Assign the ICD-10 and Anesthesia codes
Assign the ICD-10 and Anesthesia codes
1. The patient’s physical status was -P5. Anesthesiologist and CRNA services are each medically necessary in this anesthesia case.
1. 28 week gestational age infant
2. Extremely low birthweight infant (780 gram).
3. Severe hydrocephalus with unknown neurologic status.
4. Esophageal atresia/distal tracheoesophageal fistula.
5. Respiratory failure
6. Possible ventriculoseptal defect.
POSTOPERATIVE DIAGNOSES: Same. PROCEDURE: Stamm gastrostomy. ANESTHESIA: General endotracheal ESTIMATED BLOOD LOSS: Minimal COMPLICATIONS: None
2. The anesthesia service was performed by the CRNA without medical direction. The patient’s physical status was -P3.
PREOPERATIVE DIAGNOSIS: 25% body surface area burns on face, posterior neck, trunk, bilateral upper extremities, hands, left foot and ankle. The total body surface area addressed was 15% which were third degree burns.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES:
1. Split-thickness skin graft, left upper back 14 x 6 cm.
2. Sheath split-thickness skin graft, left ankle 6 x 2 cm.
ANESTHESIA: General.
3. The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 2 concurrent cases. The patient’s physical status was -P3. The CRNA placed an arterial line in the right radial artery and a central line in the left IJ (internal jugular vein) at the start of the case. The base value for 00563 is 25 and the base value for 00562 is 20.
PREOPERATIVE DIAGNOSIS: Bicuspid aortic valve status post aortic valve replacement with recurrent aortic insufficiency. POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Modified Ross procedure. Pulmonary autograft replacement of the aortic valve. Placement of pulmonary autograft within a 29-mm sinus of valsalva graft. Replacement of pulmonary root with 26-mm pulmonary homograft. ANESTHESIA: General.
4. The anesthesiologist, Dr. Larson, personally provided lumbar spinal anesthesia in the operating room prior to surgery and monitored the patient throughout the case. The patient’s physical status was -P3. PREOPERATIVE DIAGNOSIS: Necrotic left foot. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Left above-knee amputation.
PROCEDURE: Mr. Firestone was brought to the operating theater and placed in supine position on the operating table. Preoperative briefing was performed. After receiving spinal anesthesia he was prepped and draped in sterile fashion. Time out was performed. Fishmouth incision lines were marked out on the left leg for transection of the femur approximately 10 cm above the condyles. Incision was made. Dissection was carried down through the subcutaneous tissues, down through the fascia, and down through the muscles. We went through the quadriceps first. We then came down onto the femur. We utilized a Harmonic scalpel for division of the muscle bundles. We used a periosteal elevator in the femur. Transected the femur Gigli saw 10 cm proximal from the femoral condyles. I isolated, clamped, and transected the femoral vessels and ligated these with 2-0 Vicryl proximally with one being on a pass and one being on a stick-tie. We then used guillotine knife to transect the posterior muscle bundle/hamstrings. The leg was handed off the table as a specimen. Sciatic nerve was anesthetized locally with 0.5% Marcaine after grabbing it and retracting it outward. This was infiltrated up high/proximal. It was then clamped. It was transected. It was ligated and tied with 2-0 Vicryl and allowed to retract proximally. Any bleeding points of the muscle were oversewn with 3-0 Vicryl in a figure-of-eight fashion. Bone rasp was used on the femur. Hemostasis was present. I irrigated out the wound with 3 liters of LR mixed with kanamycin and bacitracin utilizing an Ortholav system. Hemostasis was present. Myodesis was performed in layers around the muscle bundles around the femur. The skin was closed with staples. Sterile dressings, Xeroform, fluffs, and Ace wrap were applied. He tolerated the procedure well and went to the recovery room in stable condition. I met with the patient’s family postoperatively to discuss the operative findings.
Pathology Report Later Indicated: Necrotic lower leg tissue.
5. The anesthesia service was performed by the CRNA with an anesthesiologist medically directing 4 concurrent cases. The patient’s physical status was-P1. The CRNA inserted an arterial line prior to the start of the case. PREOPERATIVE DIAGNOSES: Sagittal synostosis. POSTOPERATIVE DIAGNOSES: Same.
PROCEDURE: Cranial vault remodeling with bilateral parasagittal strip craniectomies, barrel staving and internal fixation with absorbable plates and screws.
ANESTHESIA: General with endotracheal intubation. ESTIMATED BLOOD LOSS: 500 cc COMPLICATIONS: None.
FINDINGS: Extremely thin poorly mineralized calvarium with patent anterior fontanelle, extreme scaphocephaly, and no signs of increased intracranial pressure.
INDICATIONS: The patient is a healthy 9-month-old boy who was born at term and noted early on to have an abnormal head shape. He was referred for further evaluation after radiography proved sagittal synostosis. He has not developed any signs of increased intracranial pressure. He has been in good health otherwise.
6. The CRNA performed the caudal block specifically for postoperative pain control (requested by the surgeon). The report does not include the procedure note for the caudal block; presume that the block was performed in the holding area separate from the anesthesia for surgery and assign a code for the caudal block. This is an otherwise normal healthy male (-P1). Anesthesia was given by an anesthesiologist and CRNA. The anesthesiologist was medically directing 4 concurrent cases.
PREOPERATIVE DIAGNOSES:
1. Redundant prepuce.
POSTOPERATIVE DIAGNOSES:
1. Redundant prepuce.
PROCEDURE: CIRCUMCISION.
DESCRIPTION OF PROCEDURE: The patient was given general mask anesthetic as well as caudal block for postoperative pain control. The abdomen and genitalia were prepped with Betadine and draped in a sterile manner. Redundant prepuce was excised using a parallel circumferential incision technique, with the bipolar electrocautery only for hemostasis. The epithelial edges were reapproximated with interrupted 5-0 plain catgut, and Vaseline gauze was applied as a bandage. The procedure was discontinued, the patient having tolerated it well, the needle and sponge counts reported as correct, the estimated blood loss is less than 10 m
7. The CRNA provided the anesthesia service under the medical direction of an anesthesiologist who was medically directing only this one case. The physical status of the patient was -P3. PREOPERATIVE DIAGNOSIS: Hypertrophic pyloric stenosis. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE: Laparoscopic pyloromyotomy. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None.
INDICATIONS: Hayden is a 6 weeks old male with a history of progressive nonbilious emesis. He underwent an ultrasound that was consistent with pyloric stenosis. He presents for elective laparoscopic pyloromyotomy.
FINDINGS: The pylorus was hypertrophic and a laparoscopic pyloromyotomy was performed without complications.
8.The anesthesia service was performed by the CRNA with the anesthesiologist medically directing 2 concurrent cases. The patient is an otherwise normal healthy male infant (< one year of age ) with a -P1 physical status. Prior to surgery, the CRNA performed a caudal injection for postoperative pain control as ordered by the surgeon. Although the CRNA’s procedure note is not included in this case, assign a code for the caudal injection.
PREOPERATIVE DIAGNOSES:
1. Hypospadias.
2. Mild bilateral hydronephrosis by ultrasound.
3. Bifid scrotum.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES:
1. Hypospadias repair.
2. Scrotoplasty.
ANESTHESIA: General plus caudal.
DESCRIPTION OF PROCEDURE: Elvis, is a 4-week-old whom after meeting with his parents in the preop holding area, I identified the child, examined him, addressed their concerns, and we then proceeded back to the operating room where a “time-in” was held. General plus caudal anesthetic were accomplished without difficulty by Dr. Larson.
9. The anesthesiologist, Dr. Larson, personally provided the anesthesia care and inserted the TEE probe for monitoring during the case at the request of the surgeon. The patient’s physical status was -P3. The Base Unit Value for 00563 is 25 and for 00562 it is 20.
PREOPERATIVE DIAGNOSIS: Complete AV canal Rastelli A unbalanced to the right with a single mitral papillary muscle. POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Complete repair of AV canal unbalanced to the right. COMPLICATIONS: None.
INDICATIONS: This is a 7-month-old child with trisomy 21 and complete AV canal. Transthoracic and then transesophageal echo have confirmed this canal is unbalanced toward the right with multiple attachments to the crest of the ventricular septum consistent with an unbalanced AV canal Rastelli A. In addition, there appears to be a single left-sided papillary muscle. The patient now at 7 months of age is ready for complete repair.
10. A CRNA provided the anesthesia service and placed a TEE probe for monitoring. Dr. Larson was medically directing this case only. Dr. Larson inserted an arterial line in the left radial artery and a central line in the RIJ after the patient was anesthetized. This patient is assigned a status of -P3.
PREOPERATIVE DIAGNOSES:
1. History of coarctation, status post repair.
2. Ventricular septal defect.
3. Congenital mitral stenonsis.
POSTOPERATIVE DIAGNOSES: Same.
PROCEDURES:
1. Closure of ventricular septal defect using a Dacron patch.
2. Repair of mitral valve.
ANESTHESIA: General.
BRIEF PREOPERATIVE HISTORY: The patient is a 10-month-old female with the diagnoses as outlined above. Patch closure of her ventricular septal defect is indicated for release of her large left-to-right shunt, which is producing pulmonary hypertension. In addition, she has congenital mitral stenosis. I have met with the parents, discussed the planned procedure, indications, and risks with them. Their questions have been answered and they understand and agreed to proceed.
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