Please can someone tell me advice on how they would code this report? I am still learning surgeries. Thanks!
Melissa Bedford,CCS,CPC
PREOP DIAGNOSIS: Deviated nasal septum
Turbinate hypertrophy
POSTOP DIAGNOSIS: Same
PROCEDURE: Septoplasty
Turbinate coblation
SURGEON:
ANESTHESIA: General endotracheal
IVF: 1000 ml
EBL: miimal
COMPLICATIONS: None
FINDINGS: dns to right inferiorly
Large maxillary crest
Spur on left
PATHOLOGY: None
INDICATIONS FOR SURGERY:
Pt with findings of deviated septum and enlarged turbinates, causing obstruction, and associated symptoms, that failed medical management.
DESCRIPTION OF OPERATION:
The patient was properly identified, brought to the operating room, placed on the operating room table and placed under adequate general endotracheal anesthetic without difficulty. The nose was injected with 1% lidocaine with 1 50,000 epinephrine and then packed with 1:1000 epi pledgets. Throat pack was placed. A timeout was performed prior to beginning the procedure.
A left-sided hemitransfixion incision was created and a submucoperichondrial flap was elevated bilaterally. The dissection was carried posterior to the bony cartilaginous junction. The dissection was also carried down to the maxillary crest. The bone/cartilage junction was identified and separated inferiorly to allow relaxation of the quadrangular cartilage. A septal knife was used to perform a submucous resection of the quadrangular cartilage for use for Dr. Hoganson's rhinoplasty portion. I ensured leaving at least 1 cm of dorsal and caudal strut. Once this was appropriately trimmed, the cartilaginous septum was sitting nicely in the midline without any bow or retraction. I then trimmed the bony septum where it was no longer contributing to the nasal blockage. I then closed the flaps with a 4-0 fast absorbing plain gut in a mattress fashion and a 5-0 chromic gut in a simple interrupted fashion at the incision site.
Next, the inferior turbinates were injected with 1% lidocaine with 1:100,000 epinephrine. I then performed Coblation with 3 passes made through each inferior turbinate on a setting of 6 and 2.
The patient was then turned over to Dr. for his portion of the surgery.
Signed by, MD on 7/18/2014 11:13 AM
POST-OPERATIVE/POST-PROCEDURE NOTE
Service date: 7/18/2014
PCP: No primary provider on file.
Surgeon: \, MD
Assistant Surgeon: none
Pre-operative diagnosis: nasal vestibular stenosis
Post-operative diagnosis: same
Procedure/description: nasal tip rhinoplasty with lateral nasal spreader graft
Operative findings: nasal vestibular stenosis
Specimens: None
Fluids/Blood: no blood
Estimated Blood Loss: Minimal
Drains/Packs: Doyle splints
Patient's condition: satisfactory
SURGEON:
ASSISTANT SURGEON:
None.
PREOPERATIVE DIAGNOSIS(ES):
Nasal vestibular stenosis and airway restriction.
POSTOPERATIVE DIAGNOSIS(ES):
Nasal vestibular stenosis and airway restriction.
SURGICAL PROCEDURE:
Nasal tip rhinoplasty with lateral alar spreader graft and for
vestibular stenosis, I performed in conjunction with Dr.
septoplasty.
SURGEON:
, MD
ANESTHESIA:
General.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Minimal.
DRAINS:
Doyle splints x2. Throat pack removed at the conclusion of the
procedure.
ESTIMATED BLOOD LOSS:
Minimal.
CONDITION:
Satisfactory.
SUMMARY OF THE PROCEDURE:
With the patient in the preoperative area, the operative site is
verified. The operative plan is reviewed with the patient.
Preoperative photographs were obtained. The patient has evidence
of a nasal airway obstruction with vestibular stenosis in
addition to a deviated septum. The plan is for a combined
procedure with initial septoplasty with Dr. followed by a
tip rhinoplasty to correct the vestibular stenosis. The patient
states he is happy with the general appearance of his nose and
that it is just only improving his breathing and airway and then
plan is for a tip rhinoplasty and lateral spreader graft and V-Y
lateral advancement of the nasal base. Addition to modification
of the cartilage of the septum to improve the midline profile and
improve the airway. The risks of the surgery reviewed. He had
an opportunity of all questions answered. He was then taken to
the operating room. Following time-out verification, sterile
prep and drape, administration of general anesthesia, and the
completion of the septoplasty portion of the procedure by Dr.
, who did harvest septal cartilage for planned grafting. An
extra 1 to 2 mm of caudal septum was trimmed as a reduction in
midline of the septum, would yield appropriate contouring of
length following the trim. A pair of mattress 4-0 chromic
sutures were placed in the septum in addition to closing the
septoplasty, an incision was performed. The lateral nasal base
contour, which created an extreme narrowing of the nasal opening
was addressed with a V-Y lateral advancement of the lateral nasal
base including excision of crest at the lateral cheek, elevation
of the base and its advancement laterally. Additionally, a
lateral cartilage alar graft was placed through a pocket through
the mucosal incision and secured with 5-0 chromic. The V-Y
advancement was closed with interrupted 6-0 nylon suture and
achieved approximately 6 to 7 mm advancement of the base. This
was performed bilaterally and assessed for symmetry. Additional
millimeter was removed from the left to improve symmetry. At the
conclusion the procedure, the patient includes symmetry and shape
and the Doyle splints were placed and secured with a through-and-
through Prolene suture. Throat pack was removed. The patient
tolerated the procedure without complication.
Melissa Bedford,CCS,CPC
PREOP DIAGNOSIS: Deviated nasal septum
Turbinate hypertrophy
POSTOP DIAGNOSIS: Same
PROCEDURE: Septoplasty
Turbinate coblation
SURGEON:
ANESTHESIA: General endotracheal
IVF: 1000 ml
EBL: miimal
COMPLICATIONS: None
FINDINGS: dns to right inferiorly
Large maxillary crest
Spur on left
PATHOLOGY: None
INDICATIONS FOR SURGERY:
Pt with findings of deviated septum and enlarged turbinates, causing obstruction, and associated symptoms, that failed medical management.
DESCRIPTION OF OPERATION:
The patient was properly identified, brought to the operating room, placed on the operating room table and placed under adequate general endotracheal anesthetic without difficulty. The nose was injected with 1% lidocaine with 1 50,000 epinephrine and then packed with 1:1000 epi pledgets. Throat pack was placed. A timeout was performed prior to beginning the procedure.
A left-sided hemitransfixion incision was created and a submucoperichondrial flap was elevated bilaterally. The dissection was carried posterior to the bony cartilaginous junction. The dissection was also carried down to the maxillary crest. The bone/cartilage junction was identified and separated inferiorly to allow relaxation of the quadrangular cartilage. A septal knife was used to perform a submucous resection of the quadrangular cartilage for use for Dr. Hoganson's rhinoplasty portion. I ensured leaving at least 1 cm of dorsal and caudal strut. Once this was appropriately trimmed, the cartilaginous septum was sitting nicely in the midline without any bow or retraction. I then trimmed the bony septum where it was no longer contributing to the nasal blockage. I then closed the flaps with a 4-0 fast absorbing plain gut in a mattress fashion and a 5-0 chromic gut in a simple interrupted fashion at the incision site.
Next, the inferior turbinates were injected with 1% lidocaine with 1:100,000 epinephrine. I then performed Coblation with 3 passes made through each inferior turbinate on a setting of 6 and 2.
The patient was then turned over to Dr. for his portion of the surgery.
Signed by, MD on 7/18/2014 11:13 AM
POST-OPERATIVE/POST-PROCEDURE NOTE
Service date: 7/18/2014
PCP: No primary provider on file.
Surgeon: \, MD
Assistant Surgeon: none
Pre-operative diagnosis: nasal vestibular stenosis
Post-operative diagnosis: same
Procedure/description: nasal tip rhinoplasty with lateral nasal spreader graft
Operative findings: nasal vestibular stenosis
Specimens: None
Fluids/Blood: no blood
Estimated Blood Loss: Minimal
Drains/Packs: Doyle splints
Patient's condition: satisfactory
SURGEON:
ASSISTANT SURGEON:
None.
PREOPERATIVE DIAGNOSIS(ES):
Nasal vestibular stenosis and airway restriction.
POSTOPERATIVE DIAGNOSIS(ES):
Nasal vestibular stenosis and airway restriction.
SURGICAL PROCEDURE:
Nasal tip rhinoplasty with lateral alar spreader graft and for
vestibular stenosis, I performed in conjunction with Dr.
septoplasty.
SURGEON:
, MD
ANESTHESIA:
General.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Minimal.
DRAINS:
Doyle splints x2. Throat pack removed at the conclusion of the
procedure.
ESTIMATED BLOOD LOSS:
Minimal.
CONDITION:
Satisfactory.
SUMMARY OF THE PROCEDURE:
With the patient in the preoperative area, the operative site is
verified. The operative plan is reviewed with the patient.
Preoperative photographs were obtained. The patient has evidence
of a nasal airway obstruction with vestibular stenosis in
addition to a deviated septum. The plan is for a combined
procedure with initial septoplasty with Dr. followed by a
tip rhinoplasty to correct the vestibular stenosis. The patient
states he is happy with the general appearance of his nose and
that it is just only improving his breathing and airway and then
plan is for a tip rhinoplasty and lateral spreader graft and V-Y
lateral advancement of the nasal base. Addition to modification
of the cartilage of the septum to improve the midline profile and
improve the airway. The risks of the surgery reviewed. He had
an opportunity of all questions answered. He was then taken to
the operating room. Following time-out verification, sterile
prep and drape, administration of general anesthesia, and the
completion of the septoplasty portion of the procedure by Dr.
, who did harvest septal cartilage for planned grafting. An
extra 1 to 2 mm of caudal septum was trimmed as a reduction in
midline of the septum, would yield appropriate contouring of
length following the trim. A pair of mattress 4-0 chromic
sutures were placed in the septum in addition to closing the
septoplasty, an incision was performed. The lateral nasal base
contour, which created an extreme narrowing of the nasal opening
was addressed with a V-Y lateral advancement of the lateral nasal
base including excision of crest at the lateral cheek, elevation
of the base and its advancement laterally. Additionally, a
lateral cartilage alar graft was placed through a pocket through
the mucosal incision and secured with 5-0 chromic. The V-Y
advancement was closed with interrupted 6-0 nylon suture and
achieved approximately 6 to 7 mm advancement of the base. This
was performed bilaterally and assessed for symmetry. Additional
millimeter was removed from the left to improve symmetry. At the
conclusion the procedure, the patient includes symmetry and shape
and the Doyle splints were placed and secured with a through-and-
through Prolene suture. Throat pack was removed. The patient
tolerated the procedure without complication.