I need help with these two cases for CPT coding. I have attached both files.
I need help with these two cases for CPT coding. I have attached both files.
ATTACHMENT PREVIEW Download attachmentLOCATION: Outpatient, HospitalPATIENT: Daniel BriggstadATTENDING PHYSICIAN: Jeff King, MDSURGEON: Jeff King, MDPREOPERATIVE DIAGNOSES1.Recurrent otitis media.2.Retained right PE tube and granulation tissue.3.Left otitis media with effusion.POSTOPERATIVE DIAGNOSES1.Recurrent otitis media.2.Retained right PE tube and granulation tissue.3.Left otitis media with effusion.4.Right tympanic membrane perforation.PROCEDURES PERFORMED1.Removal of right PE tube and granulation tissue from the tympanic membrane.2.Left myringotomy with tympanostomy tube placement.ANESTHESIA: General inhalation.SURGICAL INDICATIONS: A 4-year-old male with a history of bilateral PE tubes. Sinceextrusion of the PE tubes, he has had recurrent episodes of otitis media. There is alsogranulation tissue around the right PE tube.PROCEDURE: After consent was obtained, the patient was taken to the operating roomand placed on the operating table in supine position. After the adequate level of generalinhalation anesthesia was obtained, the patient was draped in the appropriate mannerfor PE tube placement. Attention was first focused on the right ear. Utilizing an earspeculum and microscope, the external canal was cleared of cerumen. The retainedextruded PE tube was removed from the tympanic membrane. In addition, granulationtissue was also removed. Subsequent examination shows a perforation of the posteriorinferior area. There is no effusion. Due to the significant size of the perforation, no PEtube was placed. Attention was then focused on the left side. The ear canal was clearedof wet debris and cerumen. The tympanic membrane was noted to be opaque. Themyringotomy incision was then placed in the anterior inferior quadrant. Serous effusionwas suctioned. A bobbin tympanostomy tube was then placed without difficulty.Cortisporin otic suspension and a cotton ball were then placed.The patient tolerated the procedure well, and there was no break in technique. Thepatient was awakened and taken to the postanesthesia area in good condition.
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