Answer 8. Extraction code: 07DQ0ZXRationale: Bone marrow sampling is coded with the root operation Extraction. This procedure is performed using an open approach. This is a biopsy and therefore the qualifier X, Diagnostic is assigned. There was no device. Chapter 14 Operative Report #2 PREOPERATIVE DIAGNOSIS: Ingrown great toenail, right 12
Week 4 Homework Answer Key POSTOPERATIVE DIAGNOSIS: Ingrown great toenail, right PROCEDURE: Excision of toenail INDICATION FOR PROCEDURE: The patient is a 60-year-old female who has a persistently ingrowing great toenail on the right foot that has had two past infections. The infection is now clear and the patient presents for removal of the toenail. She also has pernicious anemia, Friedrich’s ataxia, and heart disease. PROCEDURE DESCRIPTION: General anesthesia was induced. The patient is placed in the supine position, with the knees flexed, and the right foot is flat on the table. The toe is prepped and cleansed. In addition, a standard digit block is performed with 1 percent lidocaine using a 10-ml syringe and a 30-gauge needle. Approximately 3 ml is instilled on each side of the toe. A sterilized rubber band is placed around the base of the toe. The toe is resterilized and draped with the toe protruding. A nail elevator is slid under the cuticle to separate the nail plate from the overlying proximal nail fold. The nail plate is identified. A bandage scissors is used to cut from the distal end of the nail straight back beneath the proximal nail fold. The right piece of nail is grasped with a hemostat and removed in one piece, pulling straight out. The left piece of nail is grasped and removed in a similar manner. Electrocautery ablation is used to destroy the nail matrix where the nail was removed. The matrix is treated twice. Antibiotic ointment is applied and a bulky gauze dressing is placed. The foot is placed in a surgical boot. Post-op instructions are given for daily cleansing with warm water, and strenuous exercise is to be avoided completely for at least one week. The patient tolerated the procedure well and understands the discharge instructions. Answer 2. 0HDRXZZ, 0H5RXZZRationale: The root operation Extraction is coded because the nail plate is pulled out, even though the physician states “excision of toenail” in the procedure description. The body part assigned. The approach is X, External and no device value or qualifier value is appropriate for this code. The nail matrix, still part of the body part R, Toenail is destroyed by electrocautery. This is coded with the root operation Destruction because a second procedure is performed on the same body part value. The approach is X, External, and no device value or qualifier value is appropriate for this code. Operative Report #4 PREOPERATIVE DIAGNOSIS: Pacemaker malfunction POSTOPERATIVE DIAGNOSIS: Same ANESTHESIA: Local OPERATION PERFORMED: Replacement of pacemaker generator and electrode PROCEDURE: The patient was positioned on the fluoroscopy table and the right chest 13
Week 4 Homework Answer Key was prepared and draped. Local anesthesia was obtained with 1 percent lidocaine with
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