Operative Report Examination:
Take 5 Steps When Coding Complex Turbinate Excision
Published on Tue Jul 11, 2006
Determine whether the procedure was -unusual- before you append 22 When you-re coding a procedure with an operative report that seems to repeat the same information twice, don't adjust your glasses -- the simple explanation could be that your surgeon performed a bilateral procedure.
Read on as in-the-trenches coders weigh in with their take on one tricky operative note.
The following op report details an endoscopic sinus procedure that you may have coded before, but this one has a twist. Review the Op Report's Key Details Patient's diagnosis: Chronic sinusitis with chronic nasal airway obstruction due to bilateral inferior turbinate hypertrophy. Procedure overview: Bilateral endoscopic anterior and posterior ethmoidectomies, bilateral endoscopic maxillary antrostomies, and bilateral inferior turbinate excision. The pertinent details of the operative report: I medialized the left middle turbinate and took down the uncinate using a Cottle and then removed it using straight-biting forceps. I entered the ethmoid bulla low using straight suction and took down the face of the bulla using up-through-biting forceps. I began the dissection posteriorly through the ethmoid air cell system into the posterior ethmoid air cell and identified the skull base.
I continued the dissection from posterior to anterior under 25 degree endoscopic visualization and removed small fragments of bone and inflammatory tissue as encountered into the frontal recess region. I opened the natural maxillary os using forward and backbiting instrumentation and placed the packs for hemostasis.
I then medialized the right middle turbinate and took down the uncinate using a Cottle and removed it using straight-biting forceps. I continued the dissection from posterior to anterior under 25 degree endoscopic visualization and removed small fragments of bone and inflammatory tissue as encountered. I identified the natural maxillary os with a ball seeker and opened it widely using forward and backbiting instrumentation. I placed packs for hemostasis.
I injected Xylocaine 1 percent with 100,000 of epinephrine into each inferior turbinate and middle turbinate. After waiting the appropriate time, I made an incision on the medial surface of each inferior and middle turbinate in their anterior third parallel to the floor of the nose.
I then raised superior and inferior flaps on each of the four turbinates and removed a part of the underlying bone on the medial surface of each of the four turbinate bones with a rongeur. I then out fractured each of the four turbinates. There appeared to be significant increase in the size of the nasal passages bilaterally.
The patient bled consistently the entire time that the hyperplastic tissue was in his sinuses. Overall, the patient lost three units of blood during the procedure. I placed a Murocel sponge into the middle meatus and then achieved hemostasis. Break Down Your Coding Options
Step 1: [...]
