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Coding
Recommendations - Feature
Article 06/15/99
Procedure Practice
Using ICD-9-CM and CPT-4, assign codes for the procedure(s)
described in this "real-life" patient report.
Hint: The following text
is, as you would expect, very technical and "dense;"
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Preoperative
Diagnosis: Chronic serous otitis
media
Postoperative
Diagnosis: Same
Procedure Performed:
Bilateral myringotomies and insertion of ventilation
tubes
Description
of Procedure: Under general anesthesia the
right ear was prepped and draped in the usual sterile
fashion. The operating microscope was swung into position
and the right ear was examined. A distorted, hypomobile
tympanic membrane was noted. A myringotomy incision
was made in the tympanic membrane and a moderate amount
of thick fluid was aspirated from the middle ear space.
A T-tube was placed into the tympanic membrane. The
left ear was then examined under the microscope with
similar findings. Once again, a myringotomy was performed
in the interior portion of the tympanic membrane.
A considerable amount of sticky, thick fluid was aspirated
from the middle ear cavity. A T-tube was placed therein.
Cortisporin otic drops were placed in both ear canals.
The patient tolerated the procedure well and left
the operating room in satisfactory condition.
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Using the above patient report(s), do your
own coding and then compare it with our
coding recommendations.
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