Chapter 15-Practical Application
ANESTHESIA: Laryngeal mask anesthesia.
PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye.
POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used
for coding.)
PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right
eye.
PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was
prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye.
A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of
the intramuscular quadrants was dissected using Aebli scissors. The muscles were isolated using
a Gass muscle hook with an 0 silk suture attached to it. The patient had an inspection of the
intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin
sclera. The patient had an examination of the retina using an indirect ophthalmos - Answer
67107
H33.021
PREOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes.
POSTOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes.
PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes.
ANESTHESIA: General.
CONDITION: To recovery, satisfactory.
COUNTS: Needle count correct.
ESTIMATED BLOOD LOSS: Less than 1 ml.
INFORMED CONSENT: The procedure, risks, benefits, and alternatives were thoroughly
explained to the patient's parent who understands and wants the procedure done.
PROCEDURE: The patient was prepped and draped in the usual sterile manner under general
anesthesia.(General anesthesia is used for this procedure.) Starting on the right eye (This
indicates the procedure is performed on the right eye.) the upper punctum was dilated with
double-ended punctal dilator, and starting with a 4-0 probe, increasing up to a 2-0 probe, the
nasolacrimal duct was dilated until probed patent.(This indicates the nasolacrimal duct is
probed.) Then, using - Answer 68811-50
H04.553
PREOPERATIVE DIAGNOSIS: Bilateral protruding ears.
POSTOPERATIVE DIAGNOSIS: Bilateral protruding ears.
, PROCEDURE: Bilateral otoplasty.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
PROCEDURE IS AS FOLLOWS: The patient was placed supine then prepped and draped in the
usual sterile fashion. Measurements were taken from the helix to the mastoid at the superior,
mid, and inferior portions and they were within 1 to 2 mm of the same bilaterally and were
approximately 17 mm superior, 24 mm middle, and 25 mm inferior. The right ear was begun
first.(Procedure is performed on the right ear.) A curved incision was made just anterior to the
sulcus (An incision is made.) of the posterior ear. This was done with a 15-blade scalpel.
Electrocautery was used for hemostasis and further dissection. An iris scissors was used to
dissect the soft tissues off of the mastoid region and the posterior ear. The conch - Answer
69300-50
Q17.5
CASE 4
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.
ANESTHETIC: General. Time began: 10:15 a.m. Time ended: 10:35 a.m.
POSTOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.(The postoperative diagnosis
is used for coding.)
PATHOLOGY SPECIMEN: None.
OPERATION: Removal of foreign body using the microscope.
DATE OF PROCEDURE: 05/12/XX Time began: 10:21 a.m. Time ended: 10:22 a.m.
DESCRIPTION OF OPERATION:
Under general anesthesia(General anesthesia is used.) with the microscope in place, a pearly
white plastic ball was seen virtually obstructing the entire ear canal. Gently with a curette, this
was teased out of the ear canal atraumatically.(The foreign body is removed.) The ear canal and
eardrum were perfectly intact.
The patient tolerated the procedure well and was returned to the recovery room in satisfactory
condition
What are the CPT® and ICD-10-CM codes reported? - Answer 69205-RT
T16.1XXA
PREOPERATIVE DIAGNOSIS:
1. Cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
ANESTHESIA: Laryngeal mask anesthesia.
PREOPERATIVE DIAGNOSIS: Retinal detachment, right eye.
POSTOPERATIVE DIAGNOSIS: Retinal detachment, right eye.(The postoperative diagnosis is used
for coding.)
PROCEDURE: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas in the right
eye.
PROCEDURE: After the patient had received adequate laryngeal mask anesthesia, he was
prepped and draped in usual sterile fashion. A wire lid speculum was placed in the right eye.
A limbal peritomy was done for 360 degrees using 0.12 forceps and Westcott scissors. Each of
the intramuscular quadrants was dissected using Aebli scissors. The muscles were isolated using
a Gass muscle hook with an 0 silk suture attached to it. The patient had an inspection of the
intramuscular quadrants and there was no evidence of any anomalous vortex veins or thin
sclera. The patient had an examination of the retina using an indirect ophthalmos - Answer
67107
H33.021
PREOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes.
POSTOPERATIVE DIAGNOSIS: Dacryostenosis, both eyes.
PROCEDURE PERFORMED: Nasolacrimal duct probing, both eyes.
ANESTHESIA: General.
CONDITION: To recovery, satisfactory.
COUNTS: Needle count correct.
ESTIMATED BLOOD LOSS: Less than 1 ml.
INFORMED CONSENT: The procedure, risks, benefits, and alternatives were thoroughly
explained to the patient's parent who understands and wants the procedure done.
PROCEDURE: The patient was prepped and draped in the usual sterile manner under general
anesthesia.(General anesthesia is used for this procedure.) Starting on the right eye (This
indicates the procedure is performed on the right eye.) the upper punctum was dilated with
double-ended punctal dilator, and starting with a 4-0 probe, increasing up to a 2-0 probe, the
nasolacrimal duct was dilated until probed patent.(This indicates the nasolacrimal duct is
probed.) Then, using - Answer 68811-50
H04.553
PREOPERATIVE DIAGNOSIS: Bilateral protruding ears.
POSTOPERATIVE DIAGNOSIS: Bilateral protruding ears.
, PROCEDURE: Bilateral otoplasty.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
PROCEDURE IS AS FOLLOWS: The patient was placed supine then prepped and draped in the
usual sterile fashion. Measurements were taken from the helix to the mastoid at the superior,
mid, and inferior portions and they were within 1 to 2 mm of the same bilaterally and were
approximately 17 mm superior, 24 mm middle, and 25 mm inferior. The right ear was begun
first.(Procedure is performed on the right ear.) A curved incision was made just anterior to the
sulcus (An incision is made.) of the posterior ear. This was done with a 15-blade scalpel.
Electrocautery was used for hemostasis and further dissection. An iris scissors was used to
dissect the soft tissues off of the mastoid region and the posterior ear. The conch - Answer
69300-50
Q17.5
CASE 4
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.
ANESTHETIC: General. Time began: 10:15 a.m. Time ended: 10:35 a.m.
POSTOPERATIVE DIAGNOSIS: Foreign body, right external ear canal.(The postoperative diagnosis
is used for coding.)
PATHOLOGY SPECIMEN: None.
OPERATION: Removal of foreign body using the microscope.
DATE OF PROCEDURE: 05/12/XX Time began: 10:21 a.m. Time ended: 10:22 a.m.
DESCRIPTION OF OPERATION:
Under general anesthesia(General anesthesia is used.) with the microscope in place, a pearly
white plastic ball was seen virtually obstructing the entire ear canal. Gently with a curette, this
was teased out of the ear canal atraumatically.(The foreign body is removed.) The ear canal and
eardrum were perfectly intact.
The patient tolerated the procedure well and was returned to the recovery room in satisfactory
condition
What are the CPT® and ICD-10-CM codes reported? - Answer 69205-RT
T16.1XXA
PREOPERATIVE DIAGNOSIS:
1. Cataract, right eye.
POSTOPERATIVE DIAGNOSIS:
