Assign CPT anesthesia code(s) only for the following case. Do not assign surgery or ICD-10-CM codes. You will assign cod
Posted: Fri May 06, 2022 9:39 am
Assign CPT anesthesia code(s) only for the following
case. Do not assign surgery or ICD-10-CM codes. You will assign
codes for the physician medically directing or supervising the
anesthesia and also the codes for the CRNA.
T14-4 OPERATIVE REPORT, CHOLECYSTECTOMY
Do not assign diagnostic codes. Anesthesia by: MDA and
CRNA. Anesthesiologist was medically directing 4 concurrent
cases.
LOCATION:
Outpatient, Hospital
PATIENT:
Karen Daniels
PHYSICIAN:
Larry Friendly, MD
PREOPERATIVE DIAGNOSIS:
Biliary dyskinesia
POSTOPERATIVE DIAGNOSIS:
Biliary dyskinesia
PROCEDURE PERFORMED:
Laparoscopic cholecystectomy
ANESTHESIA:
General
INDICATIONS: The patient is a 78-year-old female who presents
with an abnormal CCK (cholecystokinin) HIDA (hepatobiliary
imino-diacetic acid [imaging test]) scan. She presents today for
elective laparoscopic cholecystectomy. She understands the risks of
bleeding, infection, possible damage to the biliary system, and
possible conversion to open procedure, and she wishes to
proceed.
PROCEDURE: The patient was brought to the operating table and
placed under general anesthesia. Foley catheter and orogastric
tubes were inserted, and she was prepped and draped sterilely. A
supraumbilical skin incision was made with a #11 blade, and
dissection was carried down through subcutaneous tissues. Bluntly,
midline fascia was grasped with a Kocher clamp, and 0 Vicryl
sutures were placed on either side of the midline fascia. The
Veress needle was then inserted into the abdominal cavity; drop
test confirmed placement within the peritoneal space. The abdomen
was insufflated with carbon dioxide; a 10-mm (millimeter) trocar
port and laparoscope were introduced, showing no damage to the
underlying viscera. Under direct vision, three additional trocar
ports were placed, one upper midline 10 mm, two right upper
quadrant 5 mm. The gallbladder was grasped and was elevated from
its fossa. The cystic duct and artery were dissected and doubly
clipped proximally and distally, dividing them with the scissors.
The gallbladder was then shelled from its fossa using
electrocautery and brought up and out of the upper midline
incision. The abdomen was irrigated with saline until returns were
clear. There was no bleeding from the liver bed. Clips were in with
no evidence of bleeding. When we were removing the final port, we
could see down in the right groin, and she had small indirect
inguinal hernia, which was about 3 mm in size. We removed the
remaining trocar port with no evidence of bleeding, closed the
supraumbilical and upper midline ports and fascial defects with
interrupted 0 Vicryl sutures, and closed the skin at all port sites
with subcuticular 4-0 undyed Vicryl. Steri-Strips and sterile
bandages were applied.
PATHOLOGY REPORT LATER INDICATED: Benign tissue.
T14-4:
PHYSICIAN CODE: 1 CPT (Code
anesthesia, laparoscopy) Needs two modifiers.
CRNA CODE: 1 CPT (Code anesthesia, laparoscopy) Needs
two modifiers.
QUALIFYING CIRCUMSTANCES CODE: 1 CPT (Code anesthesia,
special circumstances, extreme age)
case. Do not assign surgery or ICD-10-CM codes. You will assign
codes for the physician medically directing or supervising the
anesthesia and also the codes for the CRNA.
T14-4 OPERATIVE REPORT, CHOLECYSTECTOMY
Do not assign diagnostic codes. Anesthesia by: MDA and
CRNA. Anesthesiologist was medically directing 4 concurrent
cases.
LOCATION:
Outpatient, Hospital
PATIENT:
Karen Daniels
PHYSICIAN:
Larry Friendly, MD
PREOPERATIVE DIAGNOSIS:
Biliary dyskinesia
POSTOPERATIVE DIAGNOSIS:
Biliary dyskinesia
PROCEDURE PERFORMED:
Laparoscopic cholecystectomy
ANESTHESIA:
General
INDICATIONS: The patient is a 78-year-old female who presents
with an abnormal CCK (cholecystokinin) HIDA (hepatobiliary
imino-diacetic acid [imaging test]) scan. She presents today for
elective laparoscopic cholecystectomy. She understands the risks of
bleeding, infection, possible damage to the biliary system, and
possible conversion to open procedure, and she wishes to
proceed.
PROCEDURE: The patient was brought to the operating table and
placed under general anesthesia. Foley catheter and orogastric
tubes were inserted, and she was prepped and draped sterilely. A
supraumbilical skin incision was made with a #11 blade, and
dissection was carried down through subcutaneous tissues. Bluntly,
midline fascia was grasped with a Kocher clamp, and 0 Vicryl
sutures were placed on either side of the midline fascia. The
Veress needle was then inserted into the abdominal cavity; drop
test confirmed placement within the peritoneal space. The abdomen
was insufflated with carbon dioxide; a 10-mm (millimeter) trocar
port and laparoscope were introduced, showing no damage to the
underlying viscera. Under direct vision, three additional trocar
ports were placed, one upper midline 10 mm, two right upper
quadrant 5 mm. The gallbladder was grasped and was elevated from
its fossa. The cystic duct and artery were dissected and doubly
clipped proximally and distally, dividing them with the scissors.
The gallbladder was then shelled from its fossa using
electrocautery and brought up and out of the upper midline
incision. The abdomen was irrigated with saline until returns were
clear. There was no bleeding from the liver bed. Clips were in with
no evidence of bleeding. When we were removing the final port, we
could see down in the right groin, and she had small indirect
inguinal hernia, which was about 3 mm in size. We removed the
remaining trocar port with no evidence of bleeding, closed the
supraumbilical and upper midline ports and fascial defects with
interrupted 0 Vicryl sutures, and closed the skin at all port sites
with subcuticular 4-0 undyed Vicryl. Steri-Strips and sterile
bandages were applied.
PATHOLOGY REPORT LATER INDICATED: Benign tissue.
T14-4:
PHYSICIAN CODE: 1 CPT (Code
anesthesia, laparoscopy) Needs two modifiers.
CRNA CODE: 1 CPT (Code anesthesia, laparoscopy) Needs
two modifiers.
QUALIFYING CIRCUMSTANCES CODE: 1 CPT (Code anesthesia,
special circumstances, extreme age)