Fixing to take the ASC certification exam and I'm study. Could you give me the codes to the report below so I can check it against the ones I coded?
Thanks so much for your help
DIAGNOSIS
1. Nasal polyposis.
2. Chronic rhinosinusitis.
PROCEDURES PERFORMED:
1. Bilateral maxillary antrostomies with culture of the right maxillary sinus.
2. Bilateral ethmoidectomies with mini Propel.
3. Reduction of right concha bullosa and turbinate reduction bilaterally via submucous
resection and outfracture of the turbinates bilaterally.
SIGNIFICANT FINDINGS: Polypoid tissue of right maxillary sinus and chronic
rhinosinusitis, no dental material noted in the maxillary sinus cavity in the right. Turbinates
hypertrophied and concha bullosa was present on the right.
DESCRIPTION OF PROCEDURE: After the identification of the patient in the preoperative
area, he was brought back to the operating room and placed on the table in the supine position. After the induction of general endotracheal anesthesia, the table was turned. The patient was prepped and draped in the usual manner. The eyes were taped shut. A shoulder roll was placed under his shoulder and a donut under his head. The intranasal septum, lateral nasal wall, and turbinates were injected using 6 mL of 1% lidocaine with 1:200,000 epinephrine. Afrin-soaked pledgets were placed into the nasal passages. The pledgets were removed and the left nasal passage was first examined. Then, 0-degree scope was used to examine the nasal passage. The middle turbinate and was medialized using the Freer elevator and sickle knife was used to enter the uncinate process.
Chronic tissue was removed from the anterior ethmoid air cells using series of straight Blakesley and Thru-Cut forceps. Dissection continued through the posterior ethmoid air cells. Subsequent to this, 30-degree scope and curved suction was used to enter the maxillary os. The natural os was widened using the straight Thru-Cut and Blakesley forceps. The 45-degree scope was then used to examine the nasal passage and the left maxillary sinus cavity and chronic polypoid tissue was removed using the maxillary sinus seeker and Blakesley and Thru-Cut forceps that were upbiting. The right nasal passage was then examined. The 0-degree scope was used to examine the nasal passage. The concha bullosa was reduced off of the right using the duckbill. The polypoid tissue was noted at the ethmoidal sinus and this was removed using the straight Blakesley and Thru-Cut forceps. Dissection was continued through the posterior ethmoidal air cells and more polypoid tissue was removed. The right maxillary sinus was then examined using the curved suction and the 30-degree scope. Polypoid tissue was removed using series of up and straight Blakesley forceps as well as the maxillary sinus seeker. What appeared to be fungal material was also noted and removed. The 45-degree and 70-degree scopes were then used to examine the maxillary sinus cavity, where more chronic tissue was removed. No dental material was noted, however. The inferior turbinates were reduced bilaterally by reducing submucosal portions bilaterally. They were outfractured bilaterally as well with a septal displacer. Mini Propel stents were placed in the ethmoid cavities bilaterally and MeroPack was placed near the turbinates bilaterally saturated in saline. It was also coated with antibiotic ointment. An orogastric tube was passed into the sto ach to empty its contents.
Thanks so much for your help
DIAGNOSIS
1. Nasal polyposis.
2. Chronic rhinosinusitis.
PROCEDURES PERFORMED:
1. Bilateral maxillary antrostomies with culture of the right maxillary sinus.
2. Bilateral ethmoidectomies with mini Propel.
3. Reduction of right concha bullosa and turbinate reduction bilaterally via submucous
resection and outfracture of the turbinates bilaterally.
SIGNIFICANT FINDINGS: Polypoid tissue of right maxillary sinus and chronic
rhinosinusitis, no dental material noted in the maxillary sinus cavity in the right. Turbinates
hypertrophied and concha bullosa was present on the right.
DESCRIPTION OF PROCEDURE: After the identification of the patient in the preoperative
area, he was brought back to the operating room and placed on the table in the supine position. After the induction of general endotracheal anesthesia, the table was turned. The patient was prepped and draped in the usual manner. The eyes were taped shut. A shoulder roll was placed under his shoulder and a donut under his head. The intranasal septum, lateral nasal wall, and turbinates were injected using 6 mL of 1% lidocaine with 1:200,000 epinephrine. Afrin-soaked pledgets were placed into the nasal passages. The pledgets were removed and the left nasal passage was first examined. Then, 0-degree scope was used to examine the nasal passage. The middle turbinate and was medialized using the Freer elevator and sickle knife was used to enter the uncinate process.
Chronic tissue was removed from the anterior ethmoid air cells using series of straight Blakesley and Thru-Cut forceps. Dissection continued through the posterior ethmoid air cells. Subsequent to this, 30-degree scope and curved suction was used to enter the maxillary os. The natural os was widened using the straight Thru-Cut and Blakesley forceps. The 45-degree scope was then used to examine the nasal passage and the left maxillary sinus cavity and chronic polypoid tissue was removed using the maxillary sinus seeker and Blakesley and Thru-Cut forceps that were upbiting. The right nasal passage was then examined. The 0-degree scope was used to examine the nasal passage. The concha bullosa was reduced off of the right using the duckbill. The polypoid tissue was noted at the ethmoidal sinus and this was removed using the straight Blakesley and Thru-Cut forceps. Dissection was continued through the posterior ethmoidal air cells and more polypoid tissue was removed. The right maxillary sinus was then examined using the curved suction and the 30-degree scope. Polypoid tissue was removed using series of up and straight Blakesley forceps as well as the maxillary sinus seeker. What appeared to be fungal material was also noted and removed. The 45-degree and 70-degree scopes were then used to examine the maxillary sinus cavity, where more chronic tissue was removed. No dental material was noted, however. The inferior turbinates were reduced bilaterally by reducing submucosal portions bilaterally. They were outfractured bilaterally as well with a septal displacer. Mini Propel stents were placed in the ethmoid cavities bilaterally and MeroPack was placed near the turbinates bilaterally saturated in saline. It was also coated with antibiotic ointment. An orogastric tube was passed into the sto ach to empty its contents.