codedog
True Blue
Need someone in take on this one .I want to code this as
61782
31255-LT--- 473..2 , 212.0
31267-LT 473.0, 212.0
30115 - 212.0
Not sure if this is correct
PREOPERATIVE DIAGNOSES: Mass left nasal cavity, left maxillary and ethmoid sinuses.
POSTOPERATIVE DIAGNOSES: Schneiderian papilloma left maxillary and ethmoid sinuses and left nasal cavity, chronic maxillary and ethmoid sinusitis.
PROCEDURES PERFORMED: CT-guided endoscopic left anterior and posterior ethmoidectomy and antrostomy, removal of tumor left nasal cavity and left maxillary and ethmoid sinuses.
ANESTHESIA: General endotracheal.
HISTORY: had experienced several months of left nasal obstruction and epistaxis and was found to have a mass involving the left nasal cavity, left maxillary and ethmoid sinuses.
FINDINGS: Large polypoid mass originating from the area of the left maxillary sinus ostium and the medial wall of the maxillary sinus on the left, eroding through the lateral nasal wall at the superior edge of the inferior turbinate and the uncinate. Polypoid tissue filled the left maxillary sinus and the left nasal cavity, extending posteriorly into the nasopharynx. Edematous mucosa was present in the uncinate, and in the anterior wall of the bulla, and along the inferior medial aspect of the left orbital floor and medial wall.
OPERATIVE PROCEDURE: After satisfactory anesthesia was established, the CT-guidance system was initialized and 0.25% Marcaine with epinephrine was infiltrated into the middle turbinate and lateral nasal wall. The tumor mass was visualized and portions were removed with rasping forceps from the middle meatus and the nasal cavity, and submitted for frozen section. The frozen section was reported as Schneiderian papilloma.
The uncinate was transected with a backbiting forceps and removed with upbiting forceps, the maxillary sinus ostium was identified and enlarged with through biting and side biting forceps. This was a somewhat wider than usual antrostomy, carried inferiorly into the superior aspect of the inferior turbinate. The bulla was then opened and cleared with the microdebrider and rasping forceps, the posterior ethmoid cells were entered through the basal lamella, and under CT-guidance, the ethmoid cells were opened from posterior to anterior, to the level of the frontal recess. The entire surgical cavity was then carefully examined, and with a 30-degree telescope, the anterior maxillary sinus was reexamined. No disease was noted in the inferior, lateral, or superior aspects of the maxillary sinus except at the junctions of the medial wall. Suction cautery was then applied to the denuded areas of the antrostomy and the inferior turbinate, as well as the lateral aspect of the resected bulla. With no further suspicious areas of mucosa could be identified, the surgical cavity was filled with Bactroban ointment, and pledgets of Gelfoam were placed in the denuded areas. The patient was then extubated and sent to the recovery room in stable condition.
THANKS
61782
31255-LT--- 473..2 , 212.0
31267-LT 473.0, 212.0
30115 - 212.0
Not sure if this is correct
PREOPERATIVE DIAGNOSES: Mass left nasal cavity, left maxillary and ethmoid sinuses.
POSTOPERATIVE DIAGNOSES: Schneiderian papilloma left maxillary and ethmoid sinuses and left nasal cavity, chronic maxillary and ethmoid sinusitis.
PROCEDURES PERFORMED: CT-guided endoscopic left anterior and posterior ethmoidectomy and antrostomy, removal of tumor left nasal cavity and left maxillary and ethmoid sinuses.
ANESTHESIA: General endotracheal.
HISTORY: had experienced several months of left nasal obstruction and epistaxis and was found to have a mass involving the left nasal cavity, left maxillary and ethmoid sinuses.
FINDINGS: Large polypoid mass originating from the area of the left maxillary sinus ostium and the medial wall of the maxillary sinus on the left, eroding through the lateral nasal wall at the superior edge of the inferior turbinate and the uncinate. Polypoid tissue filled the left maxillary sinus and the left nasal cavity, extending posteriorly into the nasopharynx. Edematous mucosa was present in the uncinate, and in the anterior wall of the bulla, and along the inferior medial aspect of the left orbital floor and medial wall.
OPERATIVE PROCEDURE: After satisfactory anesthesia was established, the CT-guidance system was initialized and 0.25% Marcaine with epinephrine was infiltrated into the middle turbinate and lateral nasal wall. The tumor mass was visualized and portions were removed with rasping forceps from the middle meatus and the nasal cavity, and submitted for frozen section. The frozen section was reported as Schneiderian papilloma.
The uncinate was transected with a backbiting forceps and removed with upbiting forceps, the maxillary sinus ostium was identified and enlarged with through biting and side biting forceps. This was a somewhat wider than usual antrostomy, carried inferiorly into the superior aspect of the inferior turbinate. The bulla was then opened and cleared with the microdebrider and rasping forceps, the posterior ethmoid cells were entered through the basal lamella, and under CT-guidance, the ethmoid cells were opened from posterior to anterior, to the level of the frontal recess. The entire surgical cavity was then carefully examined, and with a 30-degree telescope, the anterior maxillary sinus was reexamined. No disease was noted in the inferior, lateral, or superior aspects of the maxillary sinus except at the junctions of the medial wall. Suction cautery was then applied to the denuded areas of the antrostomy and the inferior turbinate, as well as the lateral aspect of the resected bulla. With no further suspicious areas of mucosa could be identified, the surgical cavity was filled with Bactroban ointment, and pledgets of Gelfoam were placed in the denuded areas. The patient was then extubated and sent to the recovery room in stable condition.
THANKS
