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Outpatient surgical center

  1. Question Outpatient surgical center
    Medical Coding Books
    Can someone help me with CPT code for the following procedure. stomach evacuated?
    Dx: Chronic tonsillitis (474.00)
    Procedure: Tonsillectomy. (42825)
    DETAILS OF THE PROCEDURE: The patient was placed on the operating table in a supine position. General anesthesia was induced. She was orotracheally intubated without difficulty. The table was turned 90 degrees towards the surgeon and the patient was draped in the usual fashion. A mouth gag was placed and suspended. The right tonsil was grasped and retracted medially and removed using coblation device. An identical procedure was repeated on the opposite side. A 0.5% lidocaine with epinephrine was then injected into the tonsillar fossa bilaterally. The nose and mouth were irrigated. All instrumentation was removed and the stomach was evacuated. The patient was then allowed to awaken from general anesthesia. She was extubated without difficulty and was transferred to the recovery room in stable condition.
    Thaks in advance for your help.

  2. #2
    Milwaukee WI
    Default NO separate procedure
    The stomach contents are routinely evacuated for any number of surgeries under general anesthesia to prevent post surgical aspiration. There is no separate procedure coded for this. It's part of the tonsillectomy.

    F Tessa Bartels, CPC

  3. Question Out Patient Surgery Center
    Need help with diagnosis code and procedure code. Thank you in advance for your help.

    POST OP DX: Cystic degeneration of probable ruptured varix

    OPERATIVE PROCEDURE: After IV sedation was given, a 3-cm lateral to medial incision was made overlying the cystic structure. Superior and inferior flaps were raised. The cystic structure was delivered into the field, and a small thrombosed vein coming into the large dilated cystic structure with an exit vein leaving was identified. Clamps were placed upon both of the inflow and outflow venous side which was transected and ligated with 4-0 Vicryl. After removing the specimen from the field, the inferior and superior flaps were mobilized and approximated across the wound with 3-0 Vicryl. Then, a 4-0 Biosyn was used to approximate the skin edges. Because of the tension across the knee area with flexion and bending, three interrupted simple 4-0 nylon sutures were placed in small retentions to take tension off the line and Steri-Strips. These sutures will be removed within four to five days for cosmetic purposes.

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