kbearden1985
Networker
I cannot seem to find a code for hemorrhage control when involving an ear, more specifically a post mastoidectomy...
PREOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.
POSTOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.
PROCEDURE PERFORMED: Control of post mastoidectomy hemorrhage.
INDICATIONS: This gentleman had a tympanomastoidectomy done apparently
at Vanderbilt about a week and a half ago. He was doing well until
today when a door accidentally hit him on the ear and he began to have
profuse bleeding from the ear canal, that continued for hours. He
presented to the emergency department, attempts there were
unsuccessful, and it was opted to bring him to the operating room for
exploration and control of the hemorrhage.
DESCRIPTION OF PROCEDURE: Under general endotracheal anesthesia, the
right ear was draped and prepped in a sterile manner. There was some
bleeding arising from the external canal and a considerable amount of
blood clots present. Suction was used under the visualization of the
operating microscope. The entire tympanomastoid cavity was filled with
blood and this was suctioned. The bleeding area appeared to be in the
subcutaneous region essentially at the level of the temporalis muscle
at the posterior aspect of the incision site. It responded well to
hemostatic agents specifically Surgicel. Blood loss during the
procedure was less than 100 mL. Blood loss prior to the procedure
appeared to be about 700-800 mL. A Glasscock dressing was applied.
Hemostasis was complete. The patient was uneventfully awakened and
brought in stable condition to the recovery area.
PREOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.
POSTOPERATIVE DIAGNOSIS: Post mastoidectomy hemorrhage.
PROCEDURE PERFORMED: Control of post mastoidectomy hemorrhage.
INDICATIONS: This gentleman had a tympanomastoidectomy done apparently
at Vanderbilt about a week and a half ago. He was doing well until
today when a door accidentally hit him on the ear and he began to have
profuse bleeding from the ear canal, that continued for hours. He
presented to the emergency department, attempts there were
unsuccessful, and it was opted to bring him to the operating room for
exploration and control of the hemorrhage.
DESCRIPTION OF PROCEDURE: Under general endotracheal anesthesia, the
right ear was draped and prepped in a sterile manner. There was some
bleeding arising from the external canal and a considerable amount of
blood clots present. Suction was used under the visualization of the
operating microscope. The entire tympanomastoid cavity was filled with
blood and this was suctioned. The bleeding area appeared to be in the
subcutaneous region essentially at the level of the temporalis muscle
at the posterior aspect of the incision site. It responded well to
hemostatic agents specifically Surgicel. Blood loss during the
procedure was less than 100 mL. Blood loss prior to the procedure
appeared to be about 700-800 mL. A Glasscock dressing was applied.
Hemostasis was complete. The patient was uneventfully awakened and
brought in stable condition to the recovery area.