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View MR 004397
MR 004397
Operative Report
Preoperative Diagnosis: Calculi of the gallbladder
Postoperative Diagnosis: Calculi of the gallbladder, chronic cholecystitis
Procedure: Cholecystectomy
Indications: The patient is a 50-year-old woman who has a history of RUQ pain, which ultrasound revealed to be multiple gallstones. She presents for removal of her gallbladder.
Procedure: The patient was brought to the OR and prepped and draped in a normal sterile fashion. After adequate general endotracheal anesthesia was obtained, a trocar was placed and C02 was insufflated into the abdomen until an adequate pneumoperitoneum was achieved. A laparoscope was placed at the umbilicus and the gallbladder and liver bed were visualized. The gallbladder was enlarged and thickened, and there was evidence of chronic inflammatory changes. Two additional ports were placed and graspers were used to free the gallbladder from the liver bed with a combination of sharp dissection and electrocautery. Cystic artery and duct are clipped. Dye is injected in the gallbladder. Cholangiography revealed no intraluminal defect or obstruction. Gallbladder is dissected from the liver bed. The scope and trocars are removed.
What CPT® coding is reported for this case?
A 1-year-old is with his mom to have his scheduled vaccinations. The physician provides counseling for routine immunizations and carries out measles, mumps, rubella and varicella (MMRV)
subcutaneously and dose 3 of Hepatitis B intramuscularly without difficulty.
What CPT® codes are reported?
A patient is brought to the operating room with a right-sided peripheral vertigo. The provider makes a postauricular incision and uses an operating microscope to perform a mastoidectomy using a burr. He next destroys the semicircular canals, the utricle, and saccule completely removing the diseased labyrinth structures. The provider sutures the incision.
What CPT® code and ICD-10-CM codes are reported?