Hemic, Lymphatic, Mediastinum, Diaphragm

Front 1

A 60-year-old female patient was admitted to the hospital yesterday with a diagnosis of carcinoma of the cervical lymph nodes. Today she was taken to the operating room and put under general anesthesia. We performed a radical cervical lymphadenectomy and modified radical neck resection. The patient was taken to the recovery room in stable condition.

Back 1

Lymphadenectomy, Radical, Cervical, 38720-38724
(see 38724)

Front 2

A procedure in which a mediastinoscope is used to examine the organs in the area between the lungs and nearby lymph nodes. A mediastinoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease. The mediastinoscope is inserted into the chest through an incision above the breastbone. This procedure is usually done to get a tissue sample from the lymph nodes on the right side of the chest.

Back 2

mediastinoscopy

Front 3

Procedure Performed: This 37-year-old male patient who is obese, weight 225 lbs, Body Mass Index (BMI) 31.4 also has obstructive sleep apnea. He was found to have extra tissue in the area of his uvula. He has been brought to the operating room today and has been given a general anesthetic. His uvula 2 has been excised 1 to help relieve his obstructive sleep apnea. The patient was taken to the recovery room in good condition.

Back 3

Excision, Ulva, 42140-42145, 42140

Front 4

Diagnoses: obstructive sleep apnea, obesity, BMI 31.4.

Back 4

Index to Diseases: Apnea, 327.23; Index to Diseases: Obseity, Severe, 278.01; Index to Diseases: BMI 31.4 is V85.31

Front 5

Three days later this 30-year-old female patient came in through the emergency room because she was vomiting blood and blood clots. I was called in because of acute hemorrhaging of her operative wounds. She was rushed to the operating room for control of nasopharyngeal hemorrhage, post adenoidectomy. Patient will be admitted for 23 hours for observation.

Back 5

Hemorrhage, Nasopharnyx, 42970-42972, 42972 (Secondary surgery), (Unplanned return)
42972-78

Front 6

PROCEDURE: Removal of tonsils and adenoids.

Back 6

CPT: Tonsillectomy, 42820-42826
(42821)

Front 7

Blank is an OPERATION to surgically remove accumulations of ATHEROSCLEROTIC PLAQUE (atheromas) from the arteries

Back 7

Endarterectomy

Front 8

Procedure Performed: Laparoscopic ablation liver tumors by radiofrequency

Back 8

CPT: Ablation, Liver, Tumor
Laparoscopic 47370-47371

Front 9

Procedure Performed: Laparoscopic ablation liver tumors by radiofrequency

Back 9

CPT: Ablation, Liver, Tumor, Laparoscopic, 47370-47371.
47370 (Imaging Guidelines)
47370, 76940
The procedure was performed in the operating room, not in the physician’s office. The procedure was performed at a hospital or other outpatient surgery site. The hospital would own the equipment used to perform the ultrasonic guidance. Remember, the physician cannot code for the technical component of a procedure unless the physician “owns” the equipment used to perform. Turn to Appendix A and locate modifier

Front 10

A 38-year-old male patient with bleeding diverticulosis of the colon is treated surgically. He had a laparoscopic partial colectomy with anastomosis

Back 10

Alphabetical Index → main term laparoscopic → sub-term colectomy partial 44204-44208, 44213
Numeric Section → code 44204 laparoscopic, surgical; colectomy, partial, with anastomosis

Front 11

42-year-old female patient with severe gastroesophageal reflux disease is in the operating room for laparoscopic esophgogastric fundoplasty (eg, Nissen

Back 11

Alphabetical Index → main term laparoscopic → sub-term esphagogastric fundoplasty 43280
Numeric Section → code 43280 laparoscopy, surgical, esophagogastric Fundoplasty (eg, Nissen, Toupet procedures)

Front 12

Laparoscopic ablation liver tumors by radiofrequency

Back 12

The procedure was performed in the operating room, not in the physician’s office. The procedure was performed at a hospital or other outpatient surgery site. The hospital would own the equipment used to perform the ultrasonic guidance. Remember, the physician cannot code for the technical component of a procedure unless the physician “owns” the equipment used to perform. Turn to Appendix A and locate modifier 26 and read the description.

Procedure Performed: Laparoscopic ablation liver tumors by radiofrequency. 47370, 76940-26

Front 13

Procedure Performed: Nephrolithotomy removal of calculus

Back 13

Appendix A:
Was this procedure performed on both kidneys? Find the appropriate side of the body modifier.

Nephrolithotomy, removal of calculus (right). 50060-RT

Front 14

Dr. Blecker provided supervision and interpretation for this percutaneous renal biopsy performed ultrasonically.
Procedure Note: This 31-year-old female patient was brought into the operating room. She was prepped, draped and given general anesthesia. We made stab incisions and performed percutaneous needle biopsy using ultrasonic guidance to obtain tissue for the biopsies on both kidneys. The biopsies were obtained successfully. The patient was awakened and taken to the recovery room in stable condition.

Back 14

1. Biopsy, Kidney, 50200-50205-50
2. Radiology, 76942=50
3. No modifiers 26 and TC due to radiogy claim that includes both TC and 26.