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CANPC Anesthesiology coding essentials for successful anesthesiology coding by Vino C. Mody Jr., M.D., COC, CPC, CCS-P, CANPC, CCVTC
Case 61
Postoperative Diagnosis:
Heartburn
Diverticulosis of the colon
Internal hemorrhoids
Possible short segment Barrett esophagus
Procedure Performed:
Colonoscopy with internal hemorrhoid banding x 1
Flexible esophagogastroduodenoscopy with biopsies
Surgeon:
Dr. Optum
Anesthesia:
MAC anesthesia with topical for EGD in pharynx
Anesthesiologist performed the monitored anesthesia care (MAC) service for the case while directing one CRNA (PS III)
Estimated Blood Loss:
Minimal
Description of Procedure:
The flexible Olympus upper GI endoscope was passed through the bite block into the posterior pharynx. The esophageal orifice was identified and cannulated. Insufflation, irrigation, and suction were utilized appropriately, and representative photographs were taken. The scope was advanced down the esophagus into the stomach, past pylorus into the duodenum, brought back into the stomach, retroflexed on itself. Biopsies were taken with cold biopsy forceps of the antral mucosa for urease testing and of the distal esophagus for histopathology analysis and no significant ongoing hemorrhage ensued. The gas suctioned, scope removed slowly and carefully, and this portion of the procedure was terminated.
Olympus colonoscope was inserted into the anal canal and advanced into the rectum. The scope was advanced into the rectosigmoid junction, negotiated through a very loopy, redundant sigmoid colon into the descending colon. I was able to get past the splenic flexure. I was able to get past the transverse colon and the hepatic flexure into the ascending colon, ultimately past the ileocecal valve into the cecum.
A digital rectal exam was performed and then I proceeded to perform band ligation with single prominent internal hemorrhoid, and the Olympus upper GI endoscope was fitted with the multiband ligator as per standard routine. The hemorrhoid was suctioned and the band deployed. The band was adequately placed and the other surrounding hemorrhoids did not appear to be amenable to band ligation as they were much smaller and less prominent. The air was suctioned and the scope removed.
Findings:
The patient had normal laryngeal and posterior pharyngeal structures. The esophageal orifice was normal, proximal and middle esophagus normal. The GE junction was situated approximately 40 cm from the incisors. There was certainly some irregularity at the GE junction and a couple of tiny islands of gastric-type mucosa suggesting the presence of short segment Barrett esophagus.
The length was certainly only a few millimeters. No evidence of strictures, rings, diverticula, or significant esophagitis was seen. No significant hiatal hernia was appreciated. No polyps or carcinoma. Gastric lumen distended normally. There were no ulcer, no polyps, and no evidence of malignancy. The cardia, fundus, body, antrum, and prepyloric areas were all normal. The pylorus was patent and normal. Duodenal bulb, second, third, and fourth portions, of the duodenum were normal. Random biopsy of the antral mucosa was obtained for urease testing, and biopsies of the distal esophagus were obtained to assess for the presence of Barrett metaplasia.
Colonoscopy revealed fairly good bowel prep, although areas of the cecum and ascending colon were a bit under-prepped and probably future bowel prep should be a bit more aggressive. In any event, the patient does have some scattered medium mouthed diverticula in the left colon. No evidence of diverticulitis or strictures were seen. No polyps were seen. No evidence of carcinoma was seen. The patient had a exceedingly redundant sigmoid colon with the entire length of the colonoscope inserted by about the mid transverse colon quite a lot of manipulation and counter pressure to the abdominal wall again access to the cecum, which was ultimately successful, but required a lot of effort. The patient does have internal hemorrhoids, which were not bleeding. There was one in particular that appeared more anteriorly situated. It appeared to be larger than the rest and mildly inflamed and I chose that for internal bleeding; utilizing the multiband ligator, I placed a single band on that particular hemorrhoid without incident.
Codes
45398, 43239-59-53, 88305, 88305+88314, K64.8, K57.30, R12, K22.70
Overall anesthesiology code for the case for the billing anesthesiologist
00810-QS-QY
Overall anesthesiology code for the case for the billing CRNA
00810-QS-QX
Clinical viewpoint
The patient is being treated for heartburn (R12), Diverticulosis of colon (K57.30), Internal hemorrhoids (K64.8), and Possible short segment Barrett esophagus (K22.70). The patient underwent Flexible esophagogastroduodenoscopy, transoral, diagnositc with biopsy, single or multiple (43239-59-53) and Flexible colonoscopy, diagnostic with band ligation(s) (e.g., hemorrhoids) with specimens sent to pathology for histopathology analysis (+88314) of stomach biopsy (88305) and esophagus biopsy (88305) for presence of Barrett metaplasia. The anesthesia (00810) is for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum. The anesthesia was monitored anesthesia care (MAC) service (QS).
Case 62
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Abscess, left leg, positive for MRSA
Procedure Performed: Incision and drainage, left leg
Surgeon: Dr. Optum
Anesthesia: Regional block with moderate sedation
Anesthesiologist personally provided the regional anesthesia for the case (PS III)
Estimated Blood Loss: Less than 25 ml
Description of Procedure: The patient was brought into the operating room. The regional block had been previously administered in the holding area. Anesthesia administered the moderate sedation. The skin was incised sharply with a scalpel over the fluctuant mass in the anteromedial left leg. Copious amount of purulence was drained; this was suctioned. The wound was probed and the fibrous bands were broken up. Hemostasis was achieved with electrocautery. The wound was then packed with Betadine-soaked gauze. A dry dressing was placed around this followed by an Ace wrap. The patient tolerated the procedure well. He was transported to the recovery area in stable condition.
Findings: Pathology reports MRSA in the purulent drainage sent and cultured. Start patient on Clindamycin 600 mg IV.
Codes
10061, 88304, L02.416, B95.62
Overall anesthesiology code for the case for the billing anesthesiologist
00400-AA-P3
Clinical viewpoint
The patient underwent Incision and drainage of a complicated abscess of the leg (10061) and purulent drainage sent to pathology (88304). The cutaneous abscess of the lower limb (L02.416) had MRSA in the purulent drainage (B95.62). The anesthesia is for procedures on the integumentary system on the extremities, anterior trunk, and perineum; not otherwise specified (00400). The procedure was a major procedure requiring regional block with moderate sedation. Regional block is coded as an anesthesiology code, as it is one of the four types of anesthesia (General, regional, monitored anesthesia care, and local). Local anesthesia is bundled with the procedure.
Case 63
Date of Operation
X/XX/XXXX
Postoperative Diagnosis: End-stage renal disease with need for dialysis access. Staged right brachiobasilic arteriovenous fistula creation.
Procedure Performed: Transposition right brachiobasilic AV fistula in the subcutaneous tunnel—completion of procedure started XX/XX/XXXX
Surgeon: Dr. Optum
Anesthesia: Supraclavicular block, followed by general endotracheal anesthesia
Anesthesiologist personally provided the supraclavicular block followed by general endotracheal anesthesia
Indications: This 52-year-old female end-stage renal disease patient is in need of a permanent dialysis access. This patient currently requires hemodialysis using a temporary dialysis catheter. At this time the second and final phase of a staged right brachiobasilic arteriovenous fistula creation will be completed.
Estimated blood loss: Minimal
Description of Procedure: It ultimately became necessary to induce general anesthesia in this patient. The entire procedure was done under 2.5X loop magnification. The vein was exposed with a longitudinal incision over the inner aspect of the right upper arm, lengthening the incision in stepwise fashion, bringing the vein into view from the elbow to the axilla. The vein was then elevated by taking branches between 4-0 silk ties and baby Hemoclips. The larger branches were doubly tied on the vein side. The vein was now much more mobile. A pocket was developed in the subcutaneous tissues out laterally over the biceps muscle, elevating the skin and fat layer up and away from the underlying fascia. The vein was positioned out over the biceps muscle, and the tissues were then reapproximated down over the vein with interrupted 3-0 Vicryl, being sure not the put any undue pressure on the vein. A good strong thrill was maintained throughout. The wound was then irrigated with saline. The subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with simple and vertical mattress sutures of 4-0 nylon. Dressings were applied as well as an arm board and the procedure completed. Sponge, needle, and instrument counts reported as correct. Patient tolerated the procedure well. She was awakened, extubated, and taken to recovery room in satisfactory condition.
Codes
36819-RT,58, N18.6, Z99.2
Overall anesthesiology code for the case for the billing anesthesiologist
01844-AA-P3, 64418
Clinical viewpoint
The patient underwent arteriovenous anastomosis by upper arm basilica transposition (36819) for end-stage renal disease (N18.6) requiring dialysis access (Z99.2). The anesthesia (01844) was for vascular shunt, or shunt revision, any type (e.g dialysis). Supraclavicular block (64418), a nerve block which counts as regional anesthesia was in addition performed prior to the general endotracheal anesthesia and counts as an anesthesiology code.
Case 64
Date of Procedure: X/XX/XXXX
Postoperative Diagnosis: Malignant melanoma, chest (1 cm)
Surgeon: Dr. Optum
Anesthesia: General endotracheal
Anesthesiologist personally provided general endotracheal anesthesia (PS IV)
Procedure: Excision of skin lesion of chest wall
Description of Procedure: The mid-cheek was prepped and draped in sterile fashion, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken in addition to the 1 cm lesion. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with running subcuticular 4-0 Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.
Operative Findings: Pathology determined the lesion was malignant melanoma. Margins were clean and it does not appear that additional treatment is required at this time. Appropriate counseling on sun protection and the other risk factors and preventive measures provided.
Codes
11606, 12032-59, C43.59
Overall anesthesiology code
00300-AA-P4
Clinical viewpoint
The patient has malignant melanoma of the chest (C43.59) and underwent excision of malignant skin lesion of the chest wall with 2 cm margins for a 1 cm lesion size for a total excised diameter of 5 cm (11606) with Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm for the layered closure. The anesthesia (00300) was for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified. The patient has severe systemic disease, malignant melanoma which is a constant threat to life (P4).
Case 65
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Abdominal pain, cystic lesions of pancreas, suspicious for branchial intraductal papillary mucinous neoplasm
Surgeon: Dr. Optum
Anesthesia: Monitored anesthesia care (MAC) service
Anesthesiologist personally provided the Monitored anesthesia care (MAC) service (PS II)
Procedure: Upper endoscopic ultrasound
Description of Procedure: After obtaining informed consent the endoscope was passed under vision. Throughout the procedure, the patient’s blood pressure, pulse, and oxygen saturation were monitored continuously. The endoscopic with transducer was introduced through the mouth and advanced to the second part of the duodenum. Findings are detailed below. The upper EUS was accomplished without difficulty. The patient tolerated the procedure well.
Endosonographic Findings: An anechoic lesion suggestive of a cyst was identified in the pancreatic head. The lesion measured 4 mm by 3 mm. There was no associated mass.
An anechoic lesion suggestive of cyst was identified in the pancreatic neck. The lesion measured 9 mm by 8 mm. There was no associated mass. There was no internal debris within the fluid-filled cavity.
An anechoic lesion suggestive of cyst was identified in the pancreatic body. The lesion measured 7 mm by 6 mm. There was no associated mass. There was no internal debris within the fluid-filled cavity.
The celiac axis including lymph nodes was unremarkable. The examined portion of the left lobe of the liver and the gastrohepatic ligament were evaluated and found to be without abnormalities.
The pancreas was examined and the parenchyma demonstrated three cystic lesions as above. The main pancreatic duct measured 1.7 mm in the head, 1.1 mm in the body, and 1.0 mm in the tail. The ampulla was normal endoscopically and endosonographically. The bile duct ranged in size from 1.9 mm to 2.4 mm in size and was normal in appearance. The gallbladder was normal in appearance.
Overall Impression: A 4 mm by 3 mm cystic lesion was seen in the pancreatic head. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious for a branched intraductal papillary mucinous neoplasm.
A 9 mm by 8 mm cystic lesion was seen in the pancreatic neck. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious for branched intraductal papillary mucinous neoplasm.
A 7 mm by 6 mm cystic lesion was seen in the pancreatic body. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious of for branched intraductal papillary mucinous neoplasm.
Codes
43237, K86.2
Overall anesthesiology code for the case for the billing anesthesiologist
00740-AA-QS-P2
Clinical viewpoint
The patient has a cysts of the pancreas (K86.2) and underwent Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to esophagus, stomach or duodenum, and adjacent structures (43237). The anesthesia (00740) is for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum. Note that the anesthesia is monitored anesthesia care (MAC) service (QS).
Case 66
Postoperative Diagnosis: Adrenal mass, right sided
Umbilical hernia
Procedure Performed: Umbilical hernia repair
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case while directing 5 CRNAs (PS IV)
Indications: This is a 48-year-old patient with a 4.2 cm diameter mass in his right adrenal gland and umbilical hernia. Alternative of fully laparoscopic are open surgery or simply watching the adrenal lesion for further treatment in the future. Patient has decided to pursue removal of the lesion and repair the umbilical hernia at the time.
Description of Procedure:
An incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed.
The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided, and the liver was reflected superiorly. The vena cava identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from the top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. The specimen was placed in a collection bag and removed intact. Hemostasis was excellent.
The umbilcal hernia had been completely taken down. The edges were freshened up. #1 Vicryl was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar. The skin closed with clips. The patient tolerated the procedure well. All sponge and instrument counts were correct. The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
Codes
60545, 49587-59, 88307, 12032-51, E27.8, K42.9
Overall anesthesiology code for the case for the billing anesthesiologist
00866-AD-P4
Overall anesthesiologist code for the case for the billing CRNA
0866-QX-P4
Clinical viewpoint
The patient underwent adrenalectomy with excision of adjacent retroperitoneal tumor (60545) and incarcerated umbilical hernia repair (49587-59) for right-sided adrenal mass (E27.8) and umbilical hernia (K42.9). The anesthesia is for extraperitoneal procedures in lower abdomen, including urinary tract; adrenalectomy. Note that the anesthesiologist directed 5 CRNAs (AD) and the CRNA service was with medical direction by a physician (QX).
Case 67
Postoperative Diagnosis: ALS, dysphagia
Procedure Performed: Percutaneous endoscopic gastrostomy tube placement
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Indications: Patient is a 46-year-old male requiring PEG tube placement due to dysphagia secondary to ALS. Placement of the tube was requested by the patient’s neurologist.
Description of Procedure: The flexible endoscope was advanced through the oropharynx, past the epiglottis, and into the upper esophagus. It was then advanced into the stomach, which was partially insufflated with air. The pyloris was identified and intubated, and we surveyed the second portion of the duodenum and the duodenal sweep. These were each normal. The stomach was normal on retroflexed view. There was no hiatal hernia. The gastric mucosa appeared normal. The patient’s stomach was then fully insufflated with air until the rugae were flattened. The local needle was then passed through the patient’s skin through his abdominal wall and directly into the stomach. There was no air that was found by aspiration along this route, and it was noted to enter easily into the patient’s abdomen. This was then replaced by the introducer needle and was grasped with the endoscope and was withdrawn through the patient’s mouth. A PEG tube was then attached to the guidewire and then returned in an antegrade fashion through the patient’s asophagus and out the gastric wall through a stab incision. The endoscope was re-advanced into the stomach and the stomach was surveyed. There was no bleeding that was seen. The PEG tube was withdrawn until it reached a depth of 3 cm. At depth of 3 cm, it was seen not to blanch the gastric mucosa, yet not appear to be too loose. This appropriate placement for the PEG tube. The endoscope was then withdrawn. The scope was then withdrawn after desufflating the stomach, and the procedure terminated. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Codes
43246, R13.10, G12.21
Overall anesthesiology code for the case for the billing CRNA
00740-AA-P3
Clinical viewpoint
The patient underwent esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube (43246) for dysphagia (R13.10) secondary to amyotrophic lateral sclerosis (ALS) (G12.21). The anesthesia (00740) is for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum.
Case 68
Postoperative Diagnosis: Anal condyloma
Procedure Performed: Excision and cautery destruction of anal condyloma
Surgeon: Dr. Optum
Anesthesia: Monitored anesthesia care
0.5% Marcaine with epinephrine locally
Anesthesiologist provided the monitored anesthesia care service for the case directing one CRNA (PS II)
Details of Procedure: The patient was brought to the operative suite, identified, placed in the prone jackknife position, and anesthesia was induced. A Betadine prep was carried out. The areas were grasped, pulled up and excised at their bases and the mucosa with a knife. Specimens were sent for pathology. The base of the lesion was then cauterized with the needle-tipped cautery. Multiple areas externally and into the internal canal were removed and cauterized.
There were no immediate complications. Sterile dressing was placed over the wounds. He tolerated the procedure well and was taken to the recovery area in satisfactory condition.
Surgical Findings: There were multiple anal condyloma externally and some in the internal anal canal up to the dentate line. These were all excised and the base destroyed with the cautery.
Codes
46924, 88304, A63.0
Overall anesthesiology code for the case for the billing anesthesiologist
00902-QY-QS-P2
Overall anesthesiology code for case for the billing CRNA
00902-QX-QS-P2
Clinical viewpoint
The patient underwent Destruction of lesion(s), anus (eg. condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery), as there were multiple anal condyloma externally (A63.0) and some in the internal anal canal up to the dentate line. The specimen was sent to pathology (88304). The anesthesia (00902) is for; anorectal procedure. The anesthesiologist (QY) directed one CRNA (QX) for this monitored anesthesia care service (QS).
Case 69
Date of Service: XX/XX/XXXX
Chief Complaint: Pain in abdomen
History of Present Illness: Patient is a 58-year-old white female with a past medical history significant for an MI and depression who presents today complaining of sharp, epigastric pain of approximately 2 months duration. The abdominal pain has been gradually worsening over the past 3 weeks. The pain is located in the epigastric region of the abdomen. It does not typically radiate. The pain is not alleviated at rest and is associated with food or eating, although the patient does deal with occasional heartburn as well. Patient denies any abdominal trauma or injury. Patient described a “lump in the throat” with associated dysphagia. She has experienced some nausea with the abdominal pain but has not vomited, and also has had constipation. She endorses blood stools with some bowel movements. The blood is dark red in color and is not bright red. There is sufficient amount of blood to turn the toilet water red. Patient does not know how many times per week she experiences the bleeding. She has not seen a bloody bowel movement in the past week.
Past Medical History: Well controlled hypertension
Poorly controlled depression—takes Prozac, but still feels depressed
Hospitalizations: MI, 2008
Surgeries/procedures: Cardiac catheterization, 2008
Medications: Aspirin 81 mg po qd since her MI
Metoprolol 100 mg po qd
Prozac 20 mg po qd; started 6 months ago
NKDA
Family History: Mother died at age 72 of “natural causes”
Father died at age 78 of AAA
No known family history of colon cancer
Social history: Patient is a retired school secretary. She is divorced with 5 children and 3 grandchildren. She sees them regularly but feels sad and alone. Denies use of tobacco, illicit drugs, or alcohol.
Review of systems: Constitutional—Decreased appetite, 5 lb weight loss, fatigue
Throat—complains of “lump in throat,” dysphagia
Gastrointestinal—sharp, epigastric pain, bloody stools
All others negative
Physical exam: Vital signs: Ht 5’3” wt 160 lbs HR 80 RR 16 BP 126/78
General: Patient is a well-nourished white female in no acute distress
Lymph nodes: Nontender, no palpable masses
Neck: No masses
Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops
Lungs: Lungs clear to auscultation bilaterally; no wheezes or crackles
Abdominal: Abdomen soft and nondistended with no scars or striations
No pulsatile masses, no abdominal bruits auscultated
Tender to palpation in epigastric region and left upper quadrant; no reflux tenderness; no guarding; Murphy’s sign negative
Rectal: Hemoccult positive
Diagnostic tests: Hemoccult positive stool
Assessment & Plan
Problem List: Abdominal pain
Melena
Hemoccult was positive for blood in the stool. Discussed with patient the need to schedule a colonoscopy to evaluate the colon for presence of polyps or tumors. Also, start Protonix 40 mg po bid to decrease the level of acid in the stomach.
Procedure performed: Colonoscopy
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS II).
Codes
99254, 45378, R10.9, K92.1
Overall anesthesiology code for the billing anesthesiologist
00810-AA-P2
Clinical viewpoint
The anesthesia (00810) is for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum. The consult is an inpatient consult (99254). The patient underwent colonoscopy (45378), flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) to evaluate for the presence of polyps or tumors. Epigastric pain (R10.13) and melena (K92.1) are the diagnoses.
Case 70
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Idiopathic thrombocytopenia, splenomegaly
Procedure Performed: Splenectomy
Anesthesia: General
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Operative Findings: The spleen was larger than expected. Possible hypersplenism causing the thrombocytopenia. Splenic pathology will provide additional details. The liver was without obvious masses. The small bowel, colon, and gall bladder were without any obvious abnormalities.
Description of Procedure: The patient was taken to the operating room. A midline celiotomy incision was made a few centimeters below below the xiphoids to an infraumbilical position. The skin was divided with scalpel followed by cautery for the remaining layers. The fascia was elevated and entered with cautery to gain access to the abdomen. The incision was then extended using cautery. The spleen could be visualized at this point, and it was quite large. There were adhesions at the superior pole to the diaphragm that made attempts to move the spleen toward the midline difficult. These adhesions were divided with cautery. The spleen was pulled down and medial to begin the dissection. The inferior pole near the splenorenal ligament was divided with a combination of cautery and clamps with ties. We then took down short gatrics, which freed up the superior pole of the spleen. This created the ability to visualize the hilar structures. The remaining vessels were divided using serially applied clamps and either suture ligature or stick ties as appropriate. Separate divisions of the superior and inferior pole vessels were performed. The spleen was then completely removed and passed off the field as the specimen to be sent to pathology. Hemostasis was obtained using additional stick ties where necessary and argon beam cautery on the raw areas of prior spleen to retroperitoneal attachments and the diaphragmatic attachments to the spleen. After hemostasis was obtained, irrigation was performed. The fascia was closed with a double-looped #1 Maxon suture. The subcutaneous tissue was thoroughly irrigated, and the skin closure was performed with staples. Appropriate dressings were applied. The patient tolerated the procedure well and was transported to recovery in stable condition.
Case
38100, 88305, D69.3, R16.1
Overall anesthesiology code for the billing anesthesiologist
00790-AA-P3
Clinical viewpoint
The patient underwent splenectomy, total (separate procedure) (38100) for splenomegaly (R16.1) caused by immune thrombocytopenic purpura (D69.3). The hypersplenism might be causing the thrombocytopenia. The anesthesia (00790) is for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified.
Case 61
Postoperative Diagnosis:
Heartburn
Diverticulosis of the colon
Internal hemorrhoids
Possible short segment Barrett esophagus
Procedure Performed:
Colonoscopy with internal hemorrhoid banding x 1
Flexible esophagogastroduodenoscopy with biopsies
Surgeon:
Dr. Optum
Anesthesia:
MAC anesthesia with topical for EGD in pharynx
Anesthesiologist performed the monitored anesthesia care (MAC) service for the case while directing one CRNA (PS III)
Estimated Blood Loss:
Minimal
Description of Procedure:
The flexible Olympus upper GI endoscope was passed through the bite block into the posterior pharynx. The esophageal orifice was identified and cannulated. Insufflation, irrigation, and suction were utilized appropriately, and representative photographs were taken. The scope was advanced down the esophagus into the stomach, past pylorus into the duodenum, brought back into the stomach, retroflexed on itself. Biopsies were taken with cold biopsy forceps of the antral mucosa for urease testing and of the distal esophagus for histopathology analysis and no significant ongoing hemorrhage ensued. The gas suctioned, scope removed slowly and carefully, and this portion of the procedure was terminated.
Olympus colonoscope was inserted into the anal canal and advanced into the rectum. The scope was advanced into the rectosigmoid junction, negotiated through a very loopy, redundant sigmoid colon into the descending colon. I was able to get past the splenic flexure. I was able to get past the transverse colon and the hepatic flexure into the ascending colon, ultimately past the ileocecal valve into the cecum.
A digital rectal exam was performed and then I proceeded to perform band ligation with single prominent internal hemorrhoid, and the Olympus upper GI endoscope was fitted with the multiband ligator as per standard routine. The hemorrhoid was suctioned and the band deployed. The band was adequately placed and the other surrounding hemorrhoids did not appear to be amenable to band ligation as they were much smaller and less prominent. The air was suctioned and the scope removed.
Findings:
The patient had normal laryngeal and posterior pharyngeal structures. The esophageal orifice was normal, proximal and middle esophagus normal. The GE junction was situated approximately 40 cm from the incisors. There was certainly some irregularity at the GE junction and a couple of tiny islands of gastric-type mucosa suggesting the presence of short segment Barrett esophagus.
The length was certainly only a few millimeters. No evidence of strictures, rings, diverticula, or significant esophagitis was seen. No significant hiatal hernia was appreciated. No polyps or carcinoma. Gastric lumen distended normally. There were no ulcer, no polyps, and no evidence of malignancy. The cardia, fundus, body, antrum, and prepyloric areas were all normal. The pylorus was patent and normal. Duodenal bulb, second, third, and fourth portions, of the duodenum were normal. Random biopsy of the antral mucosa was obtained for urease testing, and biopsies of the distal esophagus were obtained to assess for the presence of Barrett metaplasia.
Colonoscopy revealed fairly good bowel prep, although areas of the cecum and ascending colon were a bit under-prepped and probably future bowel prep should be a bit more aggressive. In any event, the patient does have some scattered medium mouthed diverticula in the left colon. No evidence of diverticulitis or strictures were seen. No polyps were seen. No evidence of carcinoma was seen. The patient had a exceedingly redundant sigmoid colon with the entire length of the colonoscope inserted by about the mid transverse colon quite a lot of manipulation and counter pressure to the abdominal wall again access to the cecum, which was ultimately successful, but required a lot of effort. The patient does have internal hemorrhoids, which were not bleeding. There was one in particular that appeared more anteriorly situated. It appeared to be larger than the rest and mildly inflamed and I chose that for internal bleeding; utilizing the multiband ligator, I placed a single band on that particular hemorrhoid without incident.
Codes
45398, 43239-59-53, 88305, 88305+88314, K64.8, K57.30, R12, K22.70
Overall anesthesiology code for the case for the billing anesthesiologist
00810-QS-QY
Overall anesthesiology code for the case for the billing CRNA
00810-QS-QX
Clinical viewpoint
The patient is being treated for heartburn (R12), Diverticulosis of colon (K57.30), Internal hemorrhoids (K64.8), and Possible short segment Barrett esophagus (K22.70). The patient underwent Flexible esophagogastroduodenoscopy, transoral, diagnositc with biopsy, single or multiple (43239-59-53) and Flexible colonoscopy, diagnostic with band ligation(s) (e.g., hemorrhoids) with specimens sent to pathology for histopathology analysis (+88314) of stomach biopsy (88305) and esophagus biopsy (88305) for presence of Barrett metaplasia. The anesthesia (00810) is for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum. The anesthesia was monitored anesthesia care (MAC) service (QS).
Case 62
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Abscess, left leg, positive for MRSA
Procedure Performed: Incision and drainage, left leg
Surgeon: Dr. Optum
Anesthesia: Regional block with moderate sedation
Anesthesiologist personally provided the regional anesthesia for the case (PS III)
Estimated Blood Loss: Less than 25 ml
Description of Procedure: The patient was brought into the operating room. The regional block had been previously administered in the holding area. Anesthesia administered the moderate sedation. The skin was incised sharply with a scalpel over the fluctuant mass in the anteromedial left leg. Copious amount of purulence was drained; this was suctioned. The wound was probed and the fibrous bands were broken up. Hemostasis was achieved with electrocautery. The wound was then packed with Betadine-soaked gauze. A dry dressing was placed around this followed by an Ace wrap. The patient tolerated the procedure well. He was transported to the recovery area in stable condition.
Findings: Pathology reports MRSA in the purulent drainage sent and cultured. Start patient on Clindamycin 600 mg IV.
Codes
10061, 88304, L02.416, B95.62
Overall anesthesiology code for the case for the billing anesthesiologist
00400-AA-P3
Clinical viewpoint
The patient underwent Incision and drainage of a complicated abscess of the leg (10061) and purulent drainage sent to pathology (88304). The cutaneous abscess of the lower limb (L02.416) had MRSA in the purulent drainage (B95.62). The anesthesia is for procedures on the integumentary system on the extremities, anterior trunk, and perineum; not otherwise specified (00400). The procedure was a major procedure requiring regional block with moderate sedation. Regional block is coded as an anesthesiology code, as it is one of the four types of anesthesia (General, regional, monitored anesthesia care, and local). Local anesthesia is bundled with the procedure.
Case 63
Date of Operation
X/XX/XXXX
Postoperative Diagnosis: End-stage renal disease with need for dialysis access. Staged right brachiobasilic arteriovenous fistula creation.
Procedure Performed: Transposition right brachiobasilic AV fistula in the subcutaneous tunnel—completion of procedure started XX/XX/XXXX
Surgeon: Dr. Optum
Anesthesia: Supraclavicular block, followed by general endotracheal anesthesia
Anesthesiologist personally provided the supraclavicular block followed by general endotracheal anesthesia
Indications: This 52-year-old female end-stage renal disease patient is in need of a permanent dialysis access. This patient currently requires hemodialysis using a temporary dialysis catheter. At this time the second and final phase of a staged right brachiobasilic arteriovenous fistula creation will be completed.
Estimated blood loss: Minimal
Description of Procedure: It ultimately became necessary to induce general anesthesia in this patient. The entire procedure was done under 2.5X loop magnification. The vein was exposed with a longitudinal incision over the inner aspect of the right upper arm, lengthening the incision in stepwise fashion, bringing the vein into view from the elbow to the axilla. The vein was then elevated by taking branches between 4-0 silk ties and baby Hemoclips. The larger branches were doubly tied on the vein side. The vein was now much more mobile. A pocket was developed in the subcutaneous tissues out laterally over the biceps muscle, elevating the skin and fat layer up and away from the underlying fascia. The vein was positioned out over the biceps muscle, and the tissues were then reapproximated down over the vein with interrupted 3-0 Vicryl, being sure not the put any undue pressure on the vein. A good strong thrill was maintained throughout. The wound was then irrigated with saline. The subcutaneous tissue was closed with 3-0 Vicryl. Skin was closed with simple and vertical mattress sutures of 4-0 nylon. Dressings were applied as well as an arm board and the procedure completed. Sponge, needle, and instrument counts reported as correct. Patient tolerated the procedure well. She was awakened, extubated, and taken to recovery room in satisfactory condition.
Codes
36819-RT,58, N18.6, Z99.2
Overall anesthesiology code for the case for the billing anesthesiologist
01844-AA-P3, 64418
Clinical viewpoint
The patient underwent arteriovenous anastomosis by upper arm basilica transposition (36819) for end-stage renal disease (N18.6) requiring dialysis access (Z99.2). The anesthesia (01844) was for vascular shunt, or shunt revision, any type (e.g dialysis). Supraclavicular block (64418), a nerve block which counts as regional anesthesia was in addition performed prior to the general endotracheal anesthesia and counts as an anesthesiology code.
Case 64
Date of Procedure: X/XX/XXXX
Postoperative Diagnosis: Malignant melanoma, chest (1 cm)
Surgeon: Dr. Optum
Anesthesia: General endotracheal
Anesthesiologist personally provided general endotracheal anesthesia (PS IV)
Procedure: Excision of skin lesion of chest wall
Description of Procedure: The mid-cheek was prepped and draped in sterile fashion, and cleaned with Betadine solution. A margin of 2 cm laterally and medially around the lesion site was taken in addition to the 1 cm lesion. The incision was carried down to the muscle fascia, which was included in the specimen. Bleeding was controlled by electrocautery, and we closed the defect with running subcuticular 4-0 Vicryl using layered closure. Steri-strips and a sterile bandage were applied. The patient tolerated the procedure well.
Operative Findings: Pathology determined the lesion was malignant melanoma. Margins were clean and it does not appear that additional treatment is required at this time. Appropriate counseling on sun protection and the other risk factors and preventive measures provided.
Codes
11606, 12032-59, C43.59
Overall anesthesiology code
00300-AA-P4
Clinical viewpoint
The patient has malignant melanoma of the chest (C43.59) and underwent excision of malignant skin lesion of the chest wall with 2 cm margins for a 1 cm lesion size for a total excised diameter of 5 cm (11606) with Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm for the layered closure. The anesthesia (00300) was for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified. The patient has severe systemic disease, malignant melanoma which is a constant threat to life (P4).
Case 65
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Abdominal pain, cystic lesions of pancreas, suspicious for branchial intraductal papillary mucinous neoplasm
Surgeon: Dr. Optum
Anesthesia: Monitored anesthesia care (MAC) service
Anesthesiologist personally provided the Monitored anesthesia care (MAC) service (PS II)
Procedure: Upper endoscopic ultrasound
Description of Procedure: After obtaining informed consent the endoscope was passed under vision. Throughout the procedure, the patient’s blood pressure, pulse, and oxygen saturation were monitored continuously. The endoscopic with transducer was introduced through the mouth and advanced to the second part of the duodenum. Findings are detailed below. The upper EUS was accomplished without difficulty. The patient tolerated the procedure well.
Endosonographic Findings: An anechoic lesion suggestive of a cyst was identified in the pancreatic head. The lesion measured 4 mm by 3 mm. There was no associated mass.
An anechoic lesion suggestive of cyst was identified in the pancreatic neck. The lesion measured 9 mm by 8 mm. There was no associated mass. There was no internal debris within the fluid-filled cavity.
An anechoic lesion suggestive of cyst was identified in the pancreatic body. The lesion measured 7 mm by 6 mm. There was no associated mass. There was no internal debris within the fluid-filled cavity.
The celiac axis including lymph nodes was unremarkable. The examined portion of the left lobe of the liver and the gastrohepatic ligament were evaluated and found to be without abnormalities.
The pancreas was examined and the parenchyma demonstrated three cystic lesions as above. The main pancreatic duct measured 1.7 mm in the head, 1.1 mm in the body, and 1.0 mm in the tail. The ampulla was normal endoscopically and endosonographically. The bile duct ranged in size from 1.9 mm to 2.4 mm in size and was normal in appearance. The gallbladder was normal in appearance.
Overall Impression: A 4 mm by 3 mm cystic lesion was seen in the pancreatic head. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious for a branched intraductal papillary mucinous neoplasm.
A 9 mm by 8 mm cystic lesion was seen in the pancreatic neck. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious for branched intraductal papillary mucinous neoplasm.
A 7 mm by 6 mm cystic lesion was seen in the pancreatic body. Tissue has not been obtained. However, the endosonographic appearance is highly suspicious of for branched intraductal papillary mucinous neoplasm.
Codes
43237, K86.2
Overall anesthesiology code for the case for the billing anesthesiologist
00740-AA-QS-P2
Clinical viewpoint
The patient has a cysts of the pancreas (K86.2) and underwent Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to esophagus, stomach or duodenum, and adjacent structures (43237). The anesthesia (00740) is for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum. Note that the anesthesia is monitored anesthesia care (MAC) service (QS).
Case 66
Postoperative Diagnosis: Adrenal mass, right sided
Umbilical hernia
Procedure Performed: Umbilical hernia repair
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case while directing 5 CRNAs (PS IV)
Indications: This is a 48-year-old patient with a 4.2 cm diameter mass in his right adrenal gland and umbilical hernia. Alternative of fully laparoscopic are open surgery or simply watching the adrenal lesion for further treatment in the future. Patient has decided to pursue removal of the lesion and repair the umbilical hernia at the time.
Description of Procedure:
An incision was made from just above the umbilicus, about 5.5 cm in diameter. The umbilical hernia was taken down. An 11 mm trocar was placed in the midline, superior to the GelPort and a 5 mm trocar placed in the midaxillary line below the costal margin. A liver retractor was placed.
The colon was reflected medially by incising the white line of Toldt. The liver attachments to the adrenal kidney were divided, and the liver was reflected superiorly. The vena cava identified. The main renal vein was identified. Coming superior to the main renal vein, staying right on the vena cava, all small vessels were clipped and then divided. Coming along the superior pole of the kidney, the tumor was dissected free from the top of the kidney with clips and Bovie. The harmonic scalpel was utilized superiorly and laterally. Posterior attachments were divided between clips and once the whole adrenal was mobilized, the adrenal vein and one large adrenal artery were noted, doubly clipped, and divided. The specimen was placed in a collection bag and removed intact. Hemostasis was excellent.
The umbilcal hernia had been completely taken down. The edges were freshened up. #1 Vicryl was utilized to close the incision and 2-0 Vicryl was used to close the fascia of the trocar. The skin closed with clips. The patient tolerated the procedure well. All sponge and instrument counts were correct. The patient was awakened, extubated, and returned to recovery room in satisfactory condition.
Codes
60545, 49587-59, 88307, 12032-51, E27.8, K42.9
Overall anesthesiology code for the case for the billing anesthesiologist
00866-AD-P4
Overall anesthesiologist code for the case for the billing CRNA
0866-QX-P4
Clinical viewpoint
The patient underwent adrenalectomy with excision of adjacent retroperitoneal tumor (60545) and incarcerated umbilical hernia repair (49587-59) for right-sided adrenal mass (E27.8) and umbilical hernia (K42.9). The anesthesia is for extraperitoneal procedures in lower abdomen, including urinary tract; adrenalectomy. Note that the anesthesiologist directed 5 CRNAs (AD) and the CRNA service was with medical direction by a physician (QX).
Case 67
Postoperative Diagnosis: ALS, dysphagia
Procedure Performed: Percutaneous endoscopic gastrostomy tube placement
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Indications: Patient is a 46-year-old male requiring PEG tube placement due to dysphagia secondary to ALS. Placement of the tube was requested by the patient’s neurologist.
Description of Procedure: The flexible endoscope was advanced through the oropharynx, past the epiglottis, and into the upper esophagus. It was then advanced into the stomach, which was partially insufflated with air. The pyloris was identified and intubated, and we surveyed the second portion of the duodenum and the duodenal sweep. These were each normal. The stomach was normal on retroflexed view. There was no hiatal hernia. The gastric mucosa appeared normal. The patient’s stomach was then fully insufflated with air until the rugae were flattened. The local needle was then passed through the patient’s skin through his abdominal wall and directly into the stomach. There was no air that was found by aspiration along this route, and it was noted to enter easily into the patient’s abdomen. This was then replaced by the introducer needle and was grasped with the endoscope and was withdrawn through the patient’s mouth. A PEG tube was then attached to the guidewire and then returned in an antegrade fashion through the patient’s asophagus and out the gastric wall through a stab incision. The endoscope was re-advanced into the stomach and the stomach was surveyed. There was no bleeding that was seen. The PEG tube was withdrawn until it reached a depth of 3 cm. At depth of 3 cm, it was seen not to blanch the gastric mucosa, yet not appear to be too loose. This appropriate placement for the PEG tube. The endoscope was then withdrawn. The scope was then withdrawn after desufflating the stomach, and the procedure terminated. The patient tolerated the procedure well and was taken to the recovery room in stable condition.
Codes
43246, R13.10, G12.21
Overall anesthesiology code for the case for the billing CRNA
00740-AA-P3
Clinical viewpoint
The patient underwent esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube (43246) for dysphagia (R13.10) secondary to amyotrophic lateral sclerosis (ALS) (G12.21). The anesthesia (00740) is for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum.
Case 68
Postoperative Diagnosis: Anal condyloma
Procedure Performed: Excision and cautery destruction of anal condyloma
Surgeon: Dr. Optum
Anesthesia: Monitored anesthesia care
0.5% Marcaine with epinephrine locally
Anesthesiologist provided the monitored anesthesia care service for the case directing one CRNA (PS II)
Details of Procedure: The patient was brought to the operative suite, identified, placed in the prone jackknife position, and anesthesia was induced. A Betadine prep was carried out. The areas were grasped, pulled up and excised at their bases and the mucosa with a knife. Specimens were sent for pathology. The base of the lesion was then cauterized with the needle-tipped cautery. Multiple areas externally and into the internal canal were removed and cauterized.
There were no immediate complications. Sterile dressing was placed over the wounds. He tolerated the procedure well and was taken to the recovery area in satisfactory condition.
Surgical Findings: There were multiple anal condyloma externally and some in the internal anal canal up to the dentate line. These were all excised and the base destroyed with the cautery.
Codes
46924, 88304, A63.0
Overall anesthesiology code for the case for the billing anesthesiologist
00902-QY-QS-P2
Overall anesthesiology code for case for the billing CRNA
00902-QX-QS-P2
Clinical viewpoint
The patient underwent Destruction of lesion(s), anus (eg. condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg. laser surgery, electrosurgery, cryosurgery, chemosurgery), as there were multiple anal condyloma externally (A63.0) and some in the internal anal canal up to the dentate line. The specimen was sent to pathology (88304). The anesthesia (00902) is for; anorectal procedure. The anesthesiologist (QY) directed one CRNA (QX) for this monitored anesthesia care service (QS).
Case 69
Date of Service: XX/XX/XXXX
Chief Complaint: Pain in abdomen
History of Present Illness: Patient is a 58-year-old white female with a past medical history significant for an MI and depression who presents today complaining of sharp, epigastric pain of approximately 2 months duration. The abdominal pain has been gradually worsening over the past 3 weeks. The pain is located in the epigastric region of the abdomen. It does not typically radiate. The pain is not alleviated at rest and is associated with food or eating, although the patient does deal with occasional heartburn as well. Patient denies any abdominal trauma or injury. Patient described a “lump in the throat” with associated dysphagia. She has experienced some nausea with the abdominal pain but has not vomited, and also has had constipation. She endorses blood stools with some bowel movements. The blood is dark red in color and is not bright red. There is sufficient amount of blood to turn the toilet water red. Patient does not know how many times per week she experiences the bleeding. She has not seen a bloody bowel movement in the past week.
Past Medical History: Well controlled hypertension
Poorly controlled depression—takes Prozac, but still feels depressed
Hospitalizations: MI, 2008
Surgeries/procedures: Cardiac catheterization, 2008
Medications: Aspirin 81 mg po qd since her MI
Metoprolol 100 mg po qd
Prozac 20 mg po qd; started 6 months ago
NKDA
Family History: Mother died at age 72 of “natural causes”
Father died at age 78 of AAA
No known family history of colon cancer
Social history: Patient is a retired school secretary. She is divorced with 5 children and 3 grandchildren. She sees them regularly but feels sad and alone. Denies use of tobacco, illicit drugs, or alcohol.
Review of systems: Constitutional—Decreased appetite, 5 lb weight loss, fatigue
Throat—complains of “lump in throat,” dysphagia
Gastrointestinal—sharp, epigastric pain, bloody stools
All others negative
Physical exam: Vital signs: Ht 5’3” wt 160 lbs HR 80 RR 16 BP 126/78
General: Patient is a well-nourished white female in no acute distress
Lymph nodes: Nontender, no palpable masses
Neck: No masses
Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops
Lungs: Lungs clear to auscultation bilaterally; no wheezes or crackles
Abdominal: Abdomen soft and nondistended with no scars or striations
No pulsatile masses, no abdominal bruits auscultated
Tender to palpation in epigastric region and left upper quadrant; no reflux tenderness; no guarding; Murphy’s sign negative
Rectal: Hemoccult positive
Diagnostic tests: Hemoccult positive stool
Assessment & Plan
Problem List: Abdominal pain
Melena
Hemoccult was positive for blood in the stool. Discussed with patient the need to schedule a colonoscopy to evaluate the colon for presence of polyps or tumors. Also, start Protonix 40 mg po bid to decrease the level of acid in the stomach.
Procedure performed: Colonoscopy
Anesthesia: General endotracheal
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS II).
Codes
99254, 45378, R10.9, K92.1
Overall anesthesiology code for the billing anesthesiologist
00810-AA-P2
Clinical viewpoint
The anesthesia (00810) is for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum. The consult is an inpatient consult (99254). The patient underwent colonoscopy (45378), flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) to evaluate for the presence of polyps or tumors. Epigastric pain (R10.13) and melena (K92.1) are the diagnoses.
Case 70
Date of Procedure: XX/XX/XXXX
Postoperative Diagnosis: Idiopathic thrombocytopenia, splenomegaly
Procedure Performed: Splenectomy
Anesthesia: General
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Operative Findings: The spleen was larger than expected. Possible hypersplenism causing the thrombocytopenia. Splenic pathology will provide additional details. The liver was without obvious masses. The small bowel, colon, and gall bladder were without any obvious abnormalities.
Description of Procedure: The patient was taken to the operating room. A midline celiotomy incision was made a few centimeters below below the xiphoids to an infraumbilical position. The skin was divided with scalpel followed by cautery for the remaining layers. The fascia was elevated and entered with cautery to gain access to the abdomen. The incision was then extended using cautery. The spleen could be visualized at this point, and it was quite large. There were adhesions at the superior pole to the diaphragm that made attempts to move the spleen toward the midline difficult. These adhesions were divided with cautery. The spleen was pulled down and medial to begin the dissection. The inferior pole near the splenorenal ligament was divided with a combination of cautery and clamps with ties. We then took down short gatrics, which freed up the superior pole of the spleen. This created the ability to visualize the hilar structures. The remaining vessels were divided using serially applied clamps and either suture ligature or stick ties as appropriate. Separate divisions of the superior and inferior pole vessels were performed. The spleen was then completely removed and passed off the field as the specimen to be sent to pathology. Hemostasis was obtained using additional stick ties where necessary and argon beam cautery on the raw areas of prior spleen to retroperitoneal attachments and the diaphragmatic attachments to the spleen. After hemostasis was obtained, irrigation was performed. The fascia was closed with a double-looped #1 Maxon suture. The subcutaneous tissue was thoroughly irrigated, and the skin closure was performed with staples. Appropriate dressings were applied. The patient tolerated the procedure well and was transported to recovery in stable condition.
Case
38100, 88305, D69.3, R16.1
Overall anesthesiology code for the billing anesthesiologist
00790-AA-P3
Clinical viewpoint
The patient underwent splenectomy, total (separate procedure) (38100) for splenomegaly (R16.1) caused by immune thrombocytopenic purpura (D69.3). The hypersplenism might be causing the thrombocytopenia. The anesthesia (00790) is for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified.