Medical Billing and Coding

Topics: Knee, Anterior cruciate ligament, Lateral meniscus Pages: 14 (3009 words) Published: April 8, 2013
 Ann Borden|
 SURGEON:| Mohomad Almaz, MD|
 DIAGNOSIS:| Right carpal tunnel syndrome|
 PROCEDURE PERFORMED:| Right carpal tunnel release|
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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
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| Path:body|
4.5 points   
Question 2
LOCATION:| Outpatient, Hospital|
 PATIENT:| Larry Frost|
 SURGEON:| Mohomad Almaz, MD|
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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 beach chair position. A longitudinal incision was created over the region of the left AC joint. At this time, sharp dissection was conducted down to the fascial plane. The fascial plane was then further incised, reflecting both the deltoid and the trapezial fascia and the distal aspect of the clavicle undermining the clavicle; at this time we simply proceeded excising the distal 1 cm of the clavicle with use of a reciprocal saw. With completion of this element of the procedure, the margins of the bone were otherwise unremarkable in gross appearance. It was also significant to note at this time the acromial end of the articulation was unremarkable. The wound was irrigated, followed by controlling of punctate bleeding with use of electrocautery, followed by the closure of the deltotrapezial fascia. At this time I further imbricated sutures for stable repair, followed by repair of subcutaneous and dermal planes. A simple dressing was applied. The patient tolerated the procedure well and was transported to the recovery room in a stable manner.

CPT SERVICE CODE(S): ___________________________________________________ ICD-9-CM DX CODE(S): _______________________________________________ 3. Answer
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| Path:body|
4.5 points   
Question 3
LOCATION: Outpatient, Hospital

PATIENT: Josh Blake

SURGEON: Mohamad Almaz, MD



PROCEDURE PERFORMED: Placement of a halo

INDICATION: Fracture occurred when the patient was involved in an unspecified motor vehicle collision. It is known that Mr. Blake was the driver of the vehicle.

PROCEDURE: The patient's head was prepped and draped in the usual manner. The head was shaved. The halo apparatus was applied with screws and four-points. Then the vest was applied. The patient was then discharged to the recovery room to have films taken in the recovery room.

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