dpries@rbd-ent.com
Guest
- Messages
- 1
- Best answers
- 0
Can someone please help me - I coded this turbinoplasty as 30130-50. The facility the procedure was done at is stating it should be 30930: Can someone help me?
DIAGNOSIS:
Preoperative Diagnosis: Chronic polypoid rhinosinusitis
Postoperative Diagnosis: Same
PROCEDURE:
Operation performed: Bilateral functional endoscopic sinus surgery with total intranasal ethmoidectomies bilateral sphenoidotomies bilateral maxillary antrostomies bilateral inferior turbinoplasty
Anesthesia: General-endotracheal
Estimated Blood Loss: 40 mL
Findings: Chronic polypoid disease
Specimens: Right and left ethmoid sphenoid and maxillary sinus contents
Complications: None
Inherent Occurrences: None
Wound Classification:Class II or Clean/Contaminated (CC): An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
Procedure: Prior the induction general anesthesia patient was identified surgical site reviewed by myself the patient and family. If the adequate induction general anesthesia patient was prepped and draped in usual fashion. Nares was cocainized with a total of 4 mL of 4% cocaine on complexes. Using the 0 degrees Storz scope on the right hand side the infundibulotomy was carried with the sickle cell knife using an anterior to posterior dissection through the basal lamella anterior and posterior ethmoidal cells were removed to create a large ethmoid cavity. Frontal ethmoid recess had some nuchal polypoid material which was removed with the up-biting Blakesley. The essential shaver was used for abundant amount of polypoid disease. The sphenoid rostrum was also entered and enlarged via this approach and marked large amount of polypoid disease was removed. The natural ostium was viewed with the 30 degrees scope and opened at the expense of the anterior fontanelle with a backbiter forceps to the left on this side posteriorly with a Gruenwald forceps. Sphenoid rostrum was also enlarged with the essential shaver. An essential shaver was used to remove some of polypoid disease in the maxillary ostium. Large cavity was formed. The procedure was repeated in the opposite side. Again the infundibulotomy was caret with the sickle cell knife. Again an anterior to posterior dissection through the basal lamella with the Blakesley forceps Blakesley suction forceps and the essential shaver. Frontal ethmoid recess had some nuchal polypoid material which was removed with the up-biting Blakesley. The natural ostium was viewed with the 30 degrees scope and opening the anterior fontanelle with a backbiter forceps to the right on this side posteriorly with a Gruenwald forceps. A large amount of polypoid disease was removed. The sphenoid rostrum was also entered and enlarged in a large amount of polypoid disease was removed. Large cavity was formed. Each ethmoid cavity was then packed with small Surgifoam dressing. Each inferior turbinate was then infractured and its bulk reduced with a hand-held Coblator. Drip pad was placed mouth pack was removed patient tolerated procedure was returned to recovery room in satisfactory condition.
DIAGNOSIS:
Preoperative Diagnosis: Chronic polypoid rhinosinusitis
Postoperative Diagnosis: Same
PROCEDURE:
Operation performed: Bilateral functional endoscopic sinus surgery with total intranasal ethmoidectomies bilateral sphenoidotomies bilateral maxillary antrostomies bilateral inferior turbinoplasty
Anesthesia: General-endotracheal
Estimated Blood Loss: 40 mL
Findings: Chronic polypoid disease
Specimens: Right and left ethmoid sphenoid and maxillary sinus contents
Complications: None
Inherent Occurrences: None
Wound Classification:Class II or Clean/Contaminated (CC): An operative wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
Procedure: Prior the induction general anesthesia patient was identified surgical site reviewed by myself the patient and family. If the adequate induction general anesthesia patient was prepped and draped in usual fashion. Nares was cocainized with a total of 4 mL of 4% cocaine on complexes. Using the 0 degrees Storz scope on the right hand side the infundibulotomy was carried with the sickle cell knife using an anterior to posterior dissection through the basal lamella anterior and posterior ethmoidal cells were removed to create a large ethmoid cavity. Frontal ethmoid recess had some nuchal polypoid material which was removed with the up-biting Blakesley. The essential shaver was used for abundant amount of polypoid disease. The sphenoid rostrum was also entered and enlarged via this approach and marked large amount of polypoid disease was removed. The natural ostium was viewed with the 30 degrees scope and opened at the expense of the anterior fontanelle with a backbiter forceps to the left on this side posteriorly with a Gruenwald forceps. Sphenoid rostrum was also enlarged with the essential shaver. An essential shaver was used to remove some of polypoid disease in the maxillary ostium. Large cavity was formed. The procedure was repeated in the opposite side. Again the infundibulotomy was caret with the sickle cell knife. Again an anterior to posterior dissection through the basal lamella with the Blakesley forceps Blakesley suction forceps and the essential shaver. Frontal ethmoid recess had some nuchal polypoid material which was removed with the up-biting Blakesley. The natural ostium was viewed with the 30 degrees scope and opening the anterior fontanelle with a backbiter forceps to the right on this side posteriorly with a Gruenwald forceps. A large amount of polypoid disease was removed. The sphenoid rostrum was also entered and enlarged in a large amount of polypoid disease was removed. Large cavity was formed. Each ethmoid cavity was then packed with small Surgifoam dressing. Each inferior turbinate was then infractured and its bulk reduced with a hand-held Coblator. Drip pad was placed mouth pack was removed patient tolerated procedure was returned to recovery room in satisfactory condition.