Sample Coded Medical coding Charts Part-19

Sample coded Medical coding report 1

DIAGNOSES:
1. Chronic adenotonsillitis
2. Upper airway resistance.

PROCEDURES:
1. Tonsilloadenoidectomy.

INDICATION FOR PROCEDURE: The patient presents with a history of chronic adenotonsillitis, which had been appropriately treated by Dr. . The patient has persistent hypertrophy of her tonsils with copious amount of cryptic concretions with 3+ tonsillar enlargement. There is significant upper airway resistance per the parents. The patient has been appropriately treated by her pediatrician. Patient has failed recurrent antibiotic treatment and continues to have persistent morbidity. Because of this, operative intervention was discussed, reviewed, and recommended. The parents wish to proceed with operative intervention. The procedure was discussed risks benefits alternatives reviewed. The parent was allowed to watch videos discussing risk management and perioperative care after which again time was allowed and all questions answered. The patient was subsequently taken to the operating room for above-stated procedure.

PROCEDURE IN DETAIL: The patient was taken to the Operating Room and placed in the supine position and under general anesthesia per Anesthesia. Endotracheal intubation was achieved via the oral route without difficulty. An IV was started the patient was sedated. The patient was then placed in suspension using Crowe-Davis mouth gag without difficulty. A latex free catheter was placed in the right nostril and used to retract retract the palate about a sponge gauze. Adenoidectomy was performed on three passes using adenoid curettes. Adenoid packs saturated with oxymetazoline were placed x2 to initiate hemostasis. The right tonsil was then retracted medially and dissected using suction cautery without difficulty. The same procedure was repeated on the left side. The tonsillar fossae were injected with 0.25% Marcaine with epinephrine for a total of 2 mL. The tonsillar fossa was closed with 3-0 Vicryl interrupted x4 bilaterally. The adenoid packs were removed and hemostasis was established to the adenoid bed using suction electrocautery. The stomach was then suction-evacuated without evidence of significant return. Estimated blood loss was less than 20 mL. The patient was awakened and taken to the Recovery Room without complications. The patient will be seen in the office in two weeks. Tonsils were sent separately for pathologic evaluation.

CPT code: 42820 Tonsillectomy and adenoidectomy; younger than age 12

ICD 10: J3503 Chronic tonsillitis and adenoiditis

Sample coded Medical coding report 2

Indication for Surgery :Suspicion for foreign body in the right earlobe

Preoperative Diagnosis :Foreign body soft tissue of right earlobe

Operation : Incision and exploration for foreign body right earlobe

Surgeon(s)
Anesthesia :General

Estimated Blood Loss :Less than 1 mL

Findings : See technique details

Specimen(s) :None

Complications :None

Technique : After general anesthesia was administered by the anesthesia staff the right earlobe area was inspected and then prepped and draped. A small incision was made on the posterior surface of the right earlobe where there was thickened irregular and lobular tissue and a firmness. Scar tissue was encountered. There is no foreign body identified. There was wound appearance of a previous earring back foreign body that has come out. There were irregular lobules of skin that did did not look like they would heal together well so using some tissue scissors I smoothed out the posterior surface removing some of these irregular lobules of skin tissue leaving approximately 2-3 mm area to heal secondarily. The area was cleaned and then antibiotic ointment was placed.

CPT code: 10120-RT Incision and removal of foreign body, subcutaneous tissues; simple

ICD-10 : M795 Residual foreign body in soft tissue

Sample coded Medical coding report 3

Indication for Surgery: This 4-year-old female has had multiple bouts of otitis media requiring antibiotic therapy she was referred by her pediatrician for possible PE tube placement. She has a persistent effusion on the right and an intermittent effusion on the left. She also has a poor nasal airway. Additionally she has chronic mild hoarseness without stridor. She has a syndrome of frequent vomiting. Her hoarseness has not responded to antireflux medication.
Preoperative Diagnosis :Recurrent acute otitis media, persistent serous otitis media. Hypertrophic adenoids. Chronic hoarseness
Postoperative Diagnosis : Same with mild edema of both vocal cords no neoplasm or lesion. There is a serous effusion on the right and scant serous effusion on the left. The adenoids were moderately hypertrophic
Operation : Bilateral myringotomy with PE tube placement with use of operating microscope
Surgeon(s)

Anesthesia :General
Estimated Blood Loss
Scant
Findings :As above
Specimen(s) :Adenoids submitted in formalin for pathological examination
Complications :None
Technique :Under adequate general anesthesia the patient was positioned on the operating room table. The larynx was visualized using direct laryngoscopy. There is no evidence of neoplasia. There is no vocal polyps there is no evidence of subglottic stenosis. The epiglottis and supraglottic structures were entirely unremarkable. The vocal cord motion was normal upon lightening the patient’s anesthesia plane allowing the patient to cough. She was then brought to a deeper plane of anesthesia and I intubated the patient. The operating microscope was maneuvered into position and used throughout the procedure. The ear canal was debrided using suction cup forceps and saline irrigation. A myringotomy was made in the posterior inferior quadrant of either tympanic membrane. Effusion material was suctioned from the middle ear space. A Paparella ventilating tube was placed through the tympanic membrane. The position was verified by microscopic examination. Ciprodex ptotic suspension was placed into the middle ear space. Attention was then turned to the adenoidectomy. A Crowe Davis mouthgag was introduced. The nasopharynx was visualized using the laryngeal mirror. The nasal pharynx was palpated there was no evidence of dehiscent or exposed carotid artery. The adenoid mass was removed using adenoid curette. Hemostasis in the nasopharynx was achieved using suction cautery. The procedure was terminated and the patient was taken to recovery room in good condition.