CODE WITH ICD-10-PCS PLEASE
PREOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable
lymphoma
POSTOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable
lymphoma
PROCEDURE: Left suprainguinal lymph node biopsy
ANESTHESIA: General endotracheal
INDICATIONS FOR OPERATION: This is a 77-year-old female with
suspected lymphoma. She has had generalized lymphadenopathy seen on
CT and palpable in her inguinal region. She and her family were
counseled on the risks and benefits of this procedure.
OPERATION: The patient was brought to the operating suite and
placed on the table in the supine position. General endotracheal
anesthesia was induced. The left groin was prepped and draped in a
sterile manner. I made an incision in the left groin and dissected
down to the large peri-inguinal lymph node. Due to the extremely
large size of the lymph node, I did not remove the entire node. I
took a wedge biopsy of it and used electrocautery for hemostasis. I
closed the subcutaneous layer with 2-0 Vicryl. We irrigated and
then closed the skin with a running 2-0 Vicryl. She tolerated the
procedure well
ICD-10-PCS Code
07TJ0ZZ - Resection of left inguinal lymphatic, Open approach
CODE WITH ICD-10-PCS PLEASE PREOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable lymphoma POSTOPERATIVE DIAGNOSIS: Generalized lymphadenopathy, probable lymphoma...
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). PREOPERATIVE DIAGNOSIS: Rule out lymphoma. Enlarged lymph node of axillary area on the left. POSTOPERATIVE DIAGNOSIS: Same. ANESTHESIA: Local, using 0.5% Marcaine without epinephrine The patient was brought to the operating room, and after adequate prepping and draping of the left axillary area, a large several-centimeters-in-diameter lymph node was palpated medially and superiorly. The skin overlying this node was infiltrated with 0.5% Marcaine without epinephrine, and...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...
PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Large left inguinal hernia, direct. PROCEDURE: Repair of large direct left inguinal hernia with Prolene Hernia System Mesh (PHS) and resection of lipoma of the spermatic cord. FINDINGS: Large direct left inguinal hernia and large lipoma of the spermatic cord. DESCRIPTION OF PROCEDURE: After routine preparation, the patient was prepped and draped under general anesthesia in supine position. The bladder was decompressed with a Foley catheter. An incision was made in the left...
Assign the appropriate CPT and ICD-10-CM Code and Modifier 1. PREOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy. POSTOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy. OPERATION PERFORMED: Adenotonsillectomy. ANESTHESIA: General endotracheal. INDICATIONS: The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated. DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face...
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...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Intractable epilepsy. POSTOPERATIVE DIAGNOSIS: Intractable epilepsy. PROCEDURE PERFORMED: Craniotomy and anterior 2/3 corpus callosotomy Use of neuronavigation, Brainlab Use of intraoperative microscope INDICATIONS: The patient is a 12-year-old with intractable epilepsy and drop seizures despite multiple antiepileptic drugs. The above procedure was indicated. Informed consent was obtained both verbally and in writing DESCRIPTION OF PROCEDURE: The patient was brought to the operating room. She was intubated and...
assign the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy. POSTOPERATIVE DIAGNOSIS: Adenotonsillitis with hypertrophy. OPERATION PERFORMED: Adenotonsillectomy. ANESTHESIA: General endotracheal. INDICATIONS: The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms. Adenotonsillectomy is indicated. DESCRIPTION OF PROCEDURE: The patient was placed on the operating room table in the supine position. After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was...
code the following three operative reports assigning the appropriate CPT and ICD-10-CM codes and modifiers. PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated. PROCEDURE PERFORMED: Appendectomy. ANESTHESIA: General endotracheal. PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. A transverse right lower quadrant incision was made directly over the point of...
Code in ICD 10 pcs
32. Operative Report PREOPERATIVE DIAGNOSIS: Displaced left femoral neck fracture POSTOPERATIVE DIAGNOSIS: Displaced left femoral neck fracture PROCEDURE PERFORMED: Left hip hemiarthroplasty Case Studies INDICATIONS: This 525 had a mechanical fall. He had de TIONS: This 96-year-old male sustained a fall earlier today. He was ical fall. He had demonstrated a fracture and a hemiarthroplast d the expectations, the risk of infection, dislocation, tissue injury. anest atient and family wished to proceed. The potential for...
code in ICD 10 pcs
42. Operative Report Left femoral neck fracture PREOPERATIVE DIAGNOSIS: POSTOPERATIVE DIAGNOSIS: Left femoral neck fracture Internal fixation of left femoral neck fracture OPERATION: Synthes 7.3 cannulated screw x3 IMPLANTS: INDICATIONS: The patient is a 63-year-old male who had a fall, sustaining a left femoral neck fracture. He ws admitted to the medicine service and after a lengthy, extensive discussion regarding different treatment opions including surgical and nonsurgical management, he wished to proceed to the operating...