LOCATION: Inpatient, Hospital
PATIENT: Laurence Hooper
ATTENDING PHYSICIAN: Gary Sanchez,
SURGEON: Gary Sanchez, MD
PREOPERATIVE DIAGNOSIS: Perforated appendicitis.
POSTOPERATIVE DIAGNOSIS: Same.
ANESTHESIOLOGIST: Janice E. Larson, MD
PROCEDURE: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped sterilely. The patient's advanced age is a concern, since he is 92. A right lower quadrant skin incision was made with a #10 blade, and dissection was carried down through the subcutaneous tissue using electrocautery. The anterior sheath of the rectus fascia was opened. The rectus was retracted medially. The posterior sheath and peritoneum were grasped with curved clamps and sharply incised, allowing entry into the peritoneal cavity. There were a few adhesions, which we took down sharply. We then delivered the appendix up and into the wound. We took down the mesoappendix between Kelly clamps and tied the vascular pedicles with 2-0 silk free ties. The base of the appendix was then crushed. It was tied with 0 Vicryl. It was inverted into the base of the cecum with a 3-0 silk pursestring suture. The abdomen was then irrigated with saline until returns were clear. We closed the posterior sheath and peritoneum with running 0 Vicryl, closed the anterior sheath with interrupted 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. Before the patient left the operating room, the wound was anesthetized with a total of 30 cc of 0.50% Sensorcaine with epinephrine solution.
1. What is the main term referenced in the index of the CPT to locate the code?
2. What is the subterm used in the CPT index to locate the anesthesia code?
3. Does the quadrant entered to perform the surgical procedure affect CPT anesthesia code assignment?
4. Was the procedure at the abdominal wall or intraperitoneal?
5. Are there any Qualifying Circumstances to report?
6. Who decides what Physical Status Modifier should be reported?
7. Was the anesthesiologist providing service or medically directing cases?
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