Medical Billing Coding

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Unless stated otherwise, assume “normal, healthy patient.” Anesthesia by: MDA and
CRNA. Anesthesiologist was medically directing 4 concurrent cases.
14-2A OPERATIVE REPORT, ANESTHESIA
INDICATIONS FOR SURGERY: This is a 28-year-old healthy male who has had some
problems with sleep apnea and breathing through his nose. He is now admitted for
repair of his deviated septum with bilateral inferior turbinate reduction and removalof his tonsils.
LOCATION: Inpatient, Hospital
PATIENT: Don Albet
SURGEON: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS:
1. Septal deviation
2. Bilateral inferior turbinate hypertrophy
3. Tonsillar hypertrophy
POSTOPERATIVE DIAGNOSIS:
1. Septal deviation
2. Bilateral inferior turbinate hypertrophy
3. Tonsillar hypertrophy
PROCEDURE PERFORMED:
1. Septoplasty
2. Bilateral inferior turbinate reduction
3. Tonsillectomy
ANESTHESIA: General anesthesia
SURGICAL FINDINGS: The patient had a fairly significant left septal deviation. Some of this was anterior. He also had posteriorly on the left-hand side contact between the posterior left nasal septum and the left lateral nasal wall from a bony spur. The inferior turbinates bilaterally were grossly hypertrophic. The tonsils were extremely hypertrophied.Manycrypts were present.
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to
the operating room and placed in the supine position. He was draped in the usual
fashion. The nose was packed bilaterally with Afrin-soaked gauze. Right and left nasal septum were each injected with 3 cc of 1% Xylocaine with Epinephrine. Some of the nose hairs were trimmed. The Afrin-soaked gauze was removed bilaterally. An incision was made at the anterior end of the right nasal septum. A mucoperichondral flap was identified. This was elevated on the right nasal septum. No perforations occurred during this.Taking care to leave a good 1 cm of anterior
septal cartilage,an incision was made through the right side of
the septal cartilage at its base. Through this incision,a leftmucoperichondrial flap
was then elevated. We also elevated a mucoperiosteal flap on the left-hand sidewith the freer elevator.A strip of cartilage was removed from the inferior end of the septal cartilage at its junction with the maxillary crest.A portion of the anterior inferior left-sided septal deviation was due to the deviation of the left maxillary crest. A 4-mm osteotome was used to remove this deviated portion.

The Bony vomer was deviated to the left-hand side with a spur in contactwith the left
CASE 14-2
14-2A OPERATIVE REPORT, ANESTHESIA
CHAPTER 14 Anesthesia
lateral nasal wall, and I did remove this with Wilde forceps. The strip of cartilage
removed was approximately 2 cm in length and 1 cm in height. At least a cm of nasal dorsal strut and anterior strut was maintained. This was to provide good tip support, which was present at the end of the case. Following removal of the cartilage and the maxillary crest, the septum was signifi cantly straighter. There was still a small amount of anterior left septal deviation, but signifi cantly less. The anterior inferior edges of the turbinates bilaterally were then cauterized with needlepoint cautery. Following this, a butter knife was used to out-fracture the turbinates bilaterally. This gave a signifi cant improvement in the nasal airway. There was a small mucosal tear posteriorly on the left-hand side, which would serve as a drainage site to prevent hematoma formation beneath the mucosal fl ap. The anterior end of the right nasal septum was then closed using interrupted 4-0 chromic catgut. I then placed Doyle nasal splints bilaterally. The patient was then repositioned for tonsillectomy. The McIvor out gag was placed, and we were able to visualize the tonsils. They were extremely large with many crypts on them.
Attention was fi rst focused on the left tonsil. The retractor was placed in the superior pole, and the tonsil was retracted toward the midline. Then, using the harmonic scalpel at power level III, the tonsil was removed. Hemostasis was achieved from spot suction cautery. Similar procedure was then performed on the left tonsil. The tonsillar fossa was then irrigated, and hemostasis was achieved. Infi ltration of 1% Xylocaine with 1:100,000 units of epinephrine was placed in the retromolar and soft palate areas bilaterally.

Tension on the mouth gag was then released. Reinspection showed no active bleeding. The patient was then allowed to recover from general anesthesia. He tolerated the procedure
well. He was transferred to the recovery room in good condition. He will go home on
Kefl ex 500 mg po q.i.d. He has a prescription for Percocet for pain. He is going to be using nasal saline rinses until I see him again in 2 weeks. At that time we will be removing the stents. He will get in touch with my office if he is having any
other problems.
14-2A:
____________________________________________________
CRNA CODE:

PHYSICIAN CODE:
_______________________________________________________

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