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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 30-year-old patient with a scalp defect is having plastic surgery to insert tissue expanders. The provider inserts the implants, closes the skin, and increases the volume of the expanders by injecting saline solution. Tissue is expanded until a satisfactory aesthetic outcome is obtained to repair the scalp defect.
What CPT® code is reported?
View MR 003396
MR 003396
Operative Report
Preoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Postoperative Diagnosis: Acute MI, severe left main arteriosclerotic coronary artery disease
Procedure Performed: Placement of an intra-aortic balloon pump (IABP) right common femoral artery
Description of Procedure: Patient's right groin was prepped and draped in the usual sterile fashion. Right common femoral artery is found, and an incision is made over the artery exposing it. The artery is opened transversely, and the tip of the balloon catheter was placed in the right common femoral artery. The balloon pump had good waveform. The balloon pump catheter is secured to his skin after local anesthesia of 2 cc of 1% Xylocaine is used to numb the area. The balloon pump is secured with a 0-silk suture. The patient has sterile dressing placed. The patient tolerated the procedure. There were no complications.
What CPT® coding is reported for this case?