Medical Billing and Coding
1. Ann Borden | SURGEON: | Mohomad Almaz, MD | DIAGNOSIS: | Right carpal tunnel syndrome | PROCEDURE PERFORMED: | Right carpal tunnel release | 2. | | | 3.
PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released. We identified the median nerve and found that it was free. We did spread the soft tissues surrounding it gently.
We then released the tourniquet after 8 minutes of tourniquet time, and bleeding was controlled with pressure and also with electrocautery. We thoroughly irrigated the area with saline. We then closed the skin using 4-0 nylon suture, and a Xeroform dressing was applied under a small pressure dressing. She was taken from the operating room in good condition. She tolerated this very well.
CPT SERVICE CODE(S): ___________________________________________________
ICD-9-CM DX CODE(S): _______________________________________________ 4. Answer | | | | | Path:body | |
4.5 points
Question 2 1. LOCATION: | Outpatient, Hospital | PATIENT: | Larry Frost | SURGEON: | Mohomad Almaz, MD | | | 2. DIAGNOSIS: Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms
OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle
After satisfactory level of general anesthesia was reached and patient was in the supine position, he was further placed in a
PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released. We identified the median nerve and found that it was free. We did spread the soft tissues surrounding it gently.
We then released the tourniquet after 8 minutes of tourniquet time, and bleeding was controlled with pressure and also with electrocautery. We thoroughly irrigated the area with saline. We then closed the skin using 4-0 nylon suture, and a Xeroform dressing was applied under a small pressure dressing. She was taken from the operating room in good condition. She tolerated this very well.
CPT SERVICE CODE(S): ___________________________________________________
ICD-9-CM DX CODE(S): _______________________________________________ 4. Answer | | | | | Path:body | |
4.5 points
Question 2 1. LOCATION: | Outpatient, Hospital | PATIENT: | Larry Frost | SURGEON: | Mohomad Almaz, MD | | | 2. DIAGNOSIS: Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms
OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle
After satisfactory level of general anesthesia was reached and patient was in the supine position, he was further placed in a