KNP40806
Networker
I need some input. I have a op report that states that the esophagus was dilation with Maloney dilators sizes 30 to 38. 43220 amd 43226 just don't seem to fit based on the op report. I have attached the op report below. Can someone please read it and offer some advise on how to code this one?
PREOPERATIVE DIAGNOSIS: Esophageal stricture.
POSTOPERATIVE DIAGNOSIS: Esophageal stricture.
PROCEDURES: 1. Esophagoscopy.
2. Esophageal dilation sizes 30 to 38 utilizing Maloney dilators.
SURGEON:
ANESTHESIA: General.
COMPLICATIONS: None.
CONDITION AFTER PROCEDURE: Stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table. General anesthesia was induced by placement of an endotracheal tube in the patient's tracheal stoma. After this was performed, saline-soaked gauze was placed on the patient's upper gingival surface and a 6 x 8 mm, 32 cm rigid esophagoscope was then placed in the patient's oral cavity and advanced into the patient's esophagus. The patient had a small tight esophageal inlet at the proximal esophagoscope. After this was noted, the esophagoscope was able to pass this tight stricture and into the cervical esophagus. There were no other abnormalities noted. After this was noted, the esophagoscope was removed from the patient's oral cavity.
Next, serial dilation utilizing Maloney dilators sizes 30 to 38 was performed without difficulty. After this was performed, the esophagoscope was then replaced and the esophageal mucosa was then examined. There were no significant mucosal tears noted. There was no significant bleeding noted. The esophagoscope was removed from the patient's oral cavity and the patient was returned to the care of the anesthesia team who awoke the patient from general anesthesia in stable condition. The patient will be taken to the PACU and subsequently discharged to home for further care and treatment.
PREOPERATIVE DIAGNOSIS: Esophageal stricture.
POSTOPERATIVE DIAGNOSIS: Esophageal stricture.
PROCEDURES: 1. Esophagoscopy.
2. Esophageal dilation sizes 30 to 38 utilizing Maloney dilators.
SURGEON:
ANESTHESIA: General.
COMPLICATIONS: None.
CONDITION AFTER PROCEDURE: Stable.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in the supine position on the operating room table. General anesthesia was induced by placement of an endotracheal tube in the patient's tracheal stoma. After this was performed, saline-soaked gauze was placed on the patient's upper gingival surface and a 6 x 8 mm, 32 cm rigid esophagoscope was then placed in the patient's oral cavity and advanced into the patient's esophagus. The patient had a small tight esophageal inlet at the proximal esophagoscope. After this was noted, the esophagoscope was able to pass this tight stricture and into the cervical esophagus. There were no other abnormalities noted. After this was noted, the esophagoscope was removed from the patient's oral cavity.
Next, serial dilation utilizing Maloney dilators sizes 30 to 38 was performed without difficulty. After this was performed, the esophagoscope was then replaced and the esophageal mucosa was then examined. There were no significant mucosal tears noted. There was no significant bleeding noted. The esophagoscope was removed from the patient's oral cavity and the patient was returned to the care of the anesthesia team who awoke the patient from general anesthesia in stable condition. The patient will be taken to the PACU and subsequently discharged to home for further care and treatment.
