Coding for open carpal tunnel release.
PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
OPERATION PERFORMED: Right open carpal tunnel release.
DESCRIPTION OF THE PROCEDURE: The patient was taken to the operating suite, placed in a supine position, and induced anesthesia. The hand was prepped and draped free in the usual sterile fashion. A curvilinear incision just ulnar to the thenar crease was carried. Hemostasis was obtained along the way. General dissection down to the transverse carpal ligament was performed. Complete release of ligament was verified and silk suture was placed in the wound. The patient tolerated the procedure well, was reversed to anesthesia, and was taken to recovery room stable.
Cpt Code: 64721
Modifier: RT
Dx Code: 354.0
Px Code: 04.43
Coding for open Excision of volar ganglion cyst.
PREOPERATIVE DIAGNOSIS: Ganglion cyst, Left wrist.
POSTOPERATIVE DIAGNOSIS: Ganglion cyst, Left wrist.
PROCEDURE PERFORMED: Excision of ganglion cyst, Left wrist.
OPERATIVE PROCEDURE: The patient was taken to the operating room and given a general anesthetic. After having obtained adequate anesthetic levels, the patient was prepped and draped in the usual sterile fashion to allow free access to the left wrist. The limb was exsanguinated and the tourniquet was inflated at 300 mmHg. A linear incision was made directly over the cyst on the volar side of the wrist. The soft tissue was divided down to the cyst, which was then carefully dissected free. Vessels were coagulated. The radial artery was protected. After completely dissecting the cyst free, the cyst was then removed. The base of the cyst was coagulated with electrocautery. No other pathology was noted. All vessels were coagulated. The wound was copiously irrigated with saline. The wound was then closed with 4-0 nylon. Soft tissues surrounding the wound were then infiltrated with 0.5% Marcaine. Sterile dressings were applied and the patient was transferred to the recovery room in satisfactory condition.
Cpt Code: 25111
Modifier: LT
Dx Code: 724.41
Px Code: 82.21
Coding for knee menisectomy.
PREOPERATIVE DIAGNOSIS: Left knee posterior horn medial meniscus tear.
POSTOPERATIVE DIAGNOSIS: Left knee posterior horn medial meniscus tear.
PROCEDURE: Left knee arthroscopy with partial medial meniscectomy.
Cpt Code: 29881
Modifier: LT
Dx Code: 717.2
Px Code: 80.6
Coding for Cystoscopy.
PREOPERATIVE DIAGNOSIS: Chronic dysuria.
POSTOPERATIVE DIAGNOSIS: Chronic dysuria.
PROCEDURE: Cystoscopy with urethral calibration.
FINDINGS: Urethra revealed no stenosis. Bladder revealed very mild cystocele, but no suspicious tumors or lesions seen. No urethral mass or diverticulum appreciated.
DETAILS OF PROCEDURE: After obtaining informed consent, the patient was taken to the procedure room. Sedation was administered by Anesthesia. The patient was placed in the dorsal lithotomy position. Genitalia were prepped and draped in the usual fashion. A 10 cc of lidocaine jelly was instilled per urethra. The urethral bougies were used to calibrate the urethra. It was calibrated with #26-French with no stenosis. A #22-French cystoscope was then advanced per urethra into the bladder. The bladder was visualized with #30 and #70-degree lenses with the findings as above. The scope was removed. The patient tolerated the procedure well without any apparent complications.
These findings were discussed with the patient and significant other. Recommended she see a gynecologist for possible vaginal causes for her chronic dysuria, which actually is more of a chronic burning even can occur without urination.
Cpt Code: 52281
Modifier: None
Dx Code: 788.1, 618.01
Px Code: 58.5
Coding for Interlaminar epidural steroid injection.
PREOPERATIVE DIAGNOSIS: Spinal stenosis.
POSTOPERATIVE DIAGNOSIS: Spinal stenosis.
PROCEDURE PERFORMED: An L5-S1 interlaminar epidural steroid injection with fluoroscopic guidance.
DESCRIPTION OF THE PROCEDURE: The patient was positioned prone on the radiolucent table. The back was prepped and draped in the usual sterile fashion. The C-arm was positioned to give an AP image of the L5-S1 interspace. The skin and subcutaneous tissue over the interspace was infiltrated with 5 cc of 1% lidocaine plain. A 20 gauge Tuohy needle was then inserted and directed towards the L5-S1 interspace. Then using fluoroscopic guidance and loss of resistance technique, the needle was inserted into the epidural space, negative aspirate for CSF or blood, 80 mg of Depo-Medrol and 2 cc of sterile saline, both preservative–free, were injected into the epidural space without complications. The patient tolerated the procedure well.
Cpt Code: 62311 & 77003
Modifier: None
Dx Code: 724.02
Px Code: 03.92
Coding for Transforaminal epidural steroid injection.
PREOPERATIVE DIAGNOSIS: Lumbar radiculopathy.
POSTOPERATIVE DIAGNOSIS: Lumbar radiculopathy.
PROCEDURE PERFORMED: Bilateral L5 transforaminal epidural steroid injection.
OPERATIVE PROCEDURE: The patient was taken back to the operating room placed in a prone position. A time out was done confirming proper procedure as well as patient’s drug allergies. Betadine prep was done over the respective area. Fluoroscopy was utilized to identify the respective intervertebral foramen in AP, lateral, and oblique views. Subsequently, after Betadine prep was done, a #25-gauge 1-inch needle was used to infiltrate skin with 1% lidocaine mixed with sodium bicarbonate 8.4 mg/mL. Subsequently, a #22-gauge 5-inch spinal needle was advanced at the 6 o’clock position at the respective intervertebral foramen confirming AP and lateral views. Subsequently, iohexol 240 units/mL was injected noting good spread along the respective nerve roots and into the epidural space. There were no signs of intravascular or intrathecal uptake. Subsequently, a slow injection of Celestone preservative-free 10 mg total and triamcinolone in total plus 0.5 cc of 1% lidocaine was injected at each level. A 1% lidocaine was injected into the needle track. Post procedure, the patient was comfortable. The patient tolerated the procedure well. No complications noted.
Cpt Code: 64483
Modifier: 50
Dx Code: 724.4
Px Code: 03.92
Coding for Phacoemulsification of cataract with IOL lens.
PREOPERATIVE DIAGNOSIS: Cataract, right eye.
POSTOPERATIVE DIAGNOSIS: Cataract, right eye.
OPERATIVE TITLE: Phacoemulsification of cataract with insertion of intraocular lens, right eye.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite, and the operative eye was prepped in the usual sterile fashion for ophthalmic surgery. A drop of tetracaine was placed in the operative eye. An eyelid speculum was placed. The temporal cornea was marked for 3.0 mm; and using a diamond blade at a preset depth of 600 microns, a peripheral incision was made temporally. Next, using a 1.0 mm diamond knife, a paracentesis wound was made. Preservative-free lidocaine was then injected into the anterior chamber, followed by viscoelastic. Using a 2.85-mm diamond blade, a temporal clear corneal wound was created. Using a bent needle and capsulorrhexis forceps, a continuous curvilinear capsulorrhexis was created. The lens was then hydrodissected and hydrodelineated from the lens capsule.
The lens nucleus and cortex were removed from the capsular bag with phacoemulsification. The capsular bag was then inflated with viscoelastic, and an intraocular lens was placed. The viscoelastic was then removed from the anterior chamber and the capsular bag.
The anterior chamber was then inflated with balanced salt solution to physiologic pressure, and the wounds were checked to be watertight. The eyelid speculum and eye drapes were removed, and the patient was taken to the postoperative care area in stable condition.
Cpt Code: 66984
Modifier: RT
Dx Code: 366.9
Px Code: 13.71
Coding for YAG laser capsulotomy of eye
PREOPERATIVE DIAGNOSIS: Opacified posterior capsule of the left eye.
POSTOPERATIVE DIAGNOSIS: Opacified posterior capsule of the left eye.
OPERATIVE PROCEDURE: YAG laser capsulotomy of the left eye.
SURGEON: Ranjana Chauhan, M.D.
ANESTHESIA: Local.
ANESTHESIOLOGIST: PACU.
PROCEDURE NOTES: The patient’s operative eye was prepared with 2.5 percent phenylephrine, 1 percent tropicamide, and 0.5 percent proparacaine eyedrops. The patient was taken to the laser suite, where a lens was placed onto the left eye, and 27 applications of the YAG laser was applied to the posterior capsule. The power was 2.1 millijoules per application.The patient tolerated the procedure well without complication.
Cpt Code: 66821
Modifier: LT
Dx Code: 366.50
Px Code: 13.64
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Integumentary (skin lesion excision)coding
Integumentary (skin lesion excision)coding
PREOPERATIVE DIAGNOSES:
- A 1 cm sebaceous cyst of left upper back.
- Five irritated skin tags of neck.
POSTOPERATIVE DIAGNOSES:
- A 1 cm sebaceous cyst of left upper back.
- Five irritated skin tags of neck.
PROCEDURES PERFORMED:
- Excise 1 cm sebaceous cyst of upper back and complex closure 2.5 cm.
- Shave excise five skin tags of neck.
DESCRIPTION OF THE PROCEDURE: After being placed in the lateral position on the table, the patient’s upper back and shoulder were prepped with Hibiclens solution and sterile field obtained. 1% Xylocaine with epinephrine was used to anesthetize the above-mentioned areas. This lesion was located over the middle of the deltoid. It was excised with a vertical ellipse. Bleeders were cauterized with a Bovie. Skin edges were undermined medial and lateral in order to achieve mobilization of the tissue. For some reason, there was a fair amount of bleeding in this area. The wound was then closed in the deep dermis with interrupted 5-0 Vicryl, interrupted 4-0 Vicryl and then in the skin an interrupted 5-0 nylon. A compressive dressing was placed with Adaptic, 2x2s and tape. We then turned the patient supine. Six large skin tags distributed along her neck line were infiltrated with 1% Xylocaine with epinephrine and shave excise with a needle-point cautery. Stere-Strips were placed. The patient returned to the recovery room in good condition.
Cpt Code: 11401 & 13101, 11200
Modifier: LT
Dx Code: 706.2, 701.9
Px Code: 86.3 & 86.59, 86.3
