Preoperative and postoperative diagnosis: Scar on left eyebrow/forehead Operation: Left eyebrow/forehead scar revision A...
Preoperative and postoperative diagnosis: Scar on left eyebrow/forehead Operation: Left eyebrow/forehead scar revision Anesthesia: General This 14-year-old female sustained an oblique laceration to the medial aspect of the left eyebrow. The laceration extended superiorly above the eyebrow hairs to the lower aspect of the forehead. Initially, this was repaired in the emergency department over a year ago. The scar has not healed well. The patient was placed in the supine position and prepped and draped in the normal fashion. IV Kefzol was given. The portion of the scar was marked out with a marking pen marking the 1-cm anteromedial area. After this, 1 cc of 1% Lidocaine with 1:2000,000 of epinephrine was injected. Using a #15 blade, the widened portion of the scar was incised and then excised deeply in the subcutaneous area. The superior aspect of the incision undermining was completed, and the wound was brought together without tension. The deep layers were closed with buried 4-0 PDS sutures and a running subcuticular 5-0 Moncryl was used to close the skin. There was minimal blood loss. The patient was sent to the recovery room in satisfactory condition. CPT code(s)
Homework Answers
Diagnosis - Scar on left eyebrow/forehead
Procedure / Operation: Left eyebrow/forehead scar revision Anesthesia - General
CPT code - 13100- 13102 ,it is a complex repair code for scar revision
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Preoperative and postoperative diagnosis: Scar on left eyebrow/forehead Operation: Left eyebrow/forehead scar revision A...
PREOPERATIVE DIAGNOSIS: Scar right parietal region. POSTOPERATIVE DIAGNOSIS: Same. SURGICAL FINDINGS: 3 x 1 cm elevated...
PREOPERATIVE DIAGNOSIS: Scar right parietal region. POSTOPERATIVE DIAGNOSIS: Same. SURGICAL FINDINGS: 3 x 1 cm elevated scar right parietal region of scalp. SURGICAL PROCEDURE: Excision scar of scalp. ANESTHESIA: General endotracheal anesthesia, plus 2 cc of 1% Xylocaine and 1:100,000 epinephrine. PROCEDURE: The scalp was prepped with Betadine scrub and solution, draped in the routine sterile fashion. The lesion was anesthetized with 2 cc of 1% Xylocaine with 1:100,000 epinephrine, mostly for the epinephrine effect. After a wait of four...
Assign the CPT surgery code(s) and the appropriate HCPCS level II and CPT modifier(s). PREOPERATIVE DIAGNOSIS:...
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...
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...
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...
Medical coding. Assign both CPT and ICD-10-CM codes. PREOPERATIVE DIAGNOSIS: 1. Sebaceous cyst to the back,...
Medical coding. Assign both CPT and ICD-10-CM codes. PREOPERATIVE DIAGNOSIS: 1. Sebaceous cyst to the back, about 1.2 cm diameter 2. Dermatofibroma right thigh, centimeter diameter 3. Dermatofibroma to the left lower leg, about centimeter diameter POSTOPERATIVE DIAGNOSIS: Same PROCEDURE PERFORMED: 1. Excision of the sebaceous cyst of the posterior mid back, repair 1.5 cm long 2. Excision of the dermatofibroma of right thigh and left leg, repair each about 1.5 cm long HISTORY: This 48-year-old female was seen with...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Foreign body on...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Foreign body on the left little finger at the metacarpal phalangeal joint (broken piece of glass) POSTOPERATIVE DIAGNOSIS: Same OPERATION: Exploration of the MP joint of the left little finger with excision and removal of foreign body (broken pieces of glass) INDICATION OF SURGERY: On June 9, the patient was involved in a motor vehicle accident with a broken windshield. She tried to brace herself with her...
Case 4 Preoperative and postoperative diagnosis Painful enlarging right vulvar eyst Operation performed: Excision of right...
Case 4 Preoperative and postoperative diagnosis Painful enlarging right vulvar eyst Operation performed: Excision of right vulvar cyst Reason for surgery: This 34-year-old female patient has a vulvar cyst that is causing pain and discomfort The patient was taken to the OR and placed in the supine position. IV analgesis was started, and then she has placed in the dorsal lithotomy position. The surgical site was prepared with Lidocaine 1%, and then epinephrine and bicarb was administered. A 20- mm...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Acquired absence of...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Acquired absence of right breast from previous skin reduction mastectomy for carcinoma. POSTOPERATIVE DIAGNOSIS: Acquired absence of right breast from previous skin reduction mastectomy for carcinoma. NAME OF PROCEDURE: Reconstruction of right breast with latissimus dorsi myocutaneous flap and replacement with 300 mL silicone gel implant. DESCRIPTION OF OPERATION: Under general anesthetic, the chest wall and arm were prepped and draped in the usual fashion. An 8...
Thank you. Code(s): Operative Report #2 Operative Report Breast carcinoma Preoperative Diagnosis: Postoperative Diagnosis: Operation: Same...
Thank you.
Code(s): Operative Report #2 Operative Report Breast carcinoma Preoperative Diagnosis: Postoperative Diagnosis: Operation: Same Removal of venous access port The patient is a 44-year-old woman who had a left, modified radical mastectomy in 2010. In August she had a Port-a-cath placed in the right side. However it has caused an extreme amount of discomfort, so she has requested that it be removed. The patient was taken to the OR and placed in a supine position on the table....
Assign the CPT code for all 3 operative reports Assignment #1 PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS:...
Assign the CPT code for all 3 operative reports Assignment #1 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 maximal tenderness. Sharp dissection...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Foreign body on the left little finger at the metacarpal phalangeal joint (broken piece of glass) POSTOPERATIVE DIAGNOSIS: Same OPERATION: Exploration of the MP joint of the left little finger with excision and removal of foreign body (broken pieces of glass) INDICATION OF SURGERY: On June 9, the patient was involved in a motor vehicle accident with a broken windshield. She tried to brace herself with her...
Case 4 Preoperative and postoperative diagnosis Painful enlarging right vulvar eyst Operation performed: Excision of right vulvar cyst Reason for surgery: This 34-year-old female patient has a vulvar cyst that is causing pain and discomfort The patient was taken to the OR and placed in the supine position. IV analgesis was started, and then she has placed in the dorsal lithotomy position. The surgical site was prepared with Lidocaine 1%, and then epinephrine and bicarb was administered. A 20- mm...
Please assign the correct ICD-10-PCS codes to the following operative report: PREOPERATIVE DIAGNOSIS: Acquired absence of right breast from previous skin reduction mastectomy for carcinoma. POSTOPERATIVE DIAGNOSIS: Acquired absence of right breast from previous skin reduction mastectomy for carcinoma. NAME OF PROCEDURE: Reconstruction of right breast with latissimus dorsi myocutaneous flap and replacement with 300 mL silicone gel implant. DESCRIPTION OF OPERATION: Under general anesthetic, the chest wall and arm were prepped and draped in the usual fashion. An 8...
Thank you.
Code(s): Operative Report #2 Operative Report Breast carcinoma Preoperative Diagnosis: Postoperative Diagnosis: Operation: Same Removal of venous access port The patient is a 44-year-old woman who had a left, modified radical mastectomy in 2010. In August she had a Port-a-cath placed in the right side. However it has caused an extreme amount of discomfort, so she has requested that it be removed. The patient was taken to the OR and placed in a supine position on the table....
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