AAPC Chapter 15 & 16 Practical Application Quiz & Flashcards

Procedure performed: Scleral buckle, cryoretinopexy, drainage of subretinal fluid, C3F8 gas injection in the right eye.
Anesthesia used: Laryngeal mask anesthesia.
Primary diagnosis: Retinal detachment, confirmed postoperatively.
Multiple retinal tears identified and treated with cryoretinopexy.
Scleral buckle applied around the eye with 5-0 nylon sutures.
Subretinal fluid drained via sclerotomy and C3F8 gas injected.
Patient received postoperative pain control and eye care measures.
CPT® and ICD-10-CM codes: 67107, H33.021.

Condition addressed: Dacryostenosis in both eyes.
Procedure performed: Nasolacrimal duct probing bilaterally under general anesthesia.
Upper punctum dilated; nasolacrimal duct probed and irrigated for patency.
TobraDex eye drops administered post-procedure.
CPT® and ICD-10-CM codes: 68811-50, H04.553.

Condition treated: Right otosclerosis causing conductive hearing loss.
Procedure type: Right stapedectomy performed under general endotracheal anesthesia.
Footplate of the stapes removed; graft placed over the oval window.
Platinum Teflon cup piston used to establish ossicular continuity.
Postoperative care instructions provided to the patient.
CPT® and ICD-10-CM codes: 69660-RT, 21235-51-RT, H80.81.

Diagnosis: Adenoidal hypertrophy and serous otitis media with effusion.
Procedure performed: Bilateral ventilation tube placement and adenoidectomy under general anesthesia.
Thickened eardrums observed; tubes placed after tympanostomy.
Adenoidectomy performed using powered adenoidectomy blade.
CPT® and ICD-10-CM codes: 42830, 69436-50-51, J35.2, H65.93.

Condition: Tympanic membrane perforation with conductive hearing loss in the right ear.
Procedure: Right tympanoplasty via postauricular approach under general anesthesia.
Graft harvested from temporalis fascia; perforation edges freshened before graft placement.
Closure of incision done in layers with specific sutures.
CPT® and ICD-10-CM codes: 69620-RT, H72.01, H90.11, H74.01.

Diagnosis: Foreign body in the right external ear canal.
Procedure: Removal of foreign body using microscope, performed under general anesthesia.
Foreign body identified and removed atraumatically; ear canal remained intact.
CPT® and ICD-10-CM codes: 69205-RT, T16.1XXA.

Diagnosis: Left lower eyelid basal cell carcinoma.
Procedure: Excision of carcinoma with flaps and full-thickness skin graft; tarsorrhaphy.
Tumor resection with subsequent flap advancement from the upper eyelid.
Multiple sutures used for securing graft; pressure dressing applied afterward.
CPT® and ICD-10-CM codes: 15260-E2, 67966-51-E2, 67971-51-E2, 67875-51, C44.119.

Diagnosis: Cataract in the right eye.
Procedure performed: Complex phacoemulsification and peripheral iridectomy in the right eye.
Anesthesia: Topical anesthetic used; patient informed of potential risks.
Lens removed, and appropriate surgical techniques applied for cataract extraction.
CPT® and ICD-10-CM codes not provided.### Surgical Procedures Overview
Instruments used strategically to stretch the iris, enhancing visibility during cataract surgery.
Capsulorrhexis created using cystotome needle for flap initiation and capsulorrhexis forceps for continuous tear.
Hydrodissection and hydrodelineation of lens conducted using a flat tip hydrodissection cannula.

Phacoemulsification unit utilized to remove lens nucleus; followed by irrigation and aspiration for residual cortex removal.
Bag inflated with Amvisc plus prior to lens insertion; lens model SI40MB with 27.5 diopters injected and dialed into position.

Amvisc plus removed with irrigation and aspiration; anterior chamber inflated with balanced salt solution to achieve desired firmness.
Vancomycin (0.1 cc) injected into the anterior chamber as a preventative measure.
Wounds checked for leakage; confirmed watertight and globe firmness assessed.
Speculum disinserted post-operation; patient given postoperative eye care instructions including topical eye drops and follow-up needs.

Patient diagnosed with left eye cataract; preoperative diagnosis matched postoperative findings.
Intravenous sedation and local anesthesia administered via mixture of Bupivacaine and Lidocaine.
Limbal incision performed and Provisc injected into anterior chamber for clarity during surgery.

Capsulotomy performed with a 6 mm oval shape; hydrodissection method applied using balanced salt solution.
Lens nucleus removed through phacoemulsification and residual cortex extracted via irrigation and aspiration.
AcrySof foldable posterior chamber intraocular lens inserted into capsular bag and centered appropriately.

Provisc removed; pupil constricted with Miochol before wound check.
Watertight wound confirmed; collagen shield applied soaked with Ciloxan and Pred Forte.
Standard postoperative patch and shield placed; patient stable upon transfer to recovery room.