to the trauma center several days ago with isolated head trauma. She has been on the ventilator and unable to support her ventilation without a mechanical ventilator. She is thus unable to be weaned from a ventilator and thus in need of a tracheostomy. She also is unable 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...
Record Number: 84-50-77 Age: 53 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Atherosclerosis Coronary Arteries. Unstable Angina. Double Coronary Artery Bypass. DISCHARGE SUMMARY PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-20-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Atherosclerosis coronary arteries with chronic total occlusion. Unstable angina. Congestive heart failure, combined systolic and diastolic, chronic. PROCEDURE: Coronary artery bypass graft x 2. HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old...
Loren White, M.D. PREOPERATIVE DIAGNOSIS: Mass, right axilla, history of breast cancer. POSTOPERATIVE DIAGNOSIS: Same. OPERATION PERFORMED: Biopsy of mass, right axilla. PRELIMINARY NOTE: This patient had a mastectomy six years ago and had positive nodes at that time. Recently, she presented with a fixed mass in the right axilla, and after a good deal of discussion, she decided to have a biopsy done. We did a true cut needle biopsy and obtained a diagnosis of metastatic cancer. The patient...
Record Number: 81-50-77 Age: 32 Gender: Male Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Foreign Body Left Ankle DISCHARGE SUMMARY PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 ADMITTED: 10-15-XX DISCHARGED: 10-17-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Healing fracture left ankle with retained foreign body implant. PROCEDURE(S): Removal of foreign body implant from left ankle (K-wire and screw). HISTORY OF THE PRESENT ILLNESS: This 32-year-old male patient is admitted for removal of hardware from his...
Q: Need help with my assignment to code diagnoses(ICD-10-CM) and CPT for the following cases with explanation. Case-1 Patient Name: DOB: Age: 2Y Date of Surgery: 04/04/2014 Primary Care Physician: Cecil H Lashlee, M.D. Referring Physician(s): John F Bealer, M.D. PCP Operative Report Surgeon: John F Bealer, M.D. Assistant(s): None. Preoperative Diagnosis: Umbilical hernia. Postoperative Diagnosis: Umbilical hernia. Procedure: Umbilical herniorrhaphy. Anesthesia: General endotracheal anesthesia. Estimated Blood Loss: Less than 5 mL. Complications: There were no intraoperative complications. Counts: Correct....
Record Number: 80-50-77 Age: 77 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Health Diagnosis/Procedure: Peritrochanteric Right Hip Fracture Mild Hypertension Total Right Hip Arthroplasty DISCHARGE SUMMARY PATIENT: JOY INPATIENT RECORD NUMBER: 80-50-77 ADMITTED: 09-15-XX DISCHARGED: 09-20-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Peritrochanteric right hip fracture. Mild hypertension. PROCEDURE(S): Total right hip arthroplasty. HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old white female who presented to the emergency room with complaint of...
PREOPERATIVE DIAGNOSIS: Large right subdural hematoma. POSTOPERATIVE DIAGNOSIS: Large right subdural hematoma. PROCEDURE PERFORMED: Right craniotomy with evacuation of subdural hematoma. HISTORY: This 58-year-old patient was transferred from an outside hospital after she was found unresponsive. She was on Coumadin, and she was found to have a large right-sided subdural hematoma with significant midline shift. On exam, she is noted to have, anisocoria and large right pupil, decerebrating, to pain. The patient had received FFP as well as factor VII...