Emmy Posted Thu 12th of March, 2020 13:03:40 PM
WE ARE REQUIRE ADVICE ON DX AND CPT CODES FOR SURGEON, CO-SURGEON AND/OR RESIDENTS FOR THIS CASE. Preoperative Diagnosis:
-- Neck Mass-left
Ji, Hongzhao, MD
Surgeon(s) and Role:
* Ji, Hongzhao, MD - Primary
* Wang, Ellen Qiongman, MD - Resident Assisting
* Desai-Markowski V, Stuti, MD - Resident Surgeon
Estimated Blood Loss:
-- Seen Anesthesia Record
-- Not Applicable
-- no neck mass identified on transcervical ultrasonography
-- no fistula tract noted in left piriform sinus on microsuspension laryngoscopy
-- Operating Room to Post-Anesthesia Care Unit
-- Post-Anesthesia Care Unit to home When Criteria Met
Statement of Staff Presence:
Ji, Hongzhao, MD was present for, and supervised all significant portions of this surgery / procedure.
Statement of Medica Necessity:
XXXXXX is a XXyear old female s/p thyroidectomy and excision of left branchial cleft cyst. She has had recurrence of fluid collection with infection in the left neck concerning for residual cyst. After discussion of risks/benefits, and alternatives, patient elected to proceed to OR for above listed procedure to assess for possible cleft cyst remnant.
Description of Procedure / Operation Performed:
On 11/7/2019 XXXXXXXXXX was taken to operating room with ENT service. Once in operating room anesthesia was induced and patient intubated.
Transcervical ultrasound performed; no soft tissue cyst or mass identified in bilateral neck. Thyroid surgically absent.
Attention then turned to oral cavity. Maxillary dentition protected with toothguard, after which a Dedo laryngoscope was inserted into the oral cavity and focused over the left tonsil and left piriform sinus. Dedo suspended to the Mayo table, and left tonsil/piriform examined with 0-degree Hopkins rod telescope and probed. No sinus tract identified in either location.
Patient removed from suspension. All instruments removed from patient.
Patient was turned over to anesthesia service, awoken, and transferred to Post Anesthesia Care Unit (PACU) in good condition.
Disposition: to PACU then home
I was present for and supervised all critical portions of the procedure and was immediately available for the entire procedure, and I agree with the above note.
Hongzhao Ji, MD