Please PUT code CPT. The key terms in the operative reports are highlighted in a bold font. 1. Operative Report Preoper

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Please PUT code CPT. The key terms in
the operative reports are highlighted in a bold
font.
1.
Operative Report
Preoperative
Diagnosis:
Left inguinal hernia Postoperative
Diagnosis: Same
Procedure:
Left initial inguinal hernia repair with mesh
Anesthesia:
General
The patient is a 23-year-old man who presented with several
weeks’ history of pain in his left groin associated with a
bulge. Examination revealed that his left groin did indeed
have a bulge and his right groin was normal. We discussed the
procedure as well as the choice of anesthesia. After
preoperative evaluation and clearance, the patient was brought into
the operating suite and placed in a comfortable supine position on
the OR table. Monitoring equipment was attached, and general
anesthesia was induced. His left groin was sterilely prepped
and draped, and an inguinal incision made. This was carried
down through the subcutaneous tissues until the external oblique
fascia was reached. This was split in a direction parallel
with its fibers, and the medial aspect of the opening included the
external ring. The ileo-inguinal nerve was identified, and
care was taken to retract this inferiorly out of the way. The
cord structures were encircled and the cremasteric muscle fibers
divided. At this point, we examined the floor of the inguinal
canal, and the patient did appear to have a weakness here. We
then explored the cord. There was no evidence of an indirect
hernia. A piece of 3 X 5 mesh was obtained and trimmed to
fit. It was placed down in the inguinal canal and tacked to
the pubic tubercle. It was then run inferiorly along the
pelvic shelving edge until lateral to the internal ring and tacked
down superiorly using interrupted sutures of O-Prolene. A
single stitch was placed lateral to the cord to recreated the
internal ring. Details of the mesh were tucked underneath the
external oblique fascia. The cord and the nerve were allowed
to drop back into the wound, and the wound was infiltrated with 30
cc of half percent Marcaine. The external oblique fascia was
then closed with a running suture of O-Vicryl. Subcutaneous
tissues were approximated with interrupted sutures of 3-0
Vicryl. The skin was closed with a running subcuticular
suture of 4-0 Vicryl. Benzoin and Steri-Strips and a dry
sterile dressing were applied. All sponge, needle, and
instrument counts were correct at the end of the procedure.
The patient tolerated the procedure well and was taken to the
recovery room in stable condition.
* CPT CODE = ?????
2.
Preoperative
Diagnosis:
Bilateral otitis media
Postoperative
Diagnosis:
Same
Procedure:
Bilateral myringotomy with tubes
The patient was brought to the operating room, placed in a
supine position, and given a general anesthesia.
Myringotomies were performed bilaterally in the anterior-superior
quadrant of each tympanic membrane. The left middle ear
cavity contained a mucopurulent material: the right middle
ear cavity contained a thick mucoid material.
Tympanostomy tubes were placed bilaterally without
difficulty. The patient tolerated the procedure well and was
discharged to the recovery area.
* CPT CODE = ?????
3.
Operative Report
Preoperative
Diagnosis:
Renal Failure
Postoperative
Diagnosis:
Same
Procedure:
Insertion of subclavian venous
catheter
With this elderly patient in the head-down position, the entire
left upper chest was prepared with Betadine scrub and draped in the
usual sterile fashion. Then 1% lidocaine was used for local
anesthetic. A percutaneously subclavian venous catheter was
inserted without difficulty and secured at the skin level with 3-0
nylon, and a sterile dressing was applied. The catheter also
was irrigated with heparin solution,. Patient tolerated the
procedure well. Will follow with a chest X-ray.
* CPT CODE = ?????