Billings Community Education Online Medical Classes | Advanced Medical Coding Chapter 14
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Advanced Medical Coding Chapter 14

06 Aug Advanced Medical Coding Chapter 14

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Advanced Medical Coding Chapter 14
Question 1 of 6
Question #1: OPERATIVE REPORT, ANESTHESIA
This patient is a healthy, 42-year-old patient except for the subdural hematoma. Do not assign diagnosis codes. Ventriculography was not used during the procedure. Anesthesia by: MDA and CRNA. Anesthesiologist was medically directing 4 concurrent cases.
LOCATION: Inpatient, Hospital
PATIENT: Larry Colter
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side
POSTOPERATIVE DIAGNOSIS: Acute subdural hematoma, left side
PROCEDURE PERFORMED: Osteoplastic craniotomy
ANESTHESIA: General anesthesia

PROCEDURE: Under general anesthesia, the left side of head was prepped and draped in the usual manner, after having been placed in Mayfield pins. Hemoclips and Dandy clips were utilized on the scalp edges. Part of the temporalis muscle was taken down. Two burr holes were made, and a circumferential flap was made. The bone was elevated. The dura was incised in an inverted U-shaped fashion. We saw acute clot; probably 45-50 cc (cubic centimeter) of clot was irrigated from the frontal, temporal, and posterior parietal areas. Having cleaned it out, there was no free bleeder that I saw. I placed a piece of Gelfoam on the brain and then began closure of the dura with 3-0 Vicryl; this was done. A little patch was necessary; we used temporalis fascia. We tacked up the dura, replaced the bone flap, and utilized Wurzburg plates and burr hole cover. Having secured this, we then closed the scalp with 2-0 Vicryl on the galea with surgical staples on the skin, with a Hemovac drain having been applied prior to closure.
T14-1A:
PHYSICIAN CODE: ___________________
CRNA CODE: ___________________

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