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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 46
Anesthesiologist provided the general endotracheal anesthesia for the case. The patient is a healthy 25 year old male (PS I) who pulled his left shoulder while playing baseball. On physical exam, he is found by his physician to have a left rotator cuff tear secondary to trauma. He underwent arthroscopic rotator cuff repair.
Codes
S46.012A, Y93.64, 29827
ASA Crosswalk Lookup
29827=5 base value=01630
Overall anesthesiology code for the billing anesthesiologist
01630-AA-P1
Clinical viewpoint
The anesthesia (01630) is for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acriomioclavicular joint, and shoulder joint; not otherwise specified. The patient has a rotator cuff tear involving strain of muscles and tendons (S46.012A) secondary to trauma from playing baseball.
Case 47
Anesthesiologist provided the general endotracheal anesthesia. The patient is a healthy 30 year old female (PS I) who suffers from impingement symptoms of the left shoulder dating back to a motorcycle accident. She was seen for a diagnostic left shoulder arthroscopy with arthroscopic subacromial decompression and debridement.
Codes
M75.42, V29.9XXS, 29822+29826, 29805
ASA Crosswalk Lookup
29822=5 base value units=01630
29826=NOT A PRIMARY PROCEDURE CODE
29805=4 base value units=01622
Overall anesthesiology code for the case for the billing anesthesiologist
01630-AA-P1
Clinical viewpoint
The patient suffers from impingement syndrome of the left shoulder (M75.42) from a motorcycle accident (V29.9XXS). The base value units is highest (=5) for 01630. Anesthesia is for open or surgical arthroscopic procedures on humeral head and neck.
Case 48
Anesthesiologist provided the general endotracheal anesthesia for the case (PS I). The patient is a 25 year old healthy male (PS I) who fell during a skiing accident two months ago. He was found to have an intervertebral disc displacement (L5-S1) with myelopathy. He underwent a percutaneous Laminotomy with Transforaminal endoscopic discectomy with ultra-minimally invasive microdiscectomy and foraminotomy.
Codes
M51.06, Y93.23, Y92.838, 0275T
ASA Crosswalk Lookup
0275T=5 base value units=01936
Overall anesthesiology code for the case
01936-AA-P1
Total units calculation for a 3.5 hour operation
Total Units=Base+Time+PS+Emergency
Total units=5+14.0+0+0=19.0
Clinical viewpoint
The patient received anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic (01936). The procedure code (0275T) is a T code.
Case 49
Anesthesiologist provided the general endotracheal anesthesia for the case (PS IV), supervising two CRNAs. The anesthesiologist placed a left internal jugular central venous catheter and a right radial arterial line prior to the beginning of the case. A 45 year old female patient with multifocal breast cancer presents to have a total right modified radical mastectomy with sentinel lymph node injection and biopsy. Subcutaneous tissue dissected down and flaps were elevated to clavicle, sternum, and the rectus fascia. The breast was pulled medially and dissected out of the right axilla area. Two blue-stained sentinel nodes were removed and additional enlarged nodes were removed and sent for frozen section.
Codes
C50.911, 19307, 38792
ASA Crosswalk Lookup
19307=5 base value units=00404
38792=anesthesia care not typically required
Overall anesthesiology code for the case for the billing anesthesiologist
00404-QK-P4,
36556, 36620
Overall anesthesiology code for the case for the billing CRNA
00404-QX-P4
Total units for a 6 hour operation
Total units=Base+Time+PS+Emergency
Total units=5+24.0+2+0=29.0
Clinical viewpoint
The breast cancer patient (C50.911) underwent modified radical mastectomy (19307) involving surgical removal of the breast, dissection into the axilla, staining of two sentinel nodes (38792), and removal of the two sentinel lymph nodes. The anesthesia (00404) is for procedures on the integumentary system on the extremities, anterior trunk, and perineum; radical or modified radical procedures on the breast. PS IV yields 2 units on the units calculation. The anesthesiologist directs 2 CRNAs (QK). CRNA service is with medical direction by a physician (QX).
Case 50
Anesthesiologist performed the general endotracheal anesthesia for the case (PS III). A 35 year old male patient is suffering from chronic mastoiditis, hearing loss, and tympanic membrane perforation. He has sustained facial palsy from one of the prior surgeries and now presents for radical mastoidectomy, facial nerve decompression, and debridement, mastoid obliteration, and a temporalis muscle flap rotation.
Codes
H70.10, H91.90, H72.90, 69603, 15732
ASA Crosswalk Lookup
69603=5 base value units=00120
15732=5 base value units=00300
Overall anesthesiology code for the billing anesthesiologist
00120-AA-P3
Clinical viewpoint
The overall anesthesiology code is 00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified. In this case there was a tie in ASA Crosswalk Lookup. The first listed CPT code with corresponding anesthesiology code breaks the tie. In this case, a revision mastoidectomy; resulting in radical mastoidectomy is listed as the first CPT code (69603).
Case 51
Postoperative diagnosis: Acute suppurative appendicitis
Procedure: Laparoscopic appendectomy
Anesthesia: General endotracheal and local
Anesthesiologist performed the general endotracheal anesthesia for the case overseeing 2 CRNAs (PS III).
Anesthesia time: 2 hours
Blood loss: Minimal to none
Complications: None
Description of procedure: The 45 year old male patient was brought in to the OR. General anesthesia was induced without difficulty. Optiview technique was used to enter the abdominal cavity via the supraumbilical midline. Inspection of the abdominal cavity showed inflammatory process in the right lower quadrant, easily identifying the appendix as the source. The appendix was transected at the base of the cecum without difficulty. The appendix was placed in an Endocatch and removed via the 12 mm trocar site. I then irrigated 2 liters of normal saline in the abdominal cavity. I aspirated over the dome of the liver, right lower quadrant, and the pelvis. No surrounding injury to any bowel. No other interloop abscess is identified. The patient tolerated the procedure well. I released the pneumoperitoneum and injected all trocar sites with Marcaine, closed the skin with 4-0 Monocryl and Dermabond.
Codes
44970, K35.80
ASA Crosswalk Lookup
44970=6 base value units=00840
Overall anesthesiology code for the billing anesthesiologist
00840-QK-P3
Overall anesthesiology code for the billing CRNA
00840-QX-P3
Total Units calculation= Base+Time+PS+Emergency=
6+8.0+1+0=14.0
Clinical viewpoint
The patient has acute suppurative appendicitis (PS III) requiring Laparoscopic appendectomy. The anesthesia (00840) was for intraperitoneal procedures in the lower abdomen including laparoscopy; not otherwise specified. In this case the anesthesiologist (QK) directed 2 CRNAs (QX) for the anesthesiology case.
Case 52
Indications The patient is a 62-year-old female who presented to Dr. Optum’s office with an abnormal mammogram of the right breast. The film a suspicious area on the right breast with microcalcifications and a nonpalpable mass. After discussion with the patient about best options on how to proceed, it was decided to perform a needle-localized breast biopsy.
Postoperative diagnosis: Right breast mass
Procedure: Needle-localized excisional biopsy of the right breast
Anesthesia: General endotracheal
Anesthesiologist personally performed the general endotracheal anesthesia for the case (PS III).
Anesthesia time: 3.50 hours
Description of procedure: The patient was brought to the procedure room. The needle had been previously placed in the lesion in the right breast by radiology. After IV sedation was given, the patient was then prepped and draped in the normal sterile fashion.
After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. The lesion with needle was then grasped with an Allis clamp. Using a #10 blade scalpel, the specimen was colonized out and sent to radiology for confirmation. Next, hemostasis was obtained using electrobovie cautery. The skin was then closed with #4-0 Monocruyl suture in subcuticular fashion. Steri-Strips and a sterile dressing were applied to the surgical wound. The patient tolerated the procedure quite well and left the procedure well and left the procedure room in stable condition.
Intraoperative findings
Nonpalpable right breast mass, excised and sent to radiology with confirmation that the mass is in the specimen.
Codes
19083-RT, 88307, N63, R92.0
ASA Crosswalk Lookup
19083=3 base value units=00400
Overall anesthesiology code for the billing anesthesiologist
00400-AA-P3
Units calculation=Base+time+PS+Emergency=
3+14.0+1+0=17.0
Clinical viewpoint
The patient had microcalcifications on mammogram (R92.0) which was found to be a breast mass in the OR (N63). She has a specimen which was removed from the right breast with a needle-localized excisional biopsy (19037) and sent to pathology (88307). The anesthesia (0400) was for procedures on the integumentary system on the extremities, anterior trunk, and perineum; not otherwise specified. In this case it is important to remember that the breast is part of the integumentary system.
Case 53
Postoperative diagnosis Bilateral cervical lymphadenopathy
Procedure: Biopsy of right posterior triangle cervical node
Anesthesia: General endotracheal; Xylocaine 1% with epinephrine supplemented with IV sedation
Anesthesiology was performed by anesthesiologist directing one CRNA (PS III)
Findings: A 10 x 8 mm node was present in the posterior triangle of the right neck. This was readily palpable, removed, and sent fresh for flow cytometry and histology.
Estimated blood loss: Minimal
Description of procedure: Under satisfactory preoperative medicine, the patient was taken to the operating room. The right neck was prepped with Chloraprep and draped in the usual sterile manner. The palpable node was marked with marking pen. The skin, subcutaneous tissue, and subplatysmal tissue were infiltrated with 1% Xylocaine with epinephrine. Transverse incision was made, and the platysmal muscle was split in the direction of its fibers. The lymph node was identified and very carefully dissected from the surrounding tissue. No bleeding was encountered. The node was sent fresh. The platysma was closed with running simple suture of 4-0 Vicryl. The skin was closed with a running subcuticular suture of 4-0 Vicryl.
Codes
38520, 88305, 88182+88314, R59.1
ASA Crosswalk Lookup
38520=6 base value units=00320
Overall anesthesiology code for the billing anesthesiologist
00320-QY-P3
Overall anesthesiology code for the billing CRNA
00320-QX-P3
Clinical viewpoint
The case is bilateral cervical lymphadenopathy (R59.1) with biopsy of right posterior triangle open deep cervical lymph node, generalized as it was bilateral (38520). The anesthesia (00320) is for all procedures on esophagus, thyroid, larynx and lymphatic system of neck; not otherwise specified, age 1 year or older. The specimen was removed and sent to pathology for flow cytometry (88182) and histology (+88314).
Case 54
Postoperative diagnosis: Large primary basal cell carcinoma of the skin of the left hip
Procedures: Wide excision of basal cell carcinoma of the left hip
Intermediate layered closure with extensive mobilization of skin flaps
Jackson-Pratt drain into the wound
Anesthesia: General endotracheal; IV sedation by the anesthesiology department and 30 mL of 0.25% Marcaine plain locally
Anesthesiologist personally provided the general endotracheal anesthesia for the case while directing 5 procedures concurrently (PS IV)
Complications: None
Estimated blood loss: Minimal
Specimens Removed: A 15 cc X 6.5 cm X 3 cm area of skin and subcutaneous tissues of the left hip containing the patient’s large irregular basal cell carcinoma
Procedure Description: The patient was taken to the operating room. She was given IV sedation by the anesthesiology department. The cancer itself measured 6.6 cm X 5.2 cm in size. Using a marking pen, I then marked off an obliquely oriented elliptical incision measuring 15 cm in length X 6.5 cm in width at its widest point. I then infiltrated the incision line with 30 mL of 0.25% Marcaine without epinephrine.
Using a #10 blade scalpel, an incision was made and carried all the way down to the muscular fascia circumferentially. Then, using a Bovie electrocautery unit, the skin and subcutaneous tissues, as well as the cancer, were then divided off of the fascia. The specimen was marked with sutures for proper orientation. Once this was done, I extensively undermined the entire wound circumferentially for a distance of at least 5 cm in all directions. Once having done this, the wound would come together with mild tension. A 10 mm Jackson-Pratt drain was placed at the base of the wound and brought out through a separate stab wound inferiorly. It was secured with a 2-0 silk suture. The wound was copiously irrigated out with saline containing bacitracin. Wound was then closed in three layers with interrupted sutures of 2-0 Vicryl for the deep subcutaneous tissues and a running 3-0 Vicryl for the superficial subcutaneous subcutaneous tissues. Skin was closed with interrupted vertical mattress sutures of 4-0 nylon. Drain was then connected to suction. Large bulky dressing was applied. The patient was then moved to the recovery room in stable condition.
Codes
27043, 12032, 88305, C44.719
Overall anesthesiology code for the billing anesthesiologist
00300-AD-P4
Clinical viewpoint
The patient has basal cell carcinoma of the skin of the left hip (C44.719) size 6.6 cm X 5.2 cm. Note that the basal cell carcinoma was of the skin as seen in the operative report. The patient underwent excision, tumor, soft tissue of pelvis and hip area, subcutaneous, 3 cm or greater (27043) and repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet; 2.6 cm X 7.5 cm (12032). Note that Intermediate layered closure with extensive mobilization of skin flaps was performed and coded separately in this case. The specimen 15 cc X 6.5 cm X 3 cm of skin and subcutaneous tissues was sent to pathology (88305).
Case 55
Postoperative diagnosis: Left inguinal hernia
Cord lipoma
Procedure performed: Left inguinal hernia repair with mesh
Findings: Indirect inguinal hernia noted
Specimens received: Cord lipoma
Hernia sac
Left ilioinguinal nerve
Surgeon: Dr. Optum
Estimated blood loss: Minimal
Anesthesia: General endotracheal plus 10 ml of 0.25% Marcaine
Anesthesiologist provided the anesthesia for the case directing 2 CRNA’s (PS II)
Complications: None
Indications for Procedure: Patient is a pleasant 76-year-old gentleman who presents for a large reducible left inguinal hernia. Risks, benefits, and complications were explained to him in great detail and he wished to proceed.
Procedure: Patient was taken to the operating room. General anesthesia was administered without incident. We proceeded to use 0.25% Marcaine to anesthetize the area in a field block fashion. We then used a 4 cm incision in the left inguinal crease just below the inguinal ligament and dissected around the skin and subcutaneous tissue and through the Scarpa’s fascia down to the external oblique fascia. The external oblique was opened to the external inguinal ring. The ilioinguinal nerve was preserved. We then cut around the spermatic cord at the pubic tubercle with a Penrose drain. We then dissected the anteromedial indirect inguinal hernia sac away from the spermatic cord. There was also a large cord lipoma, and this was resected. We then did a high ligation of the hernia sac with a 2-0 Vicryl suture in a running fashion. We placed it back into the internal inguinal ring. We then closed the internal inguinal ring with a 0 PDS in a figure-of-eight interrupted fashion.
We then placed out mesh. We then created a new internal inguinal ring using the same Prolene suture and making it a snug, not a tight, fit.
Codes
49505+49568, 55520-59, 88304, 88302, K40.90, D17.6
Overall anesthesiology code for the billing anesthesiologist
00830-QK-P2
Overall anesthesiology code for the billing CRNA
00830-QX-P2
Clinical viewpoint
The postoperative diagnosis is coded. This is a patient with a unilateral inguinal hernia without obstruction or gangrene (K40.90) and a spermatic cord lipoma (D17.6) who presents for left inguinal hernia repair, reducible with mesh (49505+49568) who in addition underwent excision of the lesion of the spermatic cord (55520). There was mild systemic disease (P2). In this case a spermatic cord lipoma was found upon surgery and was therefore removed. The anesthesia was for hernia repairs in lower abdomen; not otherwise specified (00830).
Case 56
Discharge Summary
Discharge Diagnosis: Hyperglycemia, cholelithiasis, obstructive sleep apnea, insulin-dependent diabetes mellitus, and cholecystitis
Procedure: Laparoscopic cholecystectomy
Anesthesia: General endotracheal; difficult intubation
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
History of Present Illness
Patient is a 48-year-old woman suffering from morbid obesity, also known to suffer from diabetes and obstructive sleep apnea. She has been evaluated in the bariatric surgical center for placement of a lap band. During this evaluation, evidence of cholelithiasis was found, and it was decided that removal of the gallbladder prior to placement of the band would be prudent. The patient was scheduled to undergo her outpatient procedure on Thursday; however, at blood glucose check on Wednesday morning, the patient was noted to be hyperglycemic, as her blood sugar was 453. She was admitted to the hospital on Wednesday for treatment of her hyperglycemia.
Hospital Course of Treatment
Patient was admitted to the hospital. Dr. placed her on an insulin drip in an attempt to control the hyperglycemia. Her sugars did slowly come down to between 110 and 130. The patient was placed on the CPAP machine at night for management of sleep apnea. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, mild edema, and adhesions of omentum around the gallbladder. She tolerated without much difficulty, recovered in the recovery area, and was returned to the floor. Her blood sugar postprocedure was noted to be 240. She was started back on sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.
Discharge Instructions
Patient will return to the Medifast diet and continue monitoring the blood glucose levels. Patient will follow up with Dr. the surgeon and Dr. endocrinologist next week. We will determine if we will proceed with her lap band at that time. She may shower and needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars.
Codes
99223, 47562, 31500-22, 94660, K80.10, E11.65, G47.33, K66.0, E66.01, Z79.4
Overall anesthesiology code for the case for the billing anesthesiologist
00790-AA-P3
Clinical viewpoint
The patient has insulin-dependent diabetes mellitus with hyperglycemia (E11.65) which was controlled in the hospital (99223). She in addition has obstructive sleep apnea (G47.33) requiring placement on a CPAP machine for continuous positive airway pressure (CPAP) ventilation (94660) in the hospital. The patient also had morbid (severe) obesity due to excess calories (E66.01). For cholelithiasis and chronic cholecystitis (K80.10), she underwent a Laparoscopic cholecystectomy (47562). There were peritoneal adhesions (K66.0) around the omentum near the gallbladder. The intubation was a difficult intubation and required increased procedural services (31500-22). In this case, it is important to note that the intubation required for anesthesia was difficult.
Case 57
Surgery Consultation
Visit for evauation of elective surgical weight loss methods
History of Present Illness
Patient has been previously seen in my office for evaluation for a potential elective surgical weight loss procedure. Patient is a 32-year-old female with a BMI of 42.7. Her current weight is 241, and her height is 5’3””. She is currently struggling with hypertension and shortness of breath related to her morbid obesity. She also has a great personal motivation to want to lose weight as she states she’d like to increase her energy level and be able to improve her self-image.
Patient has participated in many weight loss program over the years, but always gains back more weight than she has lost. She states she lost of 100 pounds on Redux but gained it all back plus. She also has tried Weight Watchers, Atkins, Slim Fast, Dexatrim, and Resistant Starch, with varying degrees of success.
Past Medical History
Positive for hypertension and shortness of breath
Past Surgical History
Cholecystectomy, 1999
Psychological History
Mild depression
Social History
Patient is unmarried. Works as administrative assistant. She drinks socially and does not smoke.
Family History
Obesity and heart disease—mother and father
Current Medications
Topamax 100 mg twice daily (migraines), Zoloft 100 mg twice daily, multivitamin
Allergies
No known drug allergies
Review of Systems
Shortness of breath as discussed above, all others negative
Examination
Patient is alert and oriented X 3, in no acute distress.
HEENT: Normocephalic, atraumatic. Extraocular muscles intact. Anicteric sclerae.
Chest: Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm.
Abdomen: Abdomen is obese, soft, nontender, and nondistended.
Extremities: Extremities show no edema, clubbing, or cyanosis.
Assessment and Plan
Patient is interested in elective surgical weight loss via the lap band procedure. She will be asking for a letter of medical necessity from her primary care physician. We will schedule appointments with our nutritionist and social worker as well and will submit all information once complete to her insurance company for approval.
Procedure: Lap band for elective surgical weight loss
Anesthesia: General endotracheal
Anesthesiologist provided the general endotracheal anesthesia for the case directing one CRNA (PS III)
Codes
99244, 43770, E66.01, I10, R06.02, Z68.41, Z82.49, Z84.89
Overall anesthesiology code for the case for the billing anesthesiologist
00797-QY-P3
Overall anesthesiology code for the billing CRNA
00797-QX-P3
Clinical viewpoint
The anesthesia (00797) was for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure (43770) for morbid obesity (E66.01). The laparoscopic gastric restrictive procedure included placement of adjustable gastric restrictive device (eg. gastric band and subcutaneous port components. For a patient with morbid obesity, Body Mass Index (BMI) (Z68.41) should be medically coded for.
Case 58
Postoperative Diagnosis: Left breast cancer (DCIS)
Procedures Performed: Left segmental mastectomy
Left axillary sentinel node biopsy
Surgeon: Dr. Optum
Anesthesia: General endotracheal (PS III)
Anesthesiologist personally provided the anesthesia for the case while directing 4 concurrent procedures
Estimated Blood Loss: Minimal
Description of Procedure: The patient was placed supine on the operating table. General anesthesia was induced. An incision was made in the left axillary skin and deepened through the subcutaneous tissues into the axillary fat pad. The first lymph node was removed and was not blue. Ex vivo had counts in the 53 range. It was submitted as axillary lymph node #1. The second node was identified by the gamma counter and was also removed clipping lymphatics with Hemoclips and ex vivo. The node had counts in the range of 3. That was submitted as lymph node #2. There were additional counts in the axilla, and a third node was dissected out and this node was indeed stained blue. It was removed and submitted as lymph node #3 and its counts were much stronger in the range of 270. The axilla was irrigated with saline. Hemostasis was checked and found to be complete. The tissues were closed with 3-0 Vicryl and running 4-0 Monocryl subcuticular. Dr. X from pathology called and advised that there were a total of 5 sentinel nodes in the specimens and that all were negative for malignancy.
A transverse curvilinear incision was then made overlying the palpable mass in the superior aspect of the left breast. Dissection was deepened through the subcutaneous tissues. The mass was dissected out with margin around it using electrocautery and removed from the patient. The superior margin was marked with a single silk stitch. The lateral margin was marked with 2 silk stitches and the inferior margin was marked with 3 silk stitches. I personally took the specimen out to the pathologist and described the patient and the situation. After scrubbing back in, the wound was then irrigated with saline. Hemostasis was confirmed. There was no significant residual breast tissue superiorly, and the dissection along the deep aspect was down to the pectoralis muscle. Medial, lateral, and inferior marginal biopsies were than taken with scissors, and the new true margin was marked with blue ink and these margins were submitted individually for marginal biopsies for frozen section. The medial and inferior wounds were negative. The lateral one had some residual DCIS, and therefore additional lateral margin was harvested and marked accordingly. The superior aspect of this margin was identified with a 4-0 nylon stitch, and this sample was immediately taken to pathology. They reported back later and confirmed that there was no residual cancer in this final margin. Again, the wound was irrigated. Hemostasis was completed with electrocautery. There was excellent hemostasis. A drain was not deemed to be necessary. The wound was closed with 3-0 Vicryl to the subcutaneous tissue and running 4-0 Monocryl subcuticular in the skin. Dressings were applied and the procedure completed. Sponge, needle, and instrument counts reported as correct. The patient tolerated the procedure well. She was awakened, extubated, and taken to recovery room to recovery room in satisfactory condition.
Operative Findings
There were 3 sentinel nodes that were all negative for malignancy. The patient had a mass in the superior aspect of the left breast that was widely excised as a segmental mastectomy, positive for intraductal carcinoma in situ. Marginal biopsies were taken, and the lateral one had the residual DCIS. At that point an additional marginal biopsy was taken and was negative.
Codes
19301, 38525, 88309, D05.12
Overall anesthesiology code for the case for the billing anesthesiologist
01610-QK-P3
Clinical viewpoint
The patient has intraductal carcinoma in situ of the left breast (D05.12) and underwent Left segmental mastectomy (19301) and Left axillary sentinel node biopsy (38525). 3 sentinel lymph nodes were removed and sent to pathology as specimens (88309). The biopsy or excision were of open, deep axillary nodes. The anesthesia (1610) is for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla.
Case 59
Postoperative diagnosis: Recurrent diverticular disease in the sigmoid colon
Procedures Performed: Laparoscopic sigmoid resection
Laparoscopic mobilization of the splenic flexure
Flexible sigmoidectomy at completion of anastomosis to verify patency
Surgeon: Dr. Optum
Anesthesia: General endotracheal and local and postoperative pain pump inserted and implanted intra-arterially
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Specimens received: Sigmoid colon—segment measuring approximately 15 to 18 inches
Blood loss: 50 ml
Patient Disposition: Recovery room
Description of Procedure: The patient was brought int the OR. General anesthesia was induced without difficulty. Optoview technique was used into the abdominal cavity via a right lateral abdominal wall. Pneumoperitoneum established without any complications. The patient had obvious adhesions to the left lateral pelvic sidewall from diverticular disease. We were able to identify the site of involvement. We took down the entire splenic flexure without injury to the spleen or bleeding from spleen and mobilization of the omentum to the distal transverse colon. We were able to completely mobilize the left colon without difficulty, bleeding, or injury to any surrounding structures. We then placed a small incision in the suprapubic midline for the wound retractor. This was placed in the standard fashion without complication. We were able to eviscerate the sigmoid colon. We transacted proximaly using a GIA 75 mm stapler in the descending colon. We transacted distally at the recto-sigmoid junction on the rectal side using a green contour stapler. We took the mesentery of the colon using the Harmonic Ace device. No significant bleeding or complications. Segment was sent off the table. Proximal bowel was palpable and healthy. No obvious diverticular disease. Distal bowel was rectum. No diverticular disease present in the rectum as noted. We the sized from below using a 25 then a 29 mm sizer. We selected a 29 mm EEA stapler. On the proximal bowel, I removed the staple line and placed my anvil and placed a pursestring after placement of the anvil in the end fashion of the colon. From below, we brought the EEA stapler into the staple line and brought the spike out from the EEA stapler on the anterior rectal surface in order to perform our end-to-side anastomosis. The EEA stapler was fired in standard fashion. Two doughnuts were identified in the black table confirming a normal anastomosis was performed. We then clamped the colon proximally and peformed a flexible sigmoidoscopy, hyperinflating the colon. Noting that there was no intraluminal bleeding, the anastomosis was widely patent. There was no bubble leak identified, negative provocative leak test intra-abdominally with the anastomosis submerged in saline. I then decompress the colon lumen and removed the scope. I then irrigated the abdominal cavity, confirmed all counts were correct, placed 10 ml of fibrin glue around the anastomosis, and removed the wound retractor. The patient tolerated the procedure well and was taken to recovery.
Codes
44204+44213, 45330, 88309, K57.30
Overall anesthesiology code for the case for the billing anesthesiologist
00790-AA-P3, 36260
Clinical viewpoint
The patient has diverticular disease in the sigmoid colon (K57.30) without perforation, abscess, or bleeding. The patient underwent Laparoscopy, surgical, colectomy, partial with anastomosis with surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (44204+44213). The patient also received flexible sigmoidoscopy, diagnostic, including collection of specimen(s) by brushing or washing, when performed (45330). The specimen of segmental sigmoid colon (88309) measuring 15 to 18 inches was sent to pathology. The anesthesia (00790) was for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified. In this case, for anesthesia after the operation, a pain pump was inserted and implanted intra-arterially postoperatively (36260). The code for insertion of the pain pump is included in the Overall anesthesiology code for the case for the billing anesthesiologist.
Case 60
Postoperative Diagnosis: Severe chronic obstructive pulmonary disease
Respiratory failure
Procedure Performed: Placement of right subclavian triple lumen central line
Anesthesia: Local Xylocaine
Anesthesiologist personally performed the local anesthesia for the case (PS IV)
Blood Loss: Minimal
Indications Referral from Dr. Q requesting central line placement. This 54-year-old male patient in severe respiratory failure is on mechanical ventilation. This patient currently requires multiple IV drips, and the triple lumen catheter is to assist with these multiple IVs.
Description of Procedure
Patient is in his bed in the ICU, currently being mechanically ventilated. The right side of the neck was prepped and draped in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire was removed. No PVCs were encountered during the procedure. All three ports to the catheter were aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly syringe using 3-0 silk suture. Betadine ointment and sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results showed good catheter placement. Patient seemed to tolerate the procedure well.
Codes
36561, 99291, 31500, J2001, J44.9, J96.90
Overall anesthesiology code for the case for the billing anesthesiologist
36561
Note that the anesthesia was local anesthesia in this case which is bundled with the anesthesia code
Clinical viewpoint
The patient is intubated (31500) on mechanical ventilation in the ICU (99291). He underwent Placement of right subclavian triple lumen central line with subcutaneous port (36561) under Local anesthesia. The patient has Severe chronic pulmonary disease (J44.9) and respiratory failure (J96.90). He has severe systemic disease that is a constant threat to life (PS IV). In this case, Local anesthesia with Xylocaine is bundled with the procedure. The local anesthesia injection was of lidocaine HCL, 10 mg (J2001) for intravenous infusion.
Case 46
Anesthesiologist provided the general endotracheal anesthesia for the case. The patient is a healthy 25 year old male (PS I) who pulled his left shoulder while playing baseball. On physical exam, he is found by his physician to have a left rotator cuff tear secondary to trauma. He underwent arthroscopic rotator cuff repair.
Codes
S46.012A, Y93.64, 29827
ASA Crosswalk Lookup
29827=5 base value=01630
Overall anesthesiology code for the billing anesthesiologist
01630-AA-P1
Clinical viewpoint
The anesthesia (01630) is for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acriomioclavicular joint, and shoulder joint; not otherwise specified. The patient has a rotator cuff tear involving strain of muscles and tendons (S46.012A) secondary to trauma from playing baseball.
Case 47
Anesthesiologist provided the general endotracheal anesthesia. The patient is a healthy 30 year old female (PS I) who suffers from impingement symptoms of the left shoulder dating back to a motorcycle accident. She was seen for a diagnostic left shoulder arthroscopy with arthroscopic subacromial decompression and debridement.
Codes
M75.42, V29.9XXS, 29822+29826, 29805
ASA Crosswalk Lookup
29822=5 base value units=01630
29826=NOT A PRIMARY PROCEDURE CODE
29805=4 base value units=01622
Overall anesthesiology code for the case for the billing anesthesiologist
01630-AA-P1
Clinical viewpoint
The patient suffers from impingement syndrome of the left shoulder (M75.42) from a motorcycle accident (V29.9XXS). The base value units is highest (=5) for 01630. Anesthesia is for open or surgical arthroscopic procedures on humeral head and neck.
Case 48
Anesthesiologist provided the general endotracheal anesthesia for the case (PS I). The patient is a 25 year old healthy male (PS I) who fell during a skiing accident two months ago. He was found to have an intervertebral disc displacement (L5-S1) with myelopathy. He underwent a percutaneous Laminotomy with Transforaminal endoscopic discectomy with ultra-minimally invasive microdiscectomy and foraminotomy.
Codes
M51.06, Y93.23, Y92.838, 0275T
ASA Crosswalk Lookup
0275T=5 base value units=01936
Overall anesthesiology code for the case
01936-AA-P1
Total units calculation for a 3.5 hour operation
Total Units=Base+Time+PS+Emergency
Total units=5+14.0+0+0=19.0
Clinical viewpoint
The patient received anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic (01936). The procedure code (0275T) is a T code.
Case 49
Anesthesiologist provided the general endotracheal anesthesia for the case (PS IV), supervising two CRNAs. The anesthesiologist placed a left internal jugular central venous catheter and a right radial arterial line prior to the beginning of the case. A 45 year old female patient with multifocal breast cancer presents to have a total right modified radical mastectomy with sentinel lymph node injection and biopsy. Subcutaneous tissue dissected down and flaps were elevated to clavicle, sternum, and the rectus fascia. The breast was pulled medially and dissected out of the right axilla area. Two blue-stained sentinel nodes were removed and additional enlarged nodes were removed and sent for frozen section.
Codes
C50.911, 19307, 38792
ASA Crosswalk Lookup
19307=5 base value units=00404
38792=anesthesia care not typically required
Overall anesthesiology code for the case for the billing anesthesiologist
00404-QK-P4,
36556, 36620
Overall anesthesiology code for the case for the billing CRNA
00404-QX-P4
Total units for a 6 hour operation
Total units=Base+Time+PS+Emergency
Total units=5+24.0+2+0=29.0
Clinical viewpoint
The breast cancer patient (C50.911) underwent modified radical mastectomy (19307) involving surgical removal of the breast, dissection into the axilla, staining of two sentinel nodes (38792), and removal of the two sentinel lymph nodes. The anesthesia (00404) is for procedures on the integumentary system on the extremities, anterior trunk, and perineum; radical or modified radical procedures on the breast. PS IV yields 2 units on the units calculation. The anesthesiologist directs 2 CRNAs (QK). CRNA service is with medical direction by a physician (QX).
Case 50
Anesthesiologist performed the general endotracheal anesthesia for the case (PS III). A 35 year old male patient is suffering from chronic mastoiditis, hearing loss, and tympanic membrane perforation. He has sustained facial palsy from one of the prior surgeries and now presents for radical mastoidectomy, facial nerve decompression, and debridement, mastoid obliteration, and a temporalis muscle flap rotation.
Codes
H70.10, H91.90, H72.90, 69603, 15732
ASA Crosswalk Lookup
69603=5 base value units=00120
15732=5 base value units=00300
Overall anesthesiology code for the billing anesthesiologist
00120-AA-P3
Clinical viewpoint
The overall anesthesiology code is 00120 Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified. In this case there was a tie in ASA Crosswalk Lookup. The first listed CPT code with corresponding anesthesiology code breaks the tie. In this case, a revision mastoidectomy; resulting in radical mastoidectomy is listed as the first CPT code (69603).
Case 51
Postoperative diagnosis: Acute suppurative appendicitis
Procedure: Laparoscopic appendectomy
Anesthesia: General endotracheal and local
Anesthesiologist performed the general endotracheal anesthesia for the case overseeing 2 CRNAs (PS III).
Anesthesia time: 2 hours
Blood loss: Minimal to none
Complications: None
Description of procedure: The 45 year old male patient was brought in to the OR. General anesthesia was induced without difficulty. Optiview technique was used to enter the abdominal cavity via the supraumbilical midline. Inspection of the abdominal cavity showed inflammatory process in the right lower quadrant, easily identifying the appendix as the source. The appendix was transected at the base of the cecum without difficulty. The appendix was placed in an Endocatch and removed via the 12 mm trocar site. I then irrigated 2 liters of normal saline in the abdominal cavity. I aspirated over the dome of the liver, right lower quadrant, and the pelvis. No surrounding injury to any bowel. No other interloop abscess is identified. The patient tolerated the procedure well. I released the pneumoperitoneum and injected all trocar sites with Marcaine, closed the skin with 4-0 Monocryl and Dermabond.
Codes
44970, K35.80
ASA Crosswalk Lookup
44970=6 base value units=00840
Overall anesthesiology code for the billing anesthesiologist
00840-QK-P3
Overall anesthesiology code for the billing CRNA
00840-QX-P3
Total Units calculation= Base+Time+PS+Emergency=
6+8.0+1+0=14.0
Clinical viewpoint
The patient has acute suppurative appendicitis (PS III) requiring Laparoscopic appendectomy. The anesthesia (00840) was for intraperitoneal procedures in the lower abdomen including laparoscopy; not otherwise specified. In this case the anesthesiologist (QK) directed 2 CRNAs (QX) for the anesthesiology case.
Case 52
Indications The patient is a 62-year-old female who presented to Dr. Optum’s office with an abnormal mammogram of the right breast. The film a suspicious area on the right breast with microcalcifications and a nonpalpable mass. After discussion with the patient about best options on how to proceed, it was decided to perform a needle-localized breast biopsy.
Postoperative diagnosis: Right breast mass
Procedure: Needle-localized excisional biopsy of the right breast
Anesthesia: General endotracheal
Anesthesiologist personally performed the general endotracheal anesthesia for the case (PS III).
Anesthesia time: 3.50 hours
Description of procedure: The patient was brought to the procedure room. The needle had been previously placed in the lesion in the right breast by radiology. After IV sedation was given, the patient was then prepped and draped in the normal sterile fashion.
After anesthetizing the skin with 0.25% Marcaine and 1% lidocaine mixture, an incision was made with a #10 blade scalpel. The lesion with needle was then grasped with an Allis clamp. Using a #10 blade scalpel, the specimen was colonized out and sent to radiology for confirmation. Next, hemostasis was obtained using electrobovie cautery. The skin was then closed with #4-0 Monocruyl suture in subcuticular fashion. Steri-Strips and a sterile dressing were applied to the surgical wound. The patient tolerated the procedure quite well and left the procedure well and left the procedure room in stable condition.
Intraoperative findings
Nonpalpable right breast mass, excised and sent to radiology with confirmation that the mass is in the specimen.
Codes
19083-RT, 88307, N63, R92.0
ASA Crosswalk Lookup
19083=3 base value units=00400
Overall anesthesiology code for the billing anesthesiologist
00400-AA-P3
Units calculation=Base+time+PS+Emergency=
3+14.0+1+0=17.0
Clinical viewpoint
The patient had microcalcifications on mammogram (R92.0) which was found to be a breast mass in the OR (N63). She has a specimen which was removed from the right breast with a needle-localized excisional biopsy (19037) and sent to pathology (88307). The anesthesia (0400) was for procedures on the integumentary system on the extremities, anterior trunk, and perineum; not otherwise specified. In this case it is important to remember that the breast is part of the integumentary system.
Case 53
Postoperative diagnosis Bilateral cervical lymphadenopathy
Procedure: Biopsy of right posterior triangle cervical node
Anesthesia: General endotracheal; Xylocaine 1% with epinephrine supplemented with IV sedation
Anesthesiology was performed by anesthesiologist directing one CRNA (PS III)
Findings: A 10 x 8 mm node was present in the posterior triangle of the right neck. This was readily palpable, removed, and sent fresh for flow cytometry and histology.
Estimated blood loss: Minimal
Description of procedure: Under satisfactory preoperative medicine, the patient was taken to the operating room. The right neck was prepped with Chloraprep and draped in the usual sterile manner. The palpable node was marked with marking pen. The skin, subcutaneous tissue, and subplatysmal tissue were infiltrated with 1% Xylocaine with epinephrine. Transverse incision was made, and the platysmal muscle was split in the direction of its fibers. The lymph node was identified and very carefully dissected from the surrounding tissue. No bleeding was encountered. The node was sent fresh. The platysma was closed with running simple suture of 4-0 Vicryl. The skin was closed with a running subcuticular suture of 4-0 Vicryl.
Codes
38520, 88305, 88182+88314, R59.1
ASA Crosswalk Lookup
38520=6 base value units=00320
Overall anesthesiology code for the billing anesthesiologist
00320-QY-P3
Overall anesthesiology code for the billing CRNA
00320-QX-P3
Clinical viewpoint
The case is bilateral cervical lymphadenopathy (R59.1) with biopsy of right posterior triangle open deep cervical lymph node, generalized as it was bilateral (38520). The anesthesia (00320) is for all procedures on esophagus, thyroid, larynx and lymphatic system of neck; not otherwise specified, age 1 year or older. The specimen was removed and sent to pathology for flow cytometry (88182) and histology (+88314).
Case 54
Postoperative diagnosis: Large primary basal cell carcinoma of the skin of the left hip
Procedures: Wide excision of basal cell carcinoma of the left hip
Intermediate layered closure with extensive mobilization of skin flaps
Jackson-Pratt drain into the wound
Anesthesia: General endotracheal; IV sedation by the anesthesiology department and 30 mL of 0.25% Marcaine plain locally
Anesthesiologist personally provided the general endotracheal anesthesia for the case while directing 5 procedures concurrently (PS IV)
Complications: None
Estimated blood loss: Minimal
Specimens Removed: A 15 cc X 6.5 cm X 3 cm area of skin and subcutaneous tissues of the left hip containing the patient’s large irregular basal cell carcinoma
Procedure Description: The patient was taken to the operating room. She was given IV sedation by the anesthesiology department. The cancer itself measured 6.6 cm X 5.2 cm in size. Using a marking pen, I then marked off an obliquely oriented elliptical incision measuring 15 cm in length X 6.5 cm in width at its widest point. I then infiltrated the incision line with 30 mL of 0.25% Marcaine without epinephrine.
Using a #10 blade scalpel, an incision was made and carried all the way down to the muscular fascia circumferentially. Then, using a Bovie electrocautery unit, the skin and subcutaneous tissues, as well as the cancer, were then divided off of the fascia. The specimen was marked with sutures for proper orientation. Once this was done, I extensively undermined the entire wound circumferentially for a distance of at least 5 cm in all directions. Once having done this, the wound would come together with mild tension. A 10 mm Jackson-Pratt drain was placed at the base of the wound and brought out through a separate stab wound inferiorly. It was secured with a 2-0 silk suture. The wound was copiously irrigated out with saline containing bacitracin. Wound was then closed in three layers with interrupted sutures of 2-0 Vicryl for the deep subcutaneous tissues and a running 3-0 Vicryl for the superficial subcutaneous subcutaneous tissues. Skin was closed with interrupted vertical mattress sutures of 4-0 nylon. Drain was then connected to suction. Large bulky dressing was applied. The patient was then moved to the recovery room in stable condition.
Codes
27043, 12032, 88305, C44.719
Overall anesthesiology code for the billing anesthesiologist
00300-AD-P4
Clinical viewpoint
The patient has basal cell carcinoma of the skin of the left hip (C44.719) size 6.6 cm X 5.2 cm. Note that the basal cell carcinoma was of the skin as seen in the operative report. The patient underwent excision, tumor, soft tissue of pelvis and hip area, subcutaneous, 3 cm or greater (27043) and repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet; 2.6 cm X 7.5 cm (12032). Note that Intermediate layered closure with extensive mobilization of skin flaps was performed and coded separately in this case. The specimen 15 cc X 6.5 cm X 3 cm of skin and subcutaneous tissues was sent to pathology (88305).
Case 55
Postoperative diagnosis: Left inguinal hernia
Cord lipoma
Procedure performed: Left inguinal hernia repair with mesh
Findings: Indirect inguinal hernia noted
Specimens received: Cord lipoma
Hernia sac
Left ilioinguinal nerve
Surgeon: Dr. Optum
Estimated blood loss: Minimal
Anesthesia: General endotracheal plus 10 ml of 0.25% Marcaine
Anesthesiologist provided the anesthesia for the case directing 2 CRNA’s (PS II)
Complications: None
Indications for Procedure: Patient is a pleasant 76-year-old gentleman who presents for a large reducible left inguinal hernia. Risks, benefits, and complications were explained to him in great detail and he wished to proceed.
Procedure: Patient was taken to the operating room. General anesthesia was administered without incident. We proceeded to use 0.25% Marcaine to anesthetize the area in a field block fashion. We then used a 4 cm incision in the left inguinal crease just below the inguinal ligament and dissected around the skin and subcutaneous tissue and through the Scarpa’s fascia down to the external oblique fascia. The external oblique was opened to the external inguinal ring. The ilioinguinal nerve was preserved. We then cut around the spermatic cord at the pubic tubercle with a Penrose drain. We then dissected the anteromedial indirect inguinal hernia sac away from the spermatic cord. There was also a large cord lipoma, and this was resected. We then did a high ligation of the hernia sac with a 2-0 Vicryl suture in a running fashion. We placed it back into the internal inguinal ring. We then closed the internal inguinal ring with a 0 PDS in a figure-of-eight interrupted fashion.
We then placed out mesh. We then created a new internal inguinal ring using the same Prolene suture and making it a snug, not a tight, fit.
Codes
49505+49568, 55520-59, 88304, 88302, K40.90, D17.6
Overall anesthesiology code for the billing anesthesiologist
00830-QK-P2
Overall anesthesiology code for the billing CRNA
00830-QX-P2
Clinical viewpoint
The postoperative diagnosis is coded. This is a patient with a unilateral inguinal hernia without obstruction or gangrene (K40.90) and a spermatic cord lipoma (D17.6) who presents for left inguinal hernia repair, reducible with mesh (49505+49568) who in addition underwent excision of the lesion of the spermatic cord (55520). There was mild systemic disease (P2). In this case a spermatic cord lipoma was found upon surgery and was therefore removed. The anesthesia was for hernia repairs in lower abdomen; not otherwise specified (00830).
Case 56
Discharge Summary
Discharge Diagnosis: Hyperglycemia, cholelithiasis, obstructive sleep apnea, insulin-dependent diabetes mellitus, and cholecystitis
Procedure: Laparoscopic cholecystectomy
Anesthesia: General endotracheal; difficult intubation
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
History of Present Illness
Patient is a 48-year-old woman suffering from morbid obesity, also known to suffer from diabetes and obstructive sleep apnea. She has been evaluated in the bariatric surgical center for placement of a lap band. During this evaluation, evidence of cholelithiasis was found, and it was decided that removal of the gallbladder prior to placement of the band would be prudent. The patient was scheduled to undergo her outpatient procedure on Thursday; however, at blood glucose check on Wednesday morning, the patient was noted to be hyperglycemic, as her blood sugar was 453. She was admitted to the hospital on Wednesday for treatment of her hyperglycemia.
Hospital Course of Treatment
Patient was admitted to the hospital. Dr. placed her on an insulin drip in an attempt to control the hyperglycemia. Her sugars did slowly come down to between 110 and 130. The patient was placed on the CPAP machine at night for management of sleep apnea. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, mild edema, and adhesions of omentum around the gallbladder. She tolerated without much difficulty, recovered in the recovery area, and was returned to the floor. Her blood sugar postprocedure was noted to be 240. She was started back on sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure.
Discharge Instructions
Patient will return to the Medifast diet and continue monitoring the blood glucose levels. Patient will follow up with Dr. the surgeon and Dr. endocrinologist next week. We will determine if we will proceed with her lap band at that time. She may shower and needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars.
Codes
99223, 47562, 31500-22, 94660, K80.10, E11.65, G47.33, K66.0, E66.01, Z79.4
Overall anesthesiology code for the case for the billing anesthesiologist
00790-AA-P3
Clinical viewpoint
The patient has insulin-dependent diabetes mellitus with hyperglycemia (E11.65) which was controlled in the hospital (99223). She in addition has obstructive sleep apnea (G47.33) requiring placement on a CPAP machine for continuous positive airway pressure (CPAP) ventilation (94660) in the hospital. The patient also had morbid (severe) obesity due to excess calories (E66.01). For cholelithiasis and chronic cholecystitis (K80.10), she underwent a Laparoscopic cholecystectomy (47562). There were peritoneal adhesions (K66.0) around the omentum near the gallbladder. The intubation was a difficult intubation and required increased procedural services (31500-22). In this case, it is important to note that the intubation required for anesthesia was difficult.
Case 57
Surgery Consultation
Visit for evauation of elective surgical weight loss methods
History of Present Illness
Patient has been previously seen in my office for evaluation for a potential elective surgical weight loss procedure. Patient is a 32-year-old female with a BMI of 42.7. Her current weight is 241, and her height is 5’3””. She is currently struggling with hypertension and shortness of breath related to her morbid obesity. She also has a great personal motivation to want to lose weight as she states she’d like to increase her energy level and be able to improve her self-image.
Patient has participated in many weight loss program over the years, but always gains back more weight than she has lost. She states she lost of 100 pounds on Redux but gained it all back plus. She also has tried Weight Watchers, Atkins, Slim Fast, Dexatrim, and Resistant Starch, with varying degrees of success.
Past Medical History
Positive for hypertension and shortness of breath
Past Surgical History
Cholecystectomy, 1999
Psychological History
Mild depression
Social History
Patient is unmarried. Works as administrative assistant. She drinks socially and does not smoke.
Family History
Obesity and heart disease—mother and father
Current Medications
Topamax 100 mg twice daily (migraines), Zoloft 100 mg twice daily, multivitamin
Allergies
No known drug allergies
Review of Systems
Shortness of breath as discussed above, all others negative
Examination
Patient is alert and oriented X 3, in no acute distress.
HEENT: Normocephalic, atraumatic. Extraocular muscles intact. Anicteric sclerae.
Chest: Chest is clear to auscultation bilaterally. Cardiovascular is normal sinus rhythm.
Abdomen: Abdomen is obese, soft, nontender, and nondistended.
Extremities: Extremities show no edema, clubbing, or cyanosis.
Assessment and Plan
Patient is interested in elective surgical weight loss via the lap band procedure. She will be asking for a letter of medical necessity from her primary care physician. We will schedule appointments with our nutritionist and social worker as well and will submit all information once complete to her insurance company for approval.
Procedure: Lap band for elective surgical weight loss
Anesthesia: General endotracheal
Anesthesiologist provided the general endotracheal anesthesia for the case directing one CRNA (PS III)
Codes
99244, 43770, E66.01, I10, R06.02, Z68.41, Z82.49, Z84.89
Overall anesthesiology code for the case for the billing anesthesiologist
00797-QY-P3
Overall anesthesiology code for the billing CRNA
00797-QX-P3
Clinical viewpoint
The anesthesia (00797) was for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure (43770) for morbid obesity (E66.01). The laparoscopic gastric restrictive procedure included placement of adjustable gastric restrictive device (eg. gastric band and subcutaneous port components. For a patient with morbid obesity, Body Mass Index (BMI) (Z68.41) should be medically coded for.
Case 58
Postoperative Diagnosis: Left breast cancer (DCIS)
Procedures Performed: Left segmental mastectomy
Left axillary sentinel node biopsy
Surgeon: Dr. Optum
Anesthesia: General endotracheal (PS III)
Anesthesiologist personally provided the anesthesia for the case while directing 4 concurrent procedures
Estimated Blood Loss: Minimal
Description of Procedure: The patient was placed supine on the operating table. General anesthesia was induced. An incision was made in the left axillary skin and deepened through the subcutaneous tissues into the axillary fat pad. The first lymph node was removed and was not blue. Ex vivo had counts in the 53 range. It was submitted as axillary lymph node #1. The second node was identified by the gamma counter and was also removed clipping lymphatics with Hemoclips and ex vivo. The node had counts in the range of 3. That was submitted as lymph node #2. There were additional counts in the axilla, and a third node was dissected out and this node was indeed stained blue. It was removed and submitted as lymph node #3 and its counts were much stronger in the range of 270. The axilla was irrigated with saline. Hemostasis was checked and found to be complete. The tissues were closed with 3-0 Vicryl and running 4-0 Monocryl subcuticular. Dr. X from pathology called and advised that there were a total of 5 sentinel nodes in the specimens and that all were negative for malignancy.
A transverse curvilinear incision was then made overlying the palpable mass in the superior aspect of the left breast. Dissection was deepened through the subcutaneous tissues. The mass was dissected out with margin around it using electrocautery and removed from the patient. The superior margin was marked with a single silk stitch. The lateral margin was marked with 2 silk stitches and the inferior margin was marked with 3 silk stitches. I personally took the specimen out to the pathologist and described the patient and the situation. After scrubbing back in, the wound was then irrigated with saline. Hemostasis was confirmed. There was no significant residual breast tissue superiorly, and the dissection along the deep aspect was down to the pectoralis muscle. Medial, lateral, and inferior marginal biopsies were than taken with scissors, and the new true margin was marked with blue ink and these margins were submitted individually for marginal biopsies for frozen section. The medial and inferior wounds were negative. The lateral one had some residual DCIS, and therefore additional lateral margin was harvested and marked accordingly. The superior aspect of this margin was identified with a 4-0 nylon stitch, and this sample was immediately taken to pathology. They reported back later and confirmed that there was no residual cancer in this final margin. Again, the wound was irrigated. Hemostasis was completed with electrocautery. There was excellent hemostasis. A drain was not deemed to be necessary. The wound was closed with 3-0 Vicryl to the subcutaneous tissue and running 4-0 Monocryl subcuticular in the skin. Dressings were applied and the procedure completed. Sponge, needle, and instrument counts reported as correct. The patient tolerated the procedure well. She was awakened, extubated, and taken to recovery room to recovery room in satisfactory condition.
Operative Findings
There were 3 sentinel nodes that were all negative for malignancy. The patient had a mass in the superior aspect of the left breast that was widely excised as a segmental mastectomy, positive for intraductal carcinoma in situ. Marginal biopsies were taken, and the lateral one had the residual DCIS. At that point an additional marginal biopsy was taken and was negative.
Codes
19301, 38525, 88309, D05.12
Overall anesthesiology code for the case for the billing anesthesiologist
01610-QK-P3
Clinical viewpoint
The patient has intraductal carcinoma in situ of the left breast (D05.12) and underwent Left segmental mastectomy (19301) and Left axillary sentinel node biopsy (38525). 3 sentinel lymph nodes were removed and sent to pathology as specimens (88309). The biopsy or excision were of open, deep axillary nodes. The anesthesia (1610) is for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla.
Case 59
Postoperative diagnosis: Recurrent diverticular disease in the sigmoid colon
Procedures Performed: Laparoscopic sigmoid resection
Laparoscopic mobilization of the splenic flexure
Flexible sigmoidectomy at completion of anastomosis to verify patency
Surgeon: Dr. Optum
Anesthesia: General endotracheal and local and postoperative pain pump inserted and implanted intra-arterially
Anesthesiologist personally provided the general endotracheal anesthesia for the case (PS III)
Specimens received: Sigmoid colon—segment measuring approximately 15 to 18 inches
Blood loss: 50 ml
Patient Disposition: Recovery room
Description of Procedure: The patient was brought int the OR. General anesthesia was induced without difficulty. Optoview technique was used into the abdominal cavity via a right lateral abdominal wall. Pneumoperitoneum established without any complications. The patient had obvious adhesions to the left lateral pelvic sidewall from diverticular disease. We were able to identify the site of involvement. We took down the entire splenic flexure without injury to the spleen or bleeding from spleen and mobilization of the omentum to the distal transverse colon. We were able to completely mobilize the left colon without difficulty, bleeding, or injury to any surrounding structures. We then placed a small incision in the suprapubic midline for the wound retractor. This was placed in the standard fashion without complication. We were able to eviscerate the sigmoid colon. We transacted proximaly using a GIA 75 mm stapler in the descending colon. We transacted distally at the recto-sigmoid junction on the rectal side using a green contour stapler. We took the mesentery of the colon using the Harmonic Ace device. No significant bleeding or complications. Segment was sent off the table. Proximal bowel was palpable and healthy. No obvious diverticular disease. Distal bowel was rectum. No diverticular disease present in the rectum as noted. We the sized from below using a 25 then a 29 mm sizer. We selected a 29 mm EEA stapler. On the proximal bowel, I removed the staple line and placed my anvil and placed a pursestring after placement of the anvil in the end fashion of the colon. From below, we brought the EEA stapler into the staple line and brought the spike out from the EEA stapler on the anterior rectal surface in order to perform our end-to-side anastomosis. The EEA stapler was fired in standard fashion. Two doughnuts were identified in the black table confirming a normal anastomosis was performed. We then clamped the colon proximally and peformed a flexible sigmoidoscopy, hyperinflating the colon. Noting that there was no intraluminal bleeding, the anastomosis was widely patent. There was no bubble leak identified, negative provocative leak test intra-abdominally with the anastomosis submerged in saline. I then decompress the colon lumen and removed the scope. I then irrigated the abdominal cavity, confirmed all counts were correct, placed 10 ml of fibrin glue around the anastomosis, and removed the wound retractor. The patient tolerated the procedure well and was taken to recovery.
Codes
44204+44213, 45330, 88309, K57.30
Overall anesthesiology code for the case for the billing anesthesiologist
00790-AA-P3, 36260
Clinical viewpoint
The patient has diverticular disease in the sigmoid colon (K57.30) without perforation, abscess, or bleeding. The patient underwent Laparoscopy, surgical, colectomy, partial with anastomosis with surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (44204+44213). The patient also received flexible sigmoidoscopy, diagnostic, including collection of specimen(s) by brushing or washing, when performed (45330). The specimen of segmental sigmoid colon (88309) measuring 15 to 18 inches was sent to pathology. The anesthesia (00790) was for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified. In this case, for anesthesia after the operation, a pain pump was inserted and implanted intra-arterially postoperatively (36260). The code for insertion of the pain pump is included in the Overall anesthesiology code for the case for the billing anesthesiologist.
Case 60
Postoperative Diagnosis: Severe chronic obstructive pulmonary disease
Respiratory failure
Procedure Performed: Placement of right subclavian triple lumen central line
Anesthesia: Local Xylocaine
Anesthesiologist personally performed the local anesthesia for the case (PS IV)
Blood Loss: Minimal
Indications Referral from Dr. Q requesting central line placement. This 54-year-old male patient in severe respiratory failure is on mechanical ventilation. This patient currently requires multiple IV drips, and the triple lumen catheter is to assist with these multiple IVs.
Description of Procedure
Patient is in his bed in the ICU, currently being mechanically ventilated. The right side of the neck was prepped and draped in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire was removed. No PVCs were encountered during the procedure. All three ports to the catheter were aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly syringe using 3-0 silk suture. Betadine ointment and sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results showed good catheter placement. Patient seemed to tolerate the procedure well.
Codes
36561, 99291, 31500, J2001, J44.9, J96.90
Overall anesthesiology code for the case for the billing anesthesiologist
36561
Note that the anesthesia was local anesthesia in this case which is bundled with the anesthesia code
Clinical viewpoint
The patient is intubated (31500) on mechanical ventilation in the ICU (99291). He underwent Placement of right subclavian triple lumen central line with subcutaneous port (36561) under Local anesthesia. The patient has Severe chronic pulmonary disease (J44.9) and respiratory failure (J96.90). He has severe systemic disease that is a constant threat to life (PS IV). In this case, Local anesthesia with Xylocaine is bundled with the procedure. The local anesthesia injection was of lidocaine HCL, 10 mg (J2001) for intravenous infusion.