How do you code the procedures for this report, cpt says donot use the code for ventilating tube removal and tympanostomy in conjunction so how do you code it?
Patient Name: MRN: Patcom: Date of Surgery: Surgeon: Assistant(s):
PREOPERATIVE DIAGNOSIS: Eustachian tube disease and otitis media with adenoid hypertrophy.
POSTOPERATIVE DIAGNOSIS: Eustachian tube disease and otitis media with adenoid hypertrophy.
1.Bilateral myringotomy with tympanostomy tube placement. 2. Bilateral tube removal. 3. Adenoidectomy. 4.Use of the operating microscope.
ANESTHESIA: General. ESTIMATED BLOOD LOSS: 5 mL.
FLUIDS: Per Anesthesia.
FINDINGS: Granulation tissue on the left with both tubes being plugged with mild adenoid hypertrophy.
DESCRIPTION OF PROCEDURE: Rodrekus is a pleasant 3-1/2-year-old male with a history of otitis media with effusion who has had previous tubes that have since become clogged. The patient presents for tube removal and replacement of tubes, as he has continued hearing loss. The patient also presents for adenoidectomy. After informed consent and proper patient identification, the patient was brought to the operating theater and placed supine on the operating room table. General anesthesia was induced without complication. The patient's right ear was first examined and showed a blocked tympanostomy tube within the eardrum, and this was removed without complication. The ear was suctioned free of any debris, and there was no thickened fluid noted in the middle ear. An Armstrong modified Grommet tube was placed in the right ear, and then Floxin drops were applied to the ear.
We then turned to the left ear and, in a similar fashion, removed the left tympanostomy tube. However, on the left side there was a significant amount of granulation tissue occluding this tube, and this caused some bleeding within the left ear. The tube was removed, and an Armstrong modified Grommet tympanostomy tube was placed and Floxin drops were applied. Cotton balls were placed in both ears. We then turned the bed 90 degrees. A mouth gag was inserted, and the nose was sprayed with Afrin.
A red rubber catheter was passed through the right nose, and the adenoids were visualized. Using an adenoid curette, the adenoids were removed, and cautery was used to obtain hemosis. The eustachian tubes were identified and were not injured.
Once complete, the nose was irrigated, and the mouth was suctioned free of debris. The red rubber catheter and mouth gag were removed, and the patient was then awakened from general anesthesia and taken to the recovery room in stable condition.
Please note the attending Dr. was present for the entire procedure.
Dictated by: Surgeon JOB: DD.08 12 AM DT: 3:24 PM Additional CC:_______________________________________________ ___ Electronically signed by
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