Right carpal tunnel syndrome Essay

The patient was placed in the supine place on the operating room tabular array. where her right manus and forearm were prepped with Betadine and draped in a unfertile manner. We infiltrated the thenar fold country with 1 % Lidocaine. and one time equal anaesthesia had been achieved. we exsanguinated the manus and forearm with an Esmarch patch. We so created a longitudinal scratch merely at the ulnar facet of the thenar fold and carried the dissection down through the hypodermic tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was wholly released. We identified the average nervus and found that it was free. We did distribute the soft tissues environing it gently.

We so released the compression bandage after 8 proceedingss of tourniquet clip. and hemorrhage was controlled with force per unit area and besides with electrocautery. We exhaustively irrigated the country with saline. We so closed the tegument utilizing 4-0 nylon sutura. and a Xeroform dressing was applied under a little force per unit area dressing. She was taken from the operating room in good status. She tolerated this really good.

Identify the right diagnosing ( ICD-9-CM ) codification ( s ) for the outpatient infirmary visit for patient Glory Ann Borden:

We Will Write a Custom Essay Specifically
For You For Only $13.90/page!


order now

ICD-9-CM: __________
Answer
Selected Answer:
354. 0
Correct Answer:
354. 0 ( Syndrome. carpal tunnel )




Rationale: The diagnosing is carpal tunnel syndrome as indicated by 354. 0.
Question 2
Needs Rating

Location: Outpatient. Hospital
Patient: Glory Ann Borden
Surgeon: Mohomad Almaz. MD
Diagnosis: Right wrist bone tunnel syndrome
PROCEDURE PERFORMED: Right wrist bone tunnel release
Procedure: The patient was placed in the supine place on the operating room tabular array. where her right manus and forearm were prepped with Betadine and draped in a unfertile manner. We infiltrated the thenar fold country with 1 % Lidocaine. and one time equal anaesthesia had been achieved. we exsanguinated the manus and forearm with an Esmarch patch. We so created a longitudinal scratch merely at the ulnar facet of the thenar fold and carried the dissection down through the hypodermic tissue. We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was wholly released. We identified the average nervus and found that it was free. We did distribute the soft tissues environing it gently.




We so released the compression bandage after 8 proceedingss of tourniquet clip. and hemorrhage was controlled with force per unit area and besides with electrocautery. We exhaustively irrigated the country with saline. We so closed the tegument utilizing 4-0 nylon sutura. and a Xeroform dressing was applied under a little force per unit area dressing. She was taken from the operating room in good status. She tolerated this really good.

Identify the right process ( CPT-4 ) codification ( s ) for the outpatient infirmary 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 subdivision of the study and substantiated within the organic structure of the study. ( “We identified the transverse carpal ligament and incised this both proximally and distally until we were certain that it was wholly released. ” ) This service is described with 64721 with modifier -RT added to bespeak right side.

Question 3
Needs Rating

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 aura




Indication: Fracture occurred when the patient was involved in an unspecified motor vehicle hit. It is known that Mr. Blake was the driver of the vehicle. Procedure: The patient’s caput was prepped and draped in the usual mode. The caput was shaved. The aura setup was applied with prison guards and four-points. Then the waistcoat was applied. The patient was so discharged to the recovery room to hold movies taken in the recovery room.

Identify the right diagnosing ( ICD-9-CM ) codification ( s ) for the outpatient infirmary visit for patient Josh Blake:

ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ ( intimation: this one is an E-Code! )
Answer
Selected Answer:
805. 01
805. 02
E819. 0
Correct Answer:
805. 01 ( Fracture. vertebrae/vertebral. cervical. first [ Atlass ] 805. 02 ( Fracture. vertebra/vertebral. cervical. 2nd
E819. 0 ( Accident. motor vehicle. driver )









Rationale: Each break site would be coded individually. The C1 break would be coded with 805. 01. and the C2 break with 805. 02. As reported in the Indication subdivision. this was an MVC of an unspecified nature. and the patient was the driver. E819 is the codification for MVC of unspecified nature with the 4th figure of 0 to demo the patient was driving.

Question 4
Needs Rating

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 aura




Indication: Fracture occurred when the patient was involved in an unspecified motor vehicle hit. It is known that Mr. Blake was the driver of the vehicle. Procedure: The patient’s caput was prepped and draped in the usual mode. The caput was shaved. The aura setup was applied with prison guards and four-points. Then the waistcoat was applied. The patient was so discharged to the recovery room to hold movies taken in the recovery room.

Identify the right process ( CPT-4 ) codification ( s ) for the outpatient infirmary
visit for patient Josh Blake:

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




Rationale: A cranial aura is applied to stabilise the patient’s cervix to mend C1 and C2 breaks. The application of the aura is coded with 20661.
Question 5
Needs Rating

LOCATlON: Outpatient. infirmary
Patients: May Leigh
Surgeon: Mohamad Almaz. MD
Preoperative DlAGNOSIS: Osteoarthritis. left articulatio genus.
Postoperative DIAGNOSIS: Lapp.
PROCEDURE PERFORMED: Left entire articulatio genus arthroplasty.
Anesthesia: General.
ESTIMATED BLOOD LOSS: Minimal






Following satisfactory preoperative reappraisal and appraisal and full treatment. the patient was brought to the operating room where under general anaesthesia scrutiny confirmed patient to show first-class visual aspect of her right sum articulatio genus and increased valgus and crepitus of the left articulatio genus. The left articulatio genus was so elevated. scrubbed. prepped and draped in the usual manner and using a standard midplane scratch the hypodermic tissues were dissected. the median retinaculum was opened and the implicit in articulatio genus articulation identified with advanced osteoarthritic alterations present. The distal thighbone. proximal shinbone and kneecap were resected in the normal manner leting first-class adjustment of a # 2 thighbone. a # 2 shinbone. an 8-tray insert. and a 31 kneecap. Excellent tantrum. stableness. and scope of gesture were achieved.
The articulatio genus articulation was exhaustively waterpiked and irrigated. the shinbone and thighbone firmly cemented into place followed by the kneecap.

Once once more. first-class tantrum. stableness. and scope were achieved. The articulatio genus articulation was drained with two deep suction Hemovacs. The median retinaculum was closed with 0 Vicryl. hypodermic closing with 2-0 Vicryl. cutaneal borders approximated with 4-0 Ethilon in perpendicular mattress manner. and a unfertile dressing was applied. The patient tolerated the process good and returned to PAR in satisfactory status. There were no intraoperative complications. Sponge and needle count correct.

Identify the right diagnosing ( ICD-9-CM ) codification ( s ) for the outpatient infirmary visit for patient May Leigh:

ICD-9-CM: __________
Answer
Selected Answer:
715. 96
Correct Answer:
715. 96 ( Osteoarthrosis. lower leg )




Rationale: The diagnosing is stated in the Postoperative Diagnosis subdivision of the study as degenerative arthritis of the articulatio genus and is reported with 715. 96.
Question 6
Needs Rating

LOCATlON: Outpatient. infirmary
Patients: May Leigh
Surgeon: Mohamad Almaz. MD
Preoperative DlAGNOSIS: Osteoarthritis. left articulatio genus.
Postoperative DIAGNOSIS: Lapp.
PROCEDURE PERFORMED: Left entire articulatio genus arthroplasty.
Anesthesia: General.
ESTIMATED BLOOD LOSS: Minimal






Following satisfactory preoperative reappraisal and appraisal and full treatment. the patient was brought to the operating room where under general anaesthesia scrutiny confirmed patient to show first-class visual aspect of her right sum articulatio genus and increased valgus and crepitus of the left articulatio genus. The left articulatio genus was so elevated. scrubbed. prepped and draped in the usual manner and using a standard midplane scratch the hypodermic tissues were dissected. the median retinaculum was opened and the implicit in articulatio genus articulation identified with advanced osteoarthritic alterations present. The distal thighbone. proximal shinbone and kneecap were resected in the normal manner leting first-class adjustment of a # 2 thighbone. a # 2 shinbone. an 8-tray insert. and a 31 kneecap. Excellent tantrum. stableness. and scope of gesture were achieved. The articulatio genus articulation was exhaustively waterpiked and irrigated. the shinbone and thighbone firmly cemented into place followed by the kneecap.

Once once more. first-class tantrum. stableness. and scope were achieved. The articulatio genus articulation was drained with two deep suction Hemovacs. The median retinaculum was closed with 0 Vicryl. hypodermic closing with 2-0 Vicryl. cutaneal borders approximated with 4-0 Ethilon in perpendicular mattress manner. and a unfertile dressing was applied. The patient tolerated the process good and returned to PAR in satisfactory status. There were no intraoperative complications. Sponge and needle count correct.

Identify the right process ( CPT-4 ) codification ( s ) for the outpatient infirmary visit for patient May Leigh:

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




Rationale: The sawbones removed the faulty castanetss and so fitted the faulty countries with prosthetic devices ( unreal articulatio genus constituents ) . This is a replacing of a faulty articulatio genus or entire arthroplasty. The tibial constituent and the femoral constituent were replaced with prosthetic devices that were cemented in topographic point. The patellar constituent was so replaced with a prosthetic device. The faulty country was stabilized and so closed. A entire articulatio genus arthroplasty is reported with 27447 with modifier -LT to bespeak the process was performed on the left articulatio genus.

Question 7
Needs Rating

LOCATlON: Outpatient. infirmary
Patient: Stan Hope
Surgeon: Mohamad Almaz. MD
Preoperative Diagnosis: Left shoulder hurting and numbness. past shoulder hurt POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy. left shoulder
Clinical History: This is a 57-year-old with a l0-year-old rotator turnup tear hurt to his left shoulder. The patient does heavy lifting for a life. For the past 6 months the patient has been sing hurting in this shoulder with some numbness and prickling going down the arm. X raies were normal. Decision was made to travel in with an arthroscope to seek and bring out a ground for this hurting and numbness. Operative Report: Under general anaesthesia. the patient was laid in the beachchair place on the operating room tabular array. The left shoulder was examined and found to be stable. There is full scope of gesture of this shoulder besides. The appendage was so prepped and draped in the usual manner. A standard buttocks arthroscopic portal was created and the camera was introduced. First the dorsum of the articulation was inspected and this did non demo any grounds of harm. The anterior ligament constructions were normal. The biceps fond regard and its theodolite through the joint were normal. Subscapularis was integral with no abnormalcy. Old scarring of the rotator turnup was noted. But all looked as it should. Nothing abnormal was seen. The camera was so removed out of the
glenohumeral articulation and placed in the subacromial infinite. There was first-class visual image of this country. No abnormalcies could be identified and there was no grounds of any encroachments. The camera was so removed from the subacromial infinite. The country was so infiltrated with Marcaine. The posterior portal was so closed with absorbable suturas and Steri-Strips. and a Mepore dressing was placed on it. The arm was so placed in a sling ; the patient awakened and was placed on her infirmary bed and taken to the recovery room in good status.





Identify the right diagnosing ( ICD-9-CM ) codification ( s ) for the outpatient infirmary visit for patient Stan Hope:

ICD-9-CM: __________
ICD-9-CM: __________
ICD-9-CM: __________ ( intimation: this one is a V-Code! )
Answer
Selected Answer:
719. 41
782. 0
V15. 59
Correct Answer:
719. 41 ( Pain [ s ] . articulation. shoulder )
782. 0 ( Numbness )
V13. 59 ( History of. musculoskeletal upset NEC )










Rationale: The diagnostic arthroscopy consequences were that the shoulder was normal. and. as such. the Postoperative Diagnosiss of shoulder hurting ( 719. 41 ) and numbness ( 782. 0 ) would be the right codifications to utilize. The patient has a history of musculoskeletal upset ( V13. 59 ) .

Question 8
Needs Rating

LOCATlON: Outpatient. infirmary
Patient: Stan Hope
Surgeon: Mohamad Almaz. MD
Preoperative Diagnosis: Left shoulder hurting and numbness. past shoulder hurt POSTOPERATIVE DIAGNOSIS: Normal shoulder
PROCEDURE PERFORMED: Diagnostic arthroscopy. left shoulder
Clinical History: This is a 57-year-old with a l0-year-old rotator turnup tear hurt to his left shoulder. The patient does heavy lifting for a life. For the past 6 months the patient has been sing hurting in this shoulder with some numbness and prickling going down the arm. X raies were normal. Decision was made to travel in with an arthroscope to seek and bring out a ground for this hurting and numbness. Operative Report: Under general anaesthesia. the patient was laid in the beachchair place on the operating room tabular array. The left shoulder was examined and found to be stable. There is full scope of gesture of this shoulder besides. The appendage was so prepped and draped in the usual manner. A standard buttocks arthroscopic portal was created and the camera was introduced. First the dorsum of the articulation was inspected and this did non demo any grounds of harm. The anterior ligament constructions were normal. The biceps fond regard and its theodolite through the joint were normal. Subscapularis was integral with no abnormalcy. Old scarring of the rotator turnup was noted. But all looked as it should. Nothing abnormal was seen. The camera was so removed out of the glenohumeral articulation and placed in the subacromial infinite. There was first-class visual image of this country. No abnormalcies could be identified and there was no grounds of any encroachments. The camera was so removed from the subacromial infinite. The country was so infiltrated with Marcaine. The posterior portal was so closed with absorbable suturas and Steri-Strips. and a Mepore dressing was placed on it. The arm was so placed in a sling ; the patient awakened and was placed on her infirmary bed and taken to the recovery room in good status.




Identify the right process ( CPT-4 ) codification ( s ) for the outpatient infirmary visit for patient Stan Hope:

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




Rationale: The process is a diagnostic arthroscopy of the shoulder and is reported with 29805 with modifier -LT to bespeak the process was performed on the left shoulder.
Question 9
Needs Rating

Location: Outpatient. Hospital
Patient: Larry Frost
Surgeon: Mohomad Almaz. MD
Diagnosis: Localized degenerative arthritis. left distal collarbone. with continuity of creaky symptoms Operative PROCEDURE: Removal of distal 1 centimeter ( centimetre ) left collarbone ( claviculectomy ) . After satisfactory degree of general anaesthesia was reached and patient was in the supine place. he was farther placed in a beach chair place. A longitudinal scratch was created over the part of the left AC articulation. At this clip. crisp dissection was conducted down to the fascial plane. The fascial plane was so farther incised. reflecting both the deltoid and the trapezial facia and the distal facet of the collarbone sabotaging the collarbone ; at this clip we merely proceeded striking the distal 1 centimeter of the collarbone with usage of a mutual proverb. With completion of this component of the process. the borders of the bone were otherwise everyday in gross visual aspect. It was besides important to observe at this clip the acromial terminal of the articulation was everyday. The lesion was irrigated. followed by commanding of punctate hemorrhage with usage of electrocautery. followed by the closing of the deltotrapezial facia. At this clip I farther imbricated suturas for stable fix. followed by fix of hypodermic and cuticular planes. A simple dressing was applied. The patient tolerated the process good and was transported to the recovery room in a stable mode.


Identify the right diagnosing ( ICD-9-CM ) codification ( s ) for the outpatient infirmary
visit for patient Larry Frost:

ICD-9-CM: __________
Answer
Selected Answer:
715. 31
Correct Answer:
715. 31 ( Osteoarthrosis. localized. shoulder )




Rationale: The diagnosing is stated in the Diagnosis subdivision of the study to be degenerative arthritis and reported with 715. 31 to bespeak a localised osteoarthrosis of the shoulder. Question 10
Needs Rating

Location: Outpatient. Hospital
Patient: Larry Frost
Surgeon: Mohomad Almaz. MD
Diagnosis: Localized degenerative arthritis. left distal collarbone. with continuity of creaky symptoms Operative PROCEDURE: Removal of distal 1 centimeter ( centimetre ) left collarbone ( claviculectomy ) . After satisfactory degree of general anaesthesia was reached and patient was in the supine place. he was farther placed in a beach chair place. A longitudinal scratch was created over the part of the left AC articulation. At this clip. crisp dissection was conducted down to the fascial plane. The fascial plane was so farther incised. reflecting both the deltoid and the trapezial facia and the distal facet of the collarbone sabotaging the collarbone ; at this clip we merely proceeded striking the distal 1 centimeter of the collarbone with usage of a mutual proverb. With completion of this component of the process. the borders of the bone were otherwise everyday in gross visual aspect. It was besides important to observe at this clip the acromial terminal of the articulation was everyday. The lesion was irrigated. followed by commanding of punctate hemorrhage with usage of electrocautery. followed by the closing of the deltotrapezial facia. At this clip I farther imbricated suturas for stable fix. followed by fix of hypodermic and cuticular planes. A simple dressing was applied. The patient tolerated the process good and was
transported to the recovery room in a stable mode.



Identify the right process ( CPT-4 ) codification ( s ) for the outpatient infirmary visit for patient Larry Frost:

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




Rationale: The key to right describing this service is to be able to interpret the remotion of a part of the left collarbone into a claviculectomy. Once this is done the codification can be located in the index of the CPT manual and reported with 23120 with modifier -LT to bespeak the

x

Hi!
I'm Mack!

Would you like to get a custom essay? How about receiving a customized one?

Check it out