I have to correctly code these cases using 2017 CPT code book Surgical Case #2 Operative Report Preoperative Diagnosis: Bilateral inclusion cysts of…

I have to correctly code these cases using 2017 CPT code book

Surgical Case #2

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): ___________________________________________

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Surgical Case #3

Operative Report

Procedure:

Esophagogastroduodenoscopy

Instrument Used:

Olympus GIF-100

Premedication:

The patient was premedicated with a total of Fentanyl, 50 mcg, and Versed, 4 mg, intravenously.

Indications:

The patient has presented with recurrent dysphagia. She has a history of a Schatzki’s ring, which has been dilated in the past.

Procedure:

The endoscope was inserted from the mouth into the esophagus without difficulty.

The esophageal mucosa was normal. A reformed Schatzki’s ring was located at the Z line, which was at approximately 29 cm. The endoscope could be inserted through this area with no resistance. The ring was located above a 3-cm hiatal hernia. The stomach, duodenal bulb, and descending duodenum were all normal. After the endoscope was withdrawn, a #60 French Maloney dilator was passed with very mild resistance. The patient tolerated the procedure well, and there were no immediate complications.

Impression:

1. A reformed Schatzki’s ring, which was dilated

2. A 3-cm hiatal hernia

Code(s): ___________________________________________

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Surgical Case #4

Emergency Department Record

Chief Complaint:

Right shoulder dislocation

History of Present Illness:

The patient is a 53-year-old man who has dislocated his right shoulder three previous episodes. Today, he was kayaking and dislocated his shoulder while paddling.

Past Medical History:

Previous right shoulder dislocation

Medications:

Vitamins

Allergies:

Sulfa

Physical Examination:

Alert male in no acute distress

Right Upper Extremity:

He has obvious deformity with loss of the right shoulder prominence with a palpable anterior dislocation of the humeral head. He has good distal pulses with the remainder of his arm being nontender.

Emergency Department Course:

X-ray of his right shoulder shows an anterior dislocation.

Procedure:

Reduction of the shoulder dislocation. The patient was placed on a monitor with continuous pulse oximetry. He was given Demerol and Phenergan IV for pain control. In-line traction and reduction was accomplished after three attempts. Reduction films showed good position of the shoulder. He had good distal neurovascular status after reduction. He tolerated the procedure well.

Diagnosis:

Anterior dislocation, right shoulder

Disposition and Plan:

Sling and swathe for two to three days. Vicodin #30. Follow up with Dr. Smith in one to two days or call for an orthopedic referral. The patient states he has been avoiding any potential surgery at this point and would prefer to avoid it. I explained to him that he should follow up with Dr. Smith or an orthopedist. He should not use the shoulder in the next several days until reevaluation.

Code(s): ___________________________________________

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Surgical Case #5

Operative Report

Procedure:

Extracapsular cataract extraction with intraocular lens implantation, right eye

Diagnosis:

Cataract of the right eye

Technique:

The patient was given a retrobulbar injection of 2.5 to 3.0 cc of a mixture of equal parts of 2% lidocaine with epinephrine and 0.75% Marcaine with Wydase. The area around the right eye was infiltrated with an additional 6 to 7 cc of this mixture in a modified Van Lint technique. A self-maintaining pressure device was applied to the eye, and a short time later, the patient was taken to the OR.

The patient was properly positioned on the operating table, and the area around the right eye was prepped and draped in the usual fashion. A self-retaining eyelid speculum was positioned and 4-0 silk suture passed through the tendon of the superior rectus muscle, thereby deviating the eye inferiorly. A 160° fornix-based conjunctival flap was created followed by a 150° corneoscleral groove with a #64 Beaver blade. Hemostasis was maintained throughout with gentle cautery. A 6-0 silk suture was introduced to cross this groove at the 12 o’clock position and looped out of the operative field. The anterior chamber was then entered superiorly temporally, and after injecting Occucoat, an anterior capsulotomy was performed without difficulty. The nucleus was easily brought forward into the anterior chamber. The corneoscleral section was opened with scissors to the left and the nucleus delivered with irrigation and gentle lens loop manipulation. Interrupted 10-0 nylon sutures were placed at both the nasal and lateral extent of the incision. A manual irrigating aspirating setup then was used to remove remaining cortical material from both the anterior and posterior chambers.

At this point, a modified C-loop posterior chamber lens was removed from its package and irrigated and inspected. It then was positioned into the inferior capsular bag without difficulty, and the superior haptic was placed behind the iris at the 12 o’clock location. The lens was rotated to a horizontal orientation in an attempt to better enhance capsular fixation. Miochol was used to constrict the pupil, and a peripheral iridectomy was performed in the superior nasal quadrant. In addition, three or four interrupted 10-0 nylon sutures were used to close the corneal scleral section. The silk sutures were removed, and the conjunctiva advanced back into its normal location and was secured with cautery burns at the 3 and 9 o’clock positions. Approximately 20 to 30 mg of both Gentamicin and Kenalog were injected into the inferior cul-de-sac in a subconjunctival and sub-Tenon fashion. After instillation of 2% Pilocarpine and Maxitrol ophthalmic solution, the eyelid speculum was removed and the eye dressed in a sterile fashion. The patient was discharged to the recovery room in good condition.

Code(s): ___________________________________________

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