PREOPERATIVE DIAGNOSIS(ES):
Hi list! I have coded 31256-50
31255-50
31276-50
30802-50
I am not sure what to assign for the excision of the rt middle turbinate? Any guidance is appreciated. Still learning these surgeries.
TIA
M,CCS,CPC
1. Chronic pansinusitis.
2. Turbinate hyperplasia.
POSTOPERATIVE DIAGNOSIS(ES):
1. Chronic pansinusitis.
2. Turbinate hyperplasia.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Bilateral endoscopic maxillary antrostomies.
2. Bilateral endoscopic total ethmoidectomies.
3. Bilateral endoscopic frontal sinusotomies.
4. Bilateral inferior turbinate Coblation.
5. Excision of right middle turbinate.
ANESTHESIA:
General endotracheal anesthetic.
ESTIMATED BLOOD LOSS:
Less than 50 mL.
FLUIDS:
900 mL crystalloid.
COMPLICATIONS:
None.
FINDINGS:
1. Thickened and inflamed polypoid mucosa throughout.
2. Bilateral inferior turbinate hyperplasia.
3. Packing nasopore x2 with Kenalog.
INDICATIONS FOR SURGERY:
The patient has chronic pansinusitis despite the use of maximal
medical management. She is here for definitive treatment.
SUMMARY:
After properly identifying the patient, she was brought to the
operating room, placed on the operating room table, and placed
under adequate general endotracheal anesthetic without
difficulty. A time-out was performed prior to beginning the
procedure.
The patient was registered with the fusion navigation device
without difficulty. A throat pack was placed. Her nose was
packed with Afrin and Afrin pledgets.
Using the zero-degree endoscope, the left side was addressed 1st.
The middle meatus was entered. The uncinate process was
identified. Backbiting forceps were used to take down or to
incise the uncinate and then a right angle probe was used to
enter the natural os of the maxillary sinus. I then pulled the
remaining uncinate process anteriorly and uses the 0 degree
shaver to completely take down the uncinate. I then used the
registered shaver to take down the ethmoid bulla, and followed
all the way up to the skull base and then followed the skull base
posteriorly taking down air cells until the anterior wall of the
sphenoid was identified. I then used powered and manual
debridement to take down all the air cells in the ethmoid bed
verifying a completion of the dissection with image guidance.
During the removal of the anterior air cells using the upbiting
forceps to really opened up the maxillary and the frontal sinus
opening and then inserted the image guided frontal sinus seeker
and was able visibly see the opening of the frontal sinus with
the 45 degree scope and verified the opening into the frontal
sinus with the image guidance. Next, the left maxillary sinus
was widely opened with the shaver and manual debridement until
the entire sinus was opened and a visible through the 45 degree
scope. The same procedure was then performed on the right side
without change of procedural details or findings except for the
fact that I did take down the middle turbinate on the right side
because of it being somewhat paradoxical in shape and really
wanting to stay lateral.
Once both at the sinus beds were widely patent. I then injected
local anesthetic into the inferior turbinates, and performed
Coblation on a setting of 6 and 2. Three passes were made
through each inferior turbinate. I then placed nasal pore into
both middle meatus and injected with about 1 mL of Kenalog 40 on
each side. At this point, the throat pack was removed. The
patient was turned back over to Anesthesia. The patient was
awakened and extubated in operating room to recovery room in
stable condition.
Hi list! I have coded 31256-50
31255-50
31276-50
30802-50
I am not sure what to assign for the excision of the rt middle turbinate? Any guidance is appreciated. Still learning these surgeries.
TIA
M,CCS,CPC
1. Chronic pansinusitis.
2. Turbinate hyperplasia.
POSTOPERATIVE DIAGNOSIS(ES):
1. Chronic pansinusitis.
2. Turbinate hyperplasia.
PROCEDURE(S)/OPERATION(S) PERFORMED:
1. Bilateral endoscopic maxillary antrostomies.
2. Bilateral endoscopic total ethmoidectomies.
3. Bilateral endoscopic frontal sinusotomies.
4. Bilateral inferior turbinate Coblation.
5. Excision of right middle turbinate.
ANESTHESIA:
General endotracheal anesthetic.
ESTIMATED BLOOD LOSS:
Less than 50 mL.
FLUIDS:
900 mL crystalloid.
COMPLICATIONS:
None.
FINDINGS:
1. Thickened and inflamed polypoid mucosa throughout.
2. Bilateral inferior turbinate hyperplasia.
3. Packing nasopore x2 with Kenalog.
INDICATIONS FOR SURGERY:
The patient has chronic pansinusitis despite the use of maximal
medical management. She is here for definitive treatment.
SUMMARY:
After properly identifying the patient, she was brought to the
operating room, placed on the operating room table, and placed
under adequate general endotracheal anesthetic without
difficulty. A time-out was performed prior to beginning the
procedure.
The patient was registered with the fusion navigation device
without difficulty. A throat pack was placed. Her nose was
packed with Afrin and Afrin pledgets.
Using the zero-degree endoscope, the left side was addressed 1st.
The middle meatus was entered. The uncinate process was
identified. Backbiting forceps were used to take down or to
incise the uncinate and then a right angle probe was used to
enter the natural os of the maxillary sinus. I then pulled the
remaining uncinate process anteriorly and uses the 0 degree
shaver to completely take down the uncinate. I then used the
registered shaver to take down the ethmoid bulla, and followed
all the way up to the skull base and then followed the skull base
posteriorly taking down air cells until the anterior wall of the
sphenoid was identified. I then used powered and manual
debridement to take down all the air cells in the ethmoid bed
verifying a completion of the dissection with image guidance.
During the removal of the anterior air cells using the upbiting
forceps to really opened up the maxillary and the frontal sinus
opening and then inserted the image guided frontal sinus seeker
and was able visibly see the opening of the frontal sinus with
the 45 degree scope and verified the opening into the frontal
sinus with the image guidance. Next, the left maxillary sinus
was widely opened with the shaver and manual debridement until
the entire sinus was opened and a visible through the 45 degree
scope. The same procedure was then performed on the right side
without change of procedural details or findings except for the
fact that I did take down the middle turbinate on the right side
because of it being somewhat paradoxical in shape and really
wanting to stay lateral.
Once both at the sinus beds were widely patent. I then injected
local anesthetic into the inferior turbinates, and performed
Coblation on a setting of 6 and 2. Three passes were made
through each inferior turbinate. I then placed nasal pore into
both middle meatus and injected with about 1 mL of Kenalog 40 on
each side. At this point, the throat pack was removed. The
patient was turned back over to Anesthesia. The patient was
awakened and extubated in operating room to recovery room in
stable condition.
