Medical Billing and Coding Essay

2993 Words 12 Pages
1. Ann Borden | SURGEON: | Mohomad Almaz, MD | DIAGNOSIS: | Right carpal tunnel syndrome | PROCEDURE PERFORMED: | Right carpal tunnel release | 2. | | | 3.
PROCEDURE: The patient was placed in the supine position on the operating room table, where her right hand and forearm were prepped with Betadine and draped in a sterile fashion. We infiltrated the thenar crease area with 1% Xylocaine, and once adequate anesthesia had been achieved, we exsanguinated the hand and forearm with an Esmarch bandage. We then created a longitudinal incision just at the ulnar aspect of the thenar crease and carried the dissection down through the subcutaneous tissue. We identified the transverse carpal ligament and incised this
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After removing the hardware we closed the skin incisions using 4-0 nylon suture. Sterile 4 X 4 dressings were applied followed by ABD pads and an Ace wrap. The tourniquet was released after 27 minutes of tourniquet time. The patient was then taken from the operating room in good condition breathing spontaneously. The final sponge and needle counts were correct. She will be sent home on aspirin, as well as some Keflex.

CPT SERVICE CODE(S):____________________________________

ICD-9-CM DX CODE(S): _________________________________
| | | | | Path:body | |
4.5 points
Question 5 1.
LOCATlON: Outpatient, hospital

PATIENT: May Leigh

SURGEON: Mohamad Almaz, MD

PREOPERATIVE DlAGNOSIS: Osteoarthritis, left knee.


PROCEDURE PERFORMED: Left total knee arthroplasty.



Following satisfactory preoperative review and assessment and full discussion, the patient was brought to the operating room where under general anesthesia examination confirmed patient to demonstrate excellent appearance of her right total knee and increased valgus and crepitus of the left knee. The left knee was then elevated, scrubbed, prepped and draped in the usual fashion and utilizing a standard midline incision

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