The Next Step Advanced Medical Coding and Auditing 2017- 2018 1st Edition by Carol Buck

Exercise 2

Case 14-2
Assign anesthesia code(s) only for the CRNA. Do not assign surgery or diagnosis codes. The anesthesiologist was medically directing three CRNAs concurrently. The patient's physical status is P2.
LOCATION: Outpatient, Hospital
PATIENT: Gary Holter
ATTENDING PHYSICIAN: Gary Sanchez, MD
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Right inguinal hernia.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE PERFORMED: Right inguinal herniorrhaphy.
ANESTHESIA: General.
ANESTHESIOLOGIST: Janice E. Larson, MD
PROCEDURE: This 45-year-old patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. A right groin skin incision was made with a #10 blade. Dissection was carried down through the subcutaneous tissues using electrocautery. The external oblique was identified and opened along the length of its fibers along the external ring. Spermatic cord was identified and looped with a Penrose drain. Hernia sac was dissected free. High ligation was then performed with a 3-0 Vicryl suture ligature and a 2-0 silk free tie. The patulous internal ring was then closed with a simple interrupted 3-0 Vicryl suture. The floor of the canal looked quite good. We then closed the external oblique with a running 3-0 Vicryl, and Scarpa's with interrupted 3-0 Vicryl, and closed the skin with subcuticular 4-0 undyed Vicryl. Steri-Strips and sterile Band-Aids were applied. All sponge and needle counts were correct. Patient tolerated the procedure well and was taken to the recovery room in stable condition.
CPT Code(s): _________________
Abstracting Questions:
1. What area of the body was repaired? _________________
2. Does the type of hernia repaired affect the CPT anesthesia code assignment? _________________
3. Does the age of the patient affect the CPT anesthesia code? _________________
4. Are qualifying circumstances reported? _________________