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Right carpal tunnel syndrome Essay

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.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Glory Ann Borden:

ICD-9-CM: __________
Answer
Selected Answer:
354.0
Correct Answer:
354.0 (Syndrome, carpal tunnel)

RATIONALE: The diagnosis is carpal tunnel syndrome as indicated by 354.0.
Question 2
Needs Grading

LOCATION: Outpatient,Hospital
PATIENT: Glory Ann Borden
SURGEON: Mohomad Almaz, MD
DIAGNOSIS:Right carpal tunnel syndrome
PROCEDURE PERFORMED:Right carpal tunnel release
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.

Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Glory Ann Borden:

CPT-4: __________ Modifier: __________

Answer
Selected Answer:
64721-RT
Correct Answer:
64721-RT (Release, Carpal Tunnel)

RATIONALE: The service is a carpal tunnel release as indicated in the Procedure Performed section of the report and substantiated within the body of the report. (“We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was completely released.”) This service is described with 64721 with modifier -RT added to indicate right side.

Question 3
Needs Grading

LOCATION: Outpatient, Hospital
PATIENT: Josh Blake
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Fracture of CI, C2
POSTOPERATIVE DIAGNOSIS: Fracture of CI. C2
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.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Josh Blake:

ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ (hint: this one is an E-Code!)
Answer
Selected Answer:
805.01
805.02
E819.0
Correct Answer:
805.01 (Fracture, vertebrae/vertebral, cervical, first [atlas] 805.02 (Fracture, vertebra/vertebral, cervical, second
E819.0 (Accident, motor vehicle, driver)

RATIONALE: Each fracture site would be coded separately. The C1 fracture would be coded with 805.01, and the C2 fracture with 805.02. As reported in the Indication section, this was an MVC of an unspecified nature, and the patient was the driver. E819 is the code for MVC of unspecified nature with the 4th digit of 0 to show the patient was driving.

Question 4
Needs Grading

LOCATION: Outpatient, Hospital
PATIENT: Josh Blake
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Fracture of CI, C2
POSTOPERATIVE DIAGNOSIS: Fracture of CI. C2
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.

Identify the correct procedure (CPT-4) code(s) for the outpatient hospital
visit for patient Josh Blake:

CPT-4: __________
Answer
Selected Answer:
20661
Correct Answer:
20661 (Halo, Cranial)

RATIONALE: A cranial halo is applied to stabilize the patient’s neck to repair C1 and C2 fractures. The application of the halo is coded with 20661.
Question 5
Needs Grading

LOCATlON: Outpatient, hospital
PATIENT: May Leigh
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DlAGNOSIS: Osteoarthritis, left knee.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Left total knee arthroplasty.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal

Following satisfactory preoperative review and assessment and full discussion, the patient was brought to the operating room where under general anesthesia examination confirmed patient to demonstrate excellent appearance of her right total knee and increased valgus and crepitus of the left knee. The left knee was then elevated, scrubbed, prepped and draped in the usual fashion and utilizing a standard midline incision the subcutaneous tissues were dissected, the medial retinaculum was opened and the underlying knee joint identified with advanced osteoarthritic changes present. The distal femur, proximal tibia and patella were resected in the normal fashion allowing excellent fitting of a #2 femur, a #2 tibia, an 8-tray insert, and a 31 patella. Excellent fit, stability, and range of motion were achieved.
The knee joint was thoroughly waterpiked and irrigated, the tibia and femur securely cemented into position followed by the patella.

Once again, excellent fit, stability, and range were achieved. The knee joint was drained with two deep suction Hemovacs. The medial retinaculum was closed with 0 Vicryl, subcutaneous closure with 2-0 Vicryl, cutaneous margins approximated with 4-0 Ethilon in vertical mattress fashion, and a sterile dressing was applied. The patient tolerated the procedure well and returned to PAR in satisfactory condition. There were no intraoperative complications. Sponge and needle count correct.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient May Leigh:

ICD-9-CM: __________
Answer
Selected Answer:
715.96
Correct Answer:
715.96 (Osteoarthrosis, lower leg)

RATIONALE: The diagnosis is stated in the Postoperative Diagnosis section of the report as osteoarthritis of the knee and is reported with 715.96.
Question 6
Needs Grading

LOCATlON: Outpatient, hospital
PATIENT: May Leigh
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DlAGNOSIS: Osteoarthritis, left knee.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Left total knee arthroplasty.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal

Following satisfactory preoperative review and assessment and full discussion, the patient was brought to the operating room where under general anesthesia examination confirmed patient to demonstrate excellent appearance of her right total knee and increased valgus and crepitus of the left knee. The left knee was then elevated, scrubbed, prepped and draped in the usual fashion and utilizing a standard midline incision the subcutaneous tissues were dissected, the medial retinaculum was opened and the underlying knee joint identified with advanced osteoarthritic changes present. The distal femur, proximal tibia and patella were resected in the normal fashion allowing excellent fitting of a #2 femur, a #2 tibia, an 8-tray insert, and a 31 patella. Excellent fit, stability, and range of motion were achieved. The knee joint was thoroughly waterpiked and irrigated, the tibia and femur securely cemented into position followed by the patella.

Once again, excellent fit, stability, and range were achieved. The knee joint was drained with two deep suction Hemovacs. The medial retinaculum was closed with 0 Vicryl, subcutaneous closure with 2-0 Vicryl, cutaneous margins approximated with 4-0 Ethilon in vertical mattress fashion, and a sterile dressing was applied. The patient tolerated the procedure well and returned to PAR in satisfactory condition. There were no intraoperative complications. Sponge and needle count correct.

Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient May Leigh:

CPT-4: __________ Modifier: __________
Answer
Selected Answer:
27447-LT
Correct Answer:
27447-LT (Arthroplasty, Knee)

RATIONALE: The surgeon removed the defective bones and then fitted the defective areas with prostheses (artificial knee components). This is a replacement of a defective knee or total arthroplasty. The tibial component and the femoral component were replaced with prostheses that were cemented in place. The patellar component was then replaced with a prosthetic device. The defective area was stabilized and then closed. A total knee arthroplasty is reported with 27447 with modifier -LT to indicate the procedure was performed on the left knee.

Question 7
Needs Grading

LOCATlON: Outpatient, hospital
PATIENT: Stan Hope
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past shoulder injury POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder
CLINICAL HISTORY: This is a 57-year-old with a l0-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness. OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beachchair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion . A standard posterior arthroscopic portal was created and the camera was introduced. First the back of the joint was inspected and this did not show any evidence of damage. The anterior ligament structures were normal. The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the
glenohumeral joint and placed in the subacromial space. There was excellent visualization of this area. No abnormalities could be identified and there was no evidence of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on her hospital bed and taken to the recovery room in good condition.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Stan Hope:

ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ (hint: this one is a V-Code!)
Answer
Selected Answer:
719.41
782.0
V15.59
Correct Answer:
719.41 (Pain[s], joint, shoulder)
782.0 (Numbness)
V13.59 (History of, musculoskeletal disorder NEC)

RATIONALE: The diagnostic arthroscopy results were that the shoulder was normal, and, as such, the Postoperative Diagnoses of shoulder pain (719.41) and numbness (782.0) would be the correct codes to use. The patient has a history of musculoskeletal disorder (V13.59).

Question 8
Needs Grading

LOCATlON: Outpatient, hospital
PATIENT: Stan Hope
SURGEON: Mohamad Almaz, MD
PREOPERATIVE DIAGNOSIS: Left shoulder pain and numbness, past shoulder injury POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy, left shoulder
CLINICAL HISTORY: This is a 57-year-old with a l0-year-old rotator cuff tear injury to his left shoulder. The patient does heavy lifting for a living. For the past 6 months the patient has been experiencing pain in this shoulder with some numbness and tingling traveling down the arm. X-rays were normal. Decision was made to go in with an arthroscope to try and uncover a reason for this pain and numbness. OPERATIVE REPORT: Under general anesthesia, the patient was laid in the beachchair position on the operating room table. The left shoulder was examined and found to be stable. There is full range of motion of this shoulder also. The extremity was then prepped and draped in the usual fashion . A standard posterior arthroscopic portal was created and the camera was introduced. First the back of the joint was inspected and this did not show any evidence of damage. The anterior ligament structures were normal. The biceps attachment and its transit through the joint were normal. Subscapularis was intact with no abnormality. Old scarring of the rotator cuff was noted. But all looked as it should. Nothing abnormal was seen. The camera was then removed out of the glenohumeral joint and placed in the subacromial space. There was excellent visualization of this area. No abnormalities could be identified and there was no evidence of any impingements. The camera was then removed from the subacromial space. The area was then infiltrated with Marcaine. The posterior portal was then closed with absorbable sutures and Steri-Strips, and a Mepore dressing was placed on it. The arm was then placed in a sling; the patient awakened and was placed on her hospital bed and taken to the recovery room in good condition.

Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Stan Hope:

CPT-4: __________ Modifier: __________
Answer
Selected Answer:
29805-LT
Correct Answer:
29805-LT (Arthroscopy, Diagnostic, Shoulder)

RATIONALE: The procedure is a diagnostic arthroscopy of the shoulder and is reported with 29805 with modifier -LT to indicate the procedure was performed on the left shoulder.
Question 9
Needs Grading

LOCATION: Outpatient, Hospital
PATIENT:Larry Frost
SURGEON:Mohomad Almaz, MD
DIAGNOSIS:Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle (claviculectomy). 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.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital
visit for patient Larry Frost:

ICD-9-CM: __________
Answer
Selected Answer:
715.31
Correct Answer:
715.31 (Osteoarthrosis, localized, shoulder)

RATIONALE: The diagnosis is stated in the Diagnosis section of the report to be degenerative arthritis and reported with 715.31 to indicate a localized osteoarthrosis of the shoulder. Question 10
Needs Grading

LOCATION:Outpatient, Hospital
PATIENT: Larry Frost
SURGEON: Mohomad Almaz, MD
DIAGNOSIS: Localized degenerative arthritis, left distal clavicle, with persistence of arthritic symptoms OPERATIVE PROCEDURE: Removal of distal 1 cm (centimeter) left clavicle (claviculectomy). 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.

Identify the correct procedure (CPT-4) code(s) for the outpatient hospital visit for patient Larry Frost:

CPT-4: __________ Modifier: __________
Answer
Selected Answer:
23120-LT
Correct Answer:
23120-LT (Claviculectomy, Partial)

RATIONALE: The key to correctly reporting this service is to be able to translate the removal of a portion of the left clavicle into a claviculectomy. Once this is done the code can be located in the index of the CPT manual and reported with 23120 with modifier -LT to indicate the


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