I am a student currently taking medical coding and I am studying with Carol J. Bucks Step by Step Medical Coding. I have a question on a report that is on my workbook. I hope someone can help me, please see below:
PREOPERATIVE DIAGONOSIS: Neck injury, motor vehicle accident.
POSTOPERATIVE DIAGNOSIS: Same as operative.
PROCEDURE PREFORMED: Placement of halo crown and vest.
SURGICAL INDICATIONS: This 56-year-old patient was in a motoer vehicle accident and appears to have sustained a spinal cord injury with ligamentous instability at C4-5. He could not be place in a neck collar because he has a short thick neck and also because he head a tracheostomy tube. The patient would not be stabilized with traction as he has a distraction injury. It was indicated to place him in a halo vest and crown to immobilize his neck.
PROCEDURE: The hair was shaved behind both ears. There was a sterile prep done along the forehead region and the region behind both ears. The halo crown was then positioned and stabilized with the three positioners anteriorly and two laterally. I then injected xylocaine behind both ears and alont the supraorbital ridge laterally. I then placed the four pins and torqued them to 8 pounds per sq. inch. The hexagonal lock nuts were then tightened. The patient tolerated this well without any apparent complications. The halo vest was then connected to the crown. The crown was places. A large vest was used but this was still too small for the patient, and on the right side the vest had to be tied with string until some permanent straps could be fashioned by orthotics. During the placement of the vest, I mentioned the neck in neutral position and no time was there any rotation of flexion of extension of the neck.
On this specific report you have to code the Anesthesia, when I looked at the answer and it stated "Local Anesthesia not reported". My question is, why is it not reported?
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