Code the Following Report Read the following report and enter the proper code(s) in the blank(s) provided.
Question:
Code the Following Report
Read the following report and enter the proper code(s) in the blank(s) provided. Remember to code for ICD-10-CM, CPT, and HCPCS codes. If a specific category of code is not applicable please leave the box blank.
Code the operative report as if you work for the surgeon.
Operative Report
PREOPERATIVE DIAGNOSIS: Right shoulder impingement syndrome with rotator cuff tear.
POSTOPERATIVE DIAGNOSIS: Right shoulder impingement syndrome with rotator cuff tear.
OPERATION: 1) Right shoulder acromioplasty. 2) Right rotator cuff repair. 3) Excision of 1 cm nodule on the right elbow.
SURGEON: Dr. ___ [NAME].
ASSISTANT: ___ [NAME], PA-C
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 100 cc.
IV FLUIDS: 2000 cc.
INDICATIONS: This patient is a middle-aged gentleman with right shoulder pain for the past one year. He has noticed increasing pain and weakness of his right shoulder, as well as limited motion over the past few months. This has not responded to conservative treatment with medications and physical therapy.
PROCEDURE: After administration of general anesthesia, the patient was placed in a beachchair position. The right shoulder was prepped with Betadine scrubbing solution and draped with sterile towels in the usual manner. The right elbow nodule was also examined. This was not attached to the deeper structures or the skin and it felt like an epidermal inclusion cyst. The patient had requested removal due to pain or tenderness over this nodule. The right shoulder was approached through an incision over the acromion. This was 1 cm lateral to the AC joint and extended toward the coracoid process. A 6 to 7 cm incision was made down to the deltoid fascia. The deltoid was incised from the AC joint laterally to the tip of the acromion. Full-thickness anterior and posterior flaps were raised and the subacromial space entered. The supraspinatus tear was immediately noted. This was partial- thickness, but at least 75% of the thickness of the acromial surface was torn. There was a large hook on the acromion anteriorly. The acromioplasty was done by first removing 5 to 7 mm of the anterior acromion and then removing the deep half of the anterior part of the acromion. A rasp was used to smooth the undersurface and this completed the acromioplasty. It was felt that the subacromial decompression was adequate. The rotator cuff was then debrided and a trough made in the greater tuberosity just posterior to the biceps tendon. Three drill holes were made into the greater tuberosity and using towel clips and a curved needle, #2 Ethibond was passed through the rotator cuff and then through the drill holes. A total of four strands were passed through the three holes and tied over the bone to complete the rotator cuff repair. Reinforcing stitches were placed anteriorly and posteriorly to complete the supraspinatus repair. The subscapular and the infraspinatus were found to be intact. The wound was thoroughly irrigated with saline. Redundant bursa was excised. Following this, the anterior deltoid was repaired to the anterior part of the acromion through three drill holes, once again using #2 Ethibond suture. After this repair was completed, it was once again irrigated and closed in layers using 3-0 Vicryl for subcutaneous tissue and 4-0 Monocryl for the skin. Steri-Strips were applied. The nodule over the elbow was excised through a 2 cm incision which was deepened to the subcutaneous tissue. The nodule was grasped with tissue holding forceps and using a Metzenbaum scissors it was removed in its entirety. The deep surface did not have any evidence of cyst or tumor. The wound was irrigated thoroughly and closed using 3-0 Vicryl for subcutaneous tissue and 4-0 Monocryl for the skin. A sterile dressing was applied to both incisions and the patient placed in a shoulder/arm immobilizer. He was then transferred to the recovery room in stable condition.
Income Tax Fundamentals 2013
ISBN: 9781285586618
31st Edition
Authors: Gerald E. Whittenburg, Martha Altus Buller, Steven L Gill