jrs3181
Contributor
How would you code the following?
Preoperative Diagnoses: Chronic Adenoiditis and adenoid hypertrophy and chronic otitis media with effusion.
Procedure: Adenoidectomy and bilateral tube removal with culture on the left and paper patch on the right.
Description: The patient was prepped and draped in the usual manner, under a satisfactory general endotracheal anesthesia. A Crowe-Davis mouth gag was inserted after inspecting for loose teeth. A 3+ enlarged infected adenoid pad was encountered and removed with Coblation technique. Hemostatis was obtained with suction cautery and Coblation. Attention was then directed to the right ear. The previously placed T-tube was removed and the perforation freshened with silver nitrate and a paper patch applied. On the opposite side, there was pus in the ear. I removed the tube and sent it for culture and did not apply a patch. At this point, the entire procedure was terminated. The estimated blood loss was about 15cc. The patient tolerated the procedure well and went to the recovery room in a good condition.
I have:
J35.02
J35.2
H66.3X2
42831
69424 50
Preoperative Diagnoses: Chronic Adenoiditis and adenoid hypertrophy and chronic otitis media with effusion.
Procedure: Adenoidectomy and bilateral tube removal with culture on the left and paper patch on the right.
Description: The patient was prepped and draped in the usual manner, under a satisfactory general endotracheal anesthesia. A Crowe-Davis mouth gag was inserted after inspecting for loose teeth. A 3+ enlarged infected adenoid pad was encountered and removed with Coblation technique. Hemostatis was obtained with suction cautery and Coblation. Attention was then directed to the right ear. The previously placed T-tube was removed and the perforation freshened with silver nitrate and a paper patch applied. On the opposite side, there was pus in the ear. I removed the tube and sent it for culture and did not apply a patch. At this point, the entire procedure was terminated. The estimated blood loss was about 15cc. The patient tolerated the procedure well and went to the recovery room in a good condition.
I have:
J35.02
J35.2
H66.3X2
42831
69424 50