Case -AUDIT REPORT T13.1 OPERATIVE REPORT, MYRINGOTOMY AND ADENOIDECTOMY/TONSILLECTOMY

Essay

Case
-AUDIT REPORT T13.1 OPERATIVE REPORT, MYRINGOTOMY AND ADENOIDECTOMY/TONSILLECTOMY
LOCATION: Outpatient, Hospital
PATIENT: Terri Laffe
ATTENDING PHYSICIAN: Jeff King, MD
SURGEON: Jeff King, MD
PREOPERATIVE DIAGNOSIS:
1. Chronic adenotonsillitis.
2. Adenotonsillar hypertrophy.
3. Chronic serous otitis media.
POSTOPERATIVE DIAGNOSIS:
1. Chronic adenotonsillitis.
2. Adenotonsillar hypertrophy.
3. Chronic serous otitis media.
PROCEDURE PERFORMED:
1. Bilateral myringotomies.
2. Tonsillectomy.
3. Adenoidectomy.
PROCEDURE: The patient was admitted through the same-day surgery program and taken to the OR. A general endotracheal anesthesia was administered. A 4-mm speculum was then inserted in the right ear, and wax was removed from the canal. A small incision was made, and a small amount of fluid was removed. The same was then performed on the left ear. The patient was then turned 90 degrees. A McIvor mouth gag was inserted. The patient's tonsils were touching in the midline. The left tonsil was removed by snare technique, and then bismuth packs were placed. The right tonsil was removed by snare technique, and then bismuth packs were placed. Adenoids were removed with the use of adenotome curettement and biopsy forceps. Nasopharynx was both visually examined and palpated to be sure the adenoids have been removed, and then bismuth packs were placed. Packs were serially removed, and electrocautery was used to attain hemostasis in all three areas. The nasal and oral cavities were washed well with saline. All three areas were reexamined, and when good hemostasis was present, they were painted with viscous Xylocaine. The patient was then awakened from his anesthetic and returned to the recovery room in stable condition.
T13.1:
SERVICE CODE(S): 42820, 69421_____________
ICD-10-CM DX CODE(S): J35.03, J35.3, H65.23
INCORRECT/MISSING CODE(S): ________________________________________