What is the correct code for this? The doctors always want to use 31610, I don't think that's always the case. what should I look for as they don't use the term "flaps/fenestration" Thanks in advance for you help***
OPERATIVE REPORT: The patient was brought into the operative room and placed on the operative table in supine position. General anesthesia was induced without complication. The patient already had an NG tube and was intubated. The first part of procedure consisted of putting a PEG placement. This was performed and dictated separately. After the PEG was then placed uneventfully, the patient was then placed in slight hyperextension of the neck. He was then shaved and prepped and draped in sterile fashion. The midline incision about 1 to 1.5 fingerbreadths over the sternal notch was then performed. Incision was carried down through the skin, subcutaneous tissue, the fat and fascia. Fascia was identified without complication down to the strap muscle. Strap muscle was identified and separated and divided and dissection was performed down to the level of trachea itself. The very superior aspect of the thyroid gland had to be divided without complication. Electrocautery was performed uneventfully. At this point, the trachea was well identified. The Fi02 of the ventilator was then decreased significantly. A small opening was then performed of the second tracheal ring, this was performed uneventfully. The ET tube was then removed without complication and a #8 tracheostomy was then placed into the trachea. The tracheostomy was then secured to the ventilation. Good ventilation and good respiration was obtained. End-tidal CO2 was identified uneventfully. The balloon was then gently insufflated. The subcutaneous tissues were reapproximated without complication with a 2-0 Vicryl and the tracheostomy was then secured to the skin with a Prolene stitch without complication. An umbilical tape was then placed around the neck of the patient. The patient tolerated the procedure well. The patient was sent to recovery room in the ICU in a stable condition.
OPERATIVE REPORT: The patient was brought into the operative room and placed on the operative table in supine position. General anesthesia was induced without complication. The patient already had an NG tube and was intubated. The first part of procedure consisted of putting a PEG placement. This was performed and dictated separately. After the PEG was then placed uneventfully, the patient was then placed in slight hyperextension of the neck. He was then shaved and prepped and draped in sterile fashion. The midline incision about 1 to 1.5 fingerbreadths over the sternal notch was then performed. Incision was carried down through the skin, subcutaneous tissue, the fat and fascia. Fascia was identified without complication down to the strap muscle. Strap muscle was identified and separated and divided and dissection was performed down to the level of trachea itself. The very superior aspect of the thyroid gland had to be divided without complication. Electrocautery was performed uneventfully. At this point, the trachea was well identified. The Fi02 of the ventilator was then decreased significantly. A small opening was then performed of the second tracheal ring, this was performed uneventfully. The ET tube was then removed without complication and a #8 tracheostomy was then placed into the trachea. The tracheostomy was then secured to the ventilation. Good ventilation and good respiration was obtained. End-tidal CO2 was identified uneventfully. The balloon was then gently insufflated. The subcutaneous tissues were reapproximated without complication with a 2-0 Vicryl and the tracheostomy was then secured to the skin with a Prolene stitch without complication. An umbilical tape was then placed around the neck of the patient. The patient tolerated the procedure well. The patient was sent to recovery room in the ICU in a stable condition.