Instead of billing 87505-87507, could we bill 87798 if we are only looking for ONE organism offered in 87505-87507?
thanks!
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Tag Archives: Opinions
Other Auditiors opinions on HPI status of Chronic conditions
Hello,
I was doing a nursing home audit for two providers and there was differences of opinion as to what qualifies as a status of the chronic conditions. There documentation in the HPI is the patient is being seen for their monthly visit. Chronic problems being followed are diabetes, HTN, Hyperlipidemia, dementia, and Parkinson’s disease. Nursing reports no new questions or concerns at this time. There have been no new interval complaints from last seen. They are saying when the document "no new interval complaints" that is the status of the patient’s chronic conditions. To me that does not seem like a status–it is they have not had any acute issues since last time. Maybe I am thinking wrong???:confused:
Any help would be appreciated!!
op note need opinions please
PREOPERATIVE DIAGNOSES: 1. Significantly enlarged torus mandibularis of
the bilateral mandible.
2. Compression of salivary outflow.
POSTOPERATIVE DIAGNOSES: 1. Significantly enlarged torus mandibularis of
the bilateral mandible.
2. Compression salivary outflow.
3. Significant floor of mouth edema
postoperatively.
PROCEDURES PERFORMED: 1. Submucous resection of osseous, benign oral
cavity lesion, greater than 5 cm bilaterally.
2. Placement of bolster on the left.
.
COMPLICATIONS: The surgery went as planned submucous
resection of the osseous lesions was conducted. Unfortunately after the conclusion of the case, the
patient was noted to have significant postoperative swelling of floor of mouth, such that it was felt unsafe
to extubate the nasotracheal tube. The decision was made to do a direct doctor to doctor transfer to the
surgical ICU at St. Joseph’s Hospital and Medical Center. This was performed and the patient was taken
under the care of Dr. Wright and his team. The plan will be to have the patient monitored, diuresed and
treated with high-dose steroids to get the swelling to subside prior to control the extubation. This would be
anticipated to occur within the next 24 to 48 hours. The plan of care was addressed with the patient’s
family and their consent was given to proceed forward. I was participatory and present for this entire
process.
the bilateral mandible.
2. Compression of salivary outflow.
POSTOPERATIVE DIAGNOSES: 1. Significantly enlarged torus mandibularis of
the bilateral mandible.
2. Compression salivary outflow.
3. Significant floor of mouth edema
postoperatively.
PROCEDURES PERFORMED: 1. Submucous resection of osseous, benign oral
cavity lesion, greater than 5 cm bilaterally.
2. Placement of bolster on the left.
.
COMPLICATIONS: The surgery went as planned submucous
resection of the osseous lesions was conducted. Unfortunately after the conclusion of the case, the
patient was noted to have significant postoperative swelling of floor of mouth, such that it was felt unsafe
to extubate the nasotracheal tube. The decision was made to do a direct doctor to doctor transfer to the
surgical ICU at St. Joseph’s Hospital and Medical Center. This was performed and the patient was taken
under the care of Dr. Wright and his team. The plan will be to have the patient monitored, diuresed and
treated with high-dose steroids to get the swelling to subside prior to control the extubation. This would be
anticipated to occur within the next 24 to 48 hours. The plan of care was addressed with the patient’s
family and their consent was given to proceed forward. I was participatory and present for this entire
process.
INDICATION FOR PROCEDURE: Janet is a pleasant 80-year-old white female with history of
extremely large torus mandibulari of the bilateral mandible. These have grown to an extent that they are
causing compression on the floor of the mouth structures and salivary outflow tracts and also becoming
extremely uncomfortable to her. Her voice is changing. Her airway has been stable. After discussing
various options and obtaining CT imaging, the decision was made in conjunction with the patient’s wishes
to proceed forward with the surgical debulking via transoral submucous route. The risks of the procedure
discussed did include bleeding, floor of the mouth hematoma, infection, damage to the salivary ducts or
glands, damage to the lingual nerve, taste change, difficulty moving the tongue, change in the ability to
swallow, aspiration, pneumonia, swelling, airway compromise. Understanding these risks, Janet did wish
to proceed forward.
DESCRIPTION OF PROCEDURE: The patient was identified in the holding area. All consents and
paper work were up-to-date and complete. She was wheeled to the operative suite in stable condition. A
nasotracheal intubation was conducted without incident. The head of bed was rotated 90 degrees. A full
time-out was taken. The oral cavity was exposed using a Smiley mouthgag. A single silk stitch was
placed through the midline at the tip of the tongue in the raphe and secured to pull the tongue out of the
way of the surgery and prevent trauma from drilling. Starting on the right and then proceeding to the left,
mucosal incisions were made with a Colorado needle tip Bovie taking care to preserve this mucosa to the
greatest extent possible. Mucosa flaps were elevated, exposing the extremely large tori bilaterally. It
turned out that these were actually multifocal lesions. There was two on the right and three on the left.
The posterior most lesions were extremely large. At this point, the microscope was brought into the field
and using various cutting and diamond burs, the tori were dissected from an inside out fashion. The tori on
the right especially had developed a form of soft tissue. I suspect this was a narrowest space. As the
soft tissue was taken, biopsied and sent across the street to the histopathology lab at St Joseph Hospital
and Medical Center. Hemostasis was excellent. The entirety of the tori visible was removed. Great care
was taken not to violate the dental roots or the overlying mucosa. When the tori were removed, the
mucosa was re-approximated with simple interrupted stitches in a semi-watertight fashion. Decision to
place a bolster was made. This was done on the left side, secured with silk stitches, sutured around the
mandibular molars. At this point in the case, we were preparing to wrap up and extubate the patient on
one final inspection and with plans to suction the oropharynx and esophagus, it was noted that the patient
had significant floor of mouth edema that had erupted after removal of these tori. We thought by myself,
the attending surgeon that the chronic compression of the tori on the soft tissues of the floor of mouth had
allowed for fresh third spacing edema phenomenon to occur once they were removed. This was
exaggerated enough that given the patient’s advanced age and history of atrial fibrillation, we did not want
to take a chance of potentially losing an airway. The decision was made at this point by myself and in
conjunction after full discussion and disclosure with the family to transfer across the street at St. Joseph’s
Hospital and Medical Center via ambulance to the surgical ICU. A doctor to doctor conversation was
conducted between myself and Dr. Wright, who was the accepting physician. Plan of care will be to have
Janet diuresed, treated with high-dose steroids and H2 blockers to see if we can get this edema to subside
in lieu of a planned and controlled extubation. I was scrubbed and participatory and present for this entire
process and the procedure.
op note need opinions please
hi, can i get some opinions on what you all would code from this? would you code for a removal and reimplantation of the spinal stimulator device or would this be included in flap reconstruction. ive posted this in the plastics and outpatient facility. not having any luck so thought i would post her since this is general surgery maybe someone can give an opinion… thanks
PREOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
POSTOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
PROCEDURE PERFORMED: 1. Excision of open posterior cervical wound
12cm2.
2. Removal and reimplantation of spinal
stimulator device.
3. LEFT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
4. RIGHT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
5. 8 cm complex closure of open wound of
neck.
DESCRIPTION OF PROCEDURE: After the patient was brought to the operating room and
carefully positioned on the operating table and safely and effectively secured to the table and padded in all
areas to avoid any injury to them the patient was then safely and effectively anesthetized. Patient was
kept warm throughout the procedure and monitored carefully as well by the anesthesiologist.
The patient was positioned with the LEFT side up and the RIGHT side down and secured to the table
safely.
The operative areas were then prepared with antiseptic thoroughly and draped sterilely.
The operative areas were then carefully injected with 0.25% Marcaine with epinephrine for intraoperative
hemostasis and postoperative pain control as well.
This open wound of the midline posterior cervical soft tissue was excised with a very small 0.5 cm3
abscess in an extramarginal fashion approximately 12 cm2 removing all the inflammatory exudate of the
skin and subcutaneous tissue superficial and deep fascia, muscle and the devascularized soft tissue in this
area utilizing sharp instruments including scalpel, sharp curettage, scissors, cautery and double action sharp
rongeurs and then widely and copiously irrigating this with Betadine throughout the excision in preparation
for soft tissue reconstruction. In doing so a secondary defect was created in addition to the primary defect
created by the excision of the wound to allow local transposition of soft tissue in a favorable way for
reconstruction of the wound to minimize the contour defect and the deformity and distracting nature of the
defect as well as optimizing the vascular inflow and venous drainage to the soft tissue ultimately used for
reconstruction. No abscess was seen. The eschar was removed in its entirety. With careful dissection this
stimulator paddle approximate 4 cm long was then withdrawn from its long narrow pathway into which
there was this inflammatory material that appeared to be the nidus of infection. This entire tract was then
extirpated of its soft tissue inflammatory element back to well vascularized uninjured tissue. This track
was then irrigated with Betadine and packed with vancomycin. The paddle itself and the base of the wire
were irrigated copiously with I3etadine throughout the procedure to sterilize this as well. There are other
small elements of wire that did not appear to be involved in this infectious process as most of the coil the
wire well incorporated of the scar over time. The tissue removed from the depth of this wound was then
sent to the laboratory for quantitative culture and sensitivity. I inquired whether the patient had any
ALLERGY to vancotnycin and no allergy is known or documented by the family or patient to this
medication. The wound was then also treated internally with lyophilized vancomycin powder placed into
the depths of the wound on all surfaces for ftjrther antisepsis locally in the deep tissue planes prior to
closure of the wound.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the LEFT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type V classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20 cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after identifying and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20cm2 to obliterate the deep space created by the open wound and
the underlying strucfttres which required well vascularized soft tissue coverage for ultimate reconstruction
and healing of this complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the RIGHT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after idenri1ing and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20 cm2 to obliterate the deep space created by the open wound and
the underlying structures which required well vascularized soft tissue coverage for ultimate reconstruction
and healing ofthis complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
The 2 separate 20 cm2 tissue composites were then transposed 20 cm2 and imbricated across the midline
of the open wound of the posterior cervical wound 12 cm2 closing the primary and secondary defects
created by the original wound and the mobilization and transpositions utilizing 2-0 Monocryl plus inverted
simple suture materiai every 2-3 mm for a watertight well vascularized soft tissue closure overlying the
deep tissues creating an accurately reconstructed tensionless closure over the posterior cervical wound.
The wound was then closed further at the more superficial elements approximately 8 cm using a complex
multilayer running 4-0 nylon to the skin followed and interposed by 4-0 nylon wider longer simple suture
material for further security the closure of the wound every 4mm.
The wound was then sealed with dermal glue and Steri-Strips.
The patient did well and was brought to the recovery area in good condition having tolerated procedure
well. No complications occurred during or after the operation. The patient was stable in the PACU.
All postoperative orders are written extensively for the patient for their immediate and long-term care.
I spoke with her mother in detail postoperatively and she was very happy with her care.
Prescriptions, postoperative orders, care instructions and follow-up appointment had already been given to
the patient previously. She did very well the recovery area. She is happy with her care. Were delighted to
help her today.
op note need opinions please
hi, can i get some opinions on what you all would code from this? would you code for a removal and reimplantation of the spinal stimulator device or would this be included in flap reconstruction.
PREOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
POSTOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
PROCEDURE PERFORMED: 1. Excision of open posterior cervical wound
12cm2.
2. Removal and reimplantation of spinal
stimulator device.
3. LEFT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
4. RIGHT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
5. 8 cm complex closure of open wound of
neck.
DESCRIPTION OF PROCEDURE: After the patient was brought to the operating room and
carefully positioned on the operating table and safely and effectively secured to the table and padded in all
areas to avoid any injury to them the patient was then safely and effectively anesthetized. Patient was
kept warm throughout the procedure and monitored carefully as well by the anesthesiologist.
The patient was positioned with the LEFT side up and the RIGHT side down and secured to the table
safely.
The operative areas were then prepared with antiseptic thoroughly and draped sterilely.
The operative areas were then carefully injected with 0.25% Marcaine with epinephrine for intraoperative
hemostasis and postoperative pain control as well.
This open wound of the midline posterior cervical soft tissue was excised with a very small 0.5 cm3
abscess in an extramarginal fashion approximately 12 cm2 removing all the inflammatory exudate of the
skin and subcutaneous tissue superficial and deep fascia, muscle and the devascularized soft tissue in this
area utilizing sharp instruments including scalpel, sharp curettage, scissors, cautery and double action sharp
rongeurs and then widely and copiously irrigating this with Betadine throughout the excision in preparation
for soft tissue reconstruction. In doing so a secondary defect was created in addition to the primary defect
created by the excision of the wound to allow local transposition of soft tissue in a favorable way for
reconstruction of the wound to minimize the contour defect and the deformity and distracting nature of the
defect as well as optimizing the vascular inflow and venous drainage to the soft tissue ultimately used for
reconstruction. No abscess was seen. The eschar was removed in its entirety. With careful dissection this
stimulator paddle approximate 4 cm long was then withdrawn from its long narrow pathway into which
there was this inflammatory material that appeared to be the nidus of infection. This entire tract was then
extirpated of its soft tissue inflammatory element back to well vascularized uninjured tissue. This track
was then irrigated with Betadine and packed with vancomycin. The paddle itself and the base of the wire
were irrigated copiously with I3etadine throughout the procedure to sterilize this as well. There are other
small elements of wire that did not appear to be involved in this infectious process as most of the coil the
wire well incorporated of the scar over time. The tissue removed from the depth of this wound was then
sent to the laboratory for quantitative culture and sensitivity. I inquired whether the patient had any
ALLERGY to vancotnycin and no allergy is known or documented by the family or patient to this
medication. The wound was then also treated internally with lyophilized vancomycin powder placed into
the depths of the wound on all surfaces for ftjrther antisepsis locally in the deep tissue planes prior to
closure of the wound.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the LEFT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type V classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20 cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after identifying and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20cm2 to obliterate the deep space created by the open wound and
the underlying strucfttres which required well vascularized soft tissue coverage for ultimate reconstruction
and healing of this complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the RIGHT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after idenri1ing and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20 cm2 to obliterate the deep space created by the open wound and
the underlying structures which required well vascularized soft tissue coverage for ultimate reconstruction
and healing ofthis complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
The 2 separate 20 cm2 tissue composites were then transposed 20 cm2 and imbricated across the midline
of the open wound of the posterior cervical wound 12 cm2 closing the primary and secondary defects
created by the original wound and the mobilization and transpositions utilizing 2-0 Monocryl plus inverted
simple suture materiai every 2-3 mm for a watertight well vascularized soft tissue closure overlying the
deep tissues creating an accurately reconstructed tensionless closure over the posterior cervical wound.
The wound was then closed further at the more superficial elements approximately 8 cm using a complex
multilayer running 4-0 nylon to the skin followed and interposed by 4-0 nylon wider longer simple suture
material for further security the closure of the wound every 4mm.
The wound was then sealed with dermal glue and Steri-Strips.
The patient did well and was brought to the recovery area in good condition having tolerated procedure
well. No complications occurred during or after the operation. The patient was stable in the PACU.
All postoperative orders are written extensively for the patient for their immediate and long-term care.
I spoke with her mother in detail postoperatively and she was very happy with her care.
Prescriptions, postoperative orders, care instructions and follow-up appointment had already been given to
the patient previously. She did very well the recovery area. She is happy with her care. Were delighted to
help her today.
op note need opinions please
hi, can i get some opinions on what you all would code from this? would you code for a removal and reimplantation of the spinal stimulator device or would this be included in flap reconstruction.
PREOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
POSTOPERATIVE DIAGNOSIS: Posterior cervical pain stimulator device wound
recurrent.
PROCEDURE PERFORMED: 1. Excision of open posterior cervical wound
12cm2.
2. Removal and reimplantation of spinal
stimulator device.
3. LEFT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
4. RIGHT lateral neck fasciocutaneous tissue
composite reconstruction 20 cm2.
5. 8 cm complex closure of open wound of
neck.
DESCRIPTION OF PROCEDURE: After the patient was brought to the operating room and
carefully positioned on the operating table and safely and effectively secured to the table and padded in all
areas to avoid any injury to them the patient was then safely and effectively anesthetized. Patient was
kept warm throughout the procedure and monitored carefully as well by the anesthesiologist.
The patient was positioned with the LEFT side up and the RIGHT side down and secured to the table
safely.
The operative areas were then prepared with antiseptic thoroughly and draped sterilely.
The operative areas were then carefully injected with 0.25% Marcaine with epinephrine for intraoperative
hemostasis and postoperative pain control as well.
This open wound of the midline posterior cervical soft tissue was excised with a very small 0.5 cm3
abscess in an extramarginal fashion approximately 12 cm2 removing all the inflammatory exudate of the
skin and subcutaneous tissue superficial and deep fascia, muscle and the devascularized soft tissue in this
area utilizing sharp instruments including scalpel, sharp curettage, scissors, cautery and double action sharp
rongeurs and then widely and copiously irrigating this with Betadine throughout the excision in preparation
for soft tissue reconstruction. In doing so a secondary defect was created in addition to the primary defect
created by the excision of the wound to allow local transposition of soft tissue in a favorable way for
reconstruction of the wound to minimize the contour defect and the deformity and distracting nature of the
defect as well as optimizing the vascular inflow and venous drainage to the soft tissue ultimately used for
reconstruction. No abscess was seen. The eschar was removed in its entirety. With careful dissection this
stimulator paddle approximate 4 cm long was then withdrawn from its long narrow pathway into which
there was this inflammatory material that appeared to be the nidus of infection. This entire tract was then
extirpated of its soft tissue inflammatory element back to well vascularized uninjured tissue. This track
was then irrigated with Betadine and packed with vancomycin. The paddle itself and the base of the wire
were irrigated copiously with I3etadine throughout the procedure to sterilize this as well. There are other
small elements of wire that did not appear to be involved in this infectious process as most of the coil the
wire well incorporated of the scar over time. The tissue removed from the depth of this wound was then
sent to the laboratory for quantitative culture and sensitivity. I inquired whether the patient had any
ALLERGY to vancotnycin and no allergy is known or documented by the family or patient to this
medication. The wound was then also treated internally with lyophilized vancomycin powder placed into
the depths of the wound on all surfaces for ftjrther antisepsis locally in the deep tissue planes prior to
closure of the wound.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the LEFT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type V classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20 cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after identifying and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20cm2 to obliterate the deep space created by the open wound and
the underlying strucfttres which required well vascularized soft tissue coverage for ultimate reconstruction
and healing of this complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
An extensive remobilization re-elevation and further transposition of a fasciocutaneous flap tissue
composite was then elevated on the RIGHT lateral aspect of the neck which included dissection and
counter incisions of the deep fascia extensively 20 cm2 including detachment of the fascia and skin from
its origin and inserted deep structures and portions of the proximal and distal elements of the musculature.
This flap is a Type classification flap. This allowed the tissue composite flap to be advanced, transposed
and rotated 20cm2 with preservation and respect of the flaps axial based upon the posterior cervical
artery and vein perforating vessels and secondary perforating blood supply after idenri1ing and avoiding
the ingress and egress posterior cervical artery and vein perforating vessels throughout the dissection. No
innervation was identified or was relevant to this tissue advancement as a neurotized flap was not
indicated for the reconstruction however the motor nerves to the musculature itself were preserved. The
overlying skin and subcutaneous tissue was preserved with its cutaneous vascular perforators from the
fascial portion of this advancement flap tissue composite to create the fasciocutaneous flap tissue
composite for reconstruction of this open wound. This mass of the tissue composite flap and overlying soft
tissue was mobilized and transposed 20 cm2 to obliterate the deep space created by the open wound and
the underlying structures which required well vascularized soft tissue coverage for ultimate reconstruction
and healing ofthis complicated deep wound. This soft tissue composite flap was then inset within its arc of
rotation.
The 2 separate 20 cm2 tissue composites were then transposed 20 cm2 and imbricated across the midline
of the open wound of the posterior cervical wound 12 cm2 closing the primary and secondary defects
created by the original wound and the mobilization and transpositions utilizing 2-0 Monocryl plus inverted
simple suture materiai every 2-3 mm for a watertight well vascularized soft tissue closure overlying the
deep tissues creating an accurately reconstructed tensionless closure over the posterior cervical wound.
The wound was then closed further at the more superficial elements approximately 8 cm using a complex
multilayer running 4-0 nylon to the skin followed and interposed by 4-0 nylon wider longer simple suture
material for further security the closure of the wound every 4mm.
The wound was then sealed with dermal glue and Steri-Strips.
The patient did well and was brought to the recovery area in good condition having tolerated procedure
well. No complications occurred during or after the operation. The patient was stable in the PACU.
All postoperative orders are written extensively for the patient for their immediate and long-term care.
I spoke with her mother in detail postoperatively and she was very happy with her care.
Prescriptions, postoperative orders, care instructions and follow-up appointment had already been given to
the patient previously. She did very well the recovery area. She is happy with her care. Were delighted to
help her today.
E/M Update Opinions Shared at Listening Session
A representative from the Hospital and Ambulatory Policy Group at the Centers for Medicare & Medicaid Services (CMS) held a listening session regarding proposed updates to the documentation guidelines for evaluation and management (E/M) services on March 21st. The listening session was to get feedback from stakeholders on policy proposals for upcoming notice and comment […]
AAPC Knowledge Center
Opinions on coding the following procedure: we came up with 27405 & 27331. Thanks
PREOPERATIVE DIAGNOSIS(ES): Dehiscences of the left knee wound.
POSTOPERATIVE DIAGNOSIS(ES): Dehiscences of the left knee wound.
OPERATION: Irrigation and debridement the soft tissue repair and closure of
the left knee wound.
INDICATIONS FOR SURGERY: This 83-year-old female was about 3 weeks after
revision of her total knee replacement. Patient developed some dehiscence in
the wound with a small amount of drainage, with no redness around the
incision.
DESCRIPTION OF PROCEDURE: With the patient on the OR table, under general
anesthesia, the dressing was removed. The wound was assessed. Several
cultures were taken, deep and superficial, and were submitted for aerobic and
anaerobic Gram stain examination. Following that, intravenous antibiotic was
administered and the leg was prepped and draped in a sterile fashion. Time-
out was called. The patient was identified and the surgical site was
confirmed. Risk factors and allergies were discussed. As I stated earlier,
intravenous antibiotic was administered and we then extended the wound a
little bit proximally to get into some healthy tissues by blunt dissection.
The skin was separated from subcutaneous tissues and I realized that the
defect was actually in the capsule repair medially. We mobilized some of the
capsule medially and since we did have reasonable tissue laterally, I thought
we will be able to repair it snugly. We then used a pressure irrigation
system and we used a little bit over a liter of the antibiotic solution with
the pressure irrigation system to irrigate the wound. Once irrigation was
completed, we used the #2 FiberWire suture to repair the capsule, which
actually came together very nicely. We then irrigated the wound with the
pressure irrigation system one more time and used subcutaneous 0 Vicryl
sutures to approximate the skin. Following that, we used the 0 nylon type
suture to close the skin with multiple interrupted sutures in a vertical
mattress fashion. A very good repair was obtained. There was no drainage
coming from the wound. Aquacel dressing was applied. The patient was then
awakened and extubated in the operating room and moved to the recovery room
in satisfactory condition, tolerating the procedure well.
Looking for opinions on capsule reading and billing global
Good Afternoon All,
If a provider is buying the capsule cams, has the download center equipment and is paying someone to read their capsule but then reading it themselves and signing the note that the provider read the test; would this be allowed in order to bill globally?
I was told if the contractor that is being used is a 1099 employee of the practice then this would allow us to bill globally?
Would really like to get opinions and thoughts.
Any help is greatly appreciated!
Opinions on Coding Please-Unable to Perform Hysteroscopy
1. A small uterus on exam under anesthesia with no adnexal masses. 2. Cervical stenosis precluding hysteroscopy or sampling with an endometrial
biopsy Pipelle.
STATEMENT OF MEDICAL NECESSITY: This is a 45-year-old, G-1, P-0, A-1 female with no pertinent medical history, who initially presented to clinic with a diagnosis of postmenopausal bleeding, however, upon laboratory review, FSH levels are more consistent with perimenopausal bleeding. The patient also has a thickened endometrial stripe and inability to obtain sufficient tissue sample on endometrial biopsies in clinic. The sonogram also revealed a 1.6 cm polyp versus submucosal fibroid within the endometrium. The plan was for a diagnostic hysteroscopy with a possible polypectomy and D and C. The procedural risks, benefits, alternatives, and indications were reviewed with the patient.
*
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was established. The patient was placed in dorsal lithotomy position using Allen stirrups, ensuring proper positioning and cushioning to avoid nerve injury. Exam under anesthesia was performed with the findings noted above. Straight catheterization of the bladder was removed. The patient was prepped and draped in the usual sterile fashion. A weighted speculum was inserted into the posterior vaginal fornix and anterior right angle retractor was used to expose the cervix. A single tooth tenaculum was attached to the anterior lip of the cervix to assist with insertion of the hysteroscope. In preparation for hysteroscopy, normal saline was chosen as the distention medium and the pressure setting was set to 66 mmHg based on the patient’s mean arterial pressure. The hysteroscope was primed with the chosen media and focus obtained. Attempted cervical dilation began using the Hagar dilator, however, dilation was not able to be obtained with this method and we then used uterine dressing forceps to attempt cervical dilation. Given the extent of cervical stenosis, we then attempted using a lacrimal duct dilator, however, again, due to the cervical stenosis, it was felt that we were unable to sufficiently dilate the cervix to the point that we could insert the hysteroscope or/and endometrial biopsy Pipelle. The surgery was stopped at this point and the tenaculum was removed from the cervix, the weighted speculum was removed, and the patient was returned to the supine position. There was no fluid deficit due to the hysteroscope not being inserted into the uterus due to the cervical stenosis. The patient was extubated without difficulty and transferred to the recovery room in good condition. There were no
anesthetic or surgical complications. Sponge and instruments were correct.
biopsy Pipelle.
STATEMENT OF MEDICAL NECESSITY: This is a 45-year-old, G-1, P-0, A-1 female with no pertinent medical history, who initially presented to clinic with a diagnosis of postmenopausal bleeding, however, upon laboratory review, FSH levels are more consistent with perimenopausal bleeding. The patient also has a thickened endometrial stripe and inability to obtain sufficient tissue sample on endometrial biopsies in clinic. The sonogram also revealed a 1.6 cm polyp versus submucosal fibroid within the endometrium. The plan was for a diagnostic hysteroscopy with a possible polypectomy and D and C. The procedural risks, benefits, alternatives, and indications were reviewed with the patient.
*
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was established. The patient was placed in dorsal lithotomy position using Allen stirrups, ensuring proper positioning and cushioning to avoid nerve injury. Exam under anesthesia was performed with the findings noted above. Straight catheterization of the bladder was removed. The patient was prepped and draped in the usual sterile fashion. A weighted speculum was inserted into the posterior vaginal fornix and anterior right angle retractor was used to expose the cervix. A single tooth tenaculum was attached to the anterior lip of the cervix to assist with insertion of the hysteroscope. In preparation for hysteroscopy, normal saline was chosen as the distention medium and the pressure setting was set to 66 mmHg based on the patient’s mean arterial pressure. The hysteroscope was primed with the chosen media and focus obtained. Attempted cervical dilation began using the Hagar dilator, however, dilation was not able to be obtained with this method and we then used uterine dressing forceps to attempt cervical dilation. Given the extent of cervical stenosis, we then attempted using a lacrimal duct dilator, however, again, due to the cervical stenosis, it was felt that we were unable to sufficiently dilate the cervix to the point that we could insert the hysteroscope or/and endometrial biopsy Pipelle. The surgery was stopped at this point and the tenaculum was removed from the cervix, the weighted speculum was removed, and the patient was returned to the supine position. There was no fluid deficit due to the hysteroscope not being inserted into the uterus due to the cervical stenosis. The patient was extubated without difficulty and transferred to the recovery room in good condition. There were no
anesthetic or surgical complications. Sponge and instruments were correct.
Opinions on what to bill for please & thank you!
Marylou