Medical case study (operative report)


After reading the operative report below, provide a complete response and codes to the questions that follow.

Findings:  The patient had a superficial wound dehiscence with exposure of his  leads. He had a small area of lead fraying on lead one. After the leads  were freed up from the scar and the pocket, that showed one area of lead  dropout on interrogation.

The patient was taken to the  operating room and placed in the supine position. General endotracheal  anesthesia was obtained. The patient had the usual monitors placed. The  patient was then rolled prone onto the Jackson OSI table. All of the  soft tissue areas were well padded. The patient had the usual monitors  placed. He then had the chest wound for the new generator site  identified with the incision identified using C-arm fluoroscopy in the  AP plane and the course of the lead was followed and the lead was  planned to be explanted at a new level and then reconnected to the  generator, which would be disconnected from the lead to the present  location pocket. The patient had a timeout done per protocol confirming  the correct patient, correct procedure, and all equipment that was  necessary from the Boston Scientific pacemaker rep. The patient then had  the incisions injected with local and the initial incision was made  over the area where the generator was. Sharp dissection was used to get  down to the generator layer, and bipolar cautery was used for  hemostasis. The leads were dissected free from the superficial aspect of  the incision and then the area of the generator was exposed, and the  generator was explanted and then it was disconnected from the leads, and  the temporary stoppers were placed in the lead holes on the generator  and secured and then the generator was placed in antibiotic solution.  The area of the leads was then inspected and noted to be markedly  scarred in the pocket where they had been positioned behind the  generator. These were dissected free using the Bovie cautery on cutting  mode and, once the leads had been freed up from all the scar, the new  pocket was made hemostatic and was irrigated out. The leads were then  exposed through the other incision for the new generator site. This was  placed approximately 5 in. above the present site and then, once the  leads had been identified in the depth of the new incision, they were  mobilized and dissected free and then mobilized up to the new incision  and then wrapped in an antibiotic soaked lap. The new pocket was created  using a Bovie cautery and the Army-Navy retractors and, once hemostasis  was obtained using the suction cautery, the area was irrigated out and  then the old generator site was irrigated out. Then the generator was  brought up after we had changed our gloves on the field and then the  generator had the stoppers removed and the leads were then placed in  their usual positions. The generator was placed halfway in the pocket  and then interrogated by the Boston Scientific rep, and the #1 lead was  noted to have one area of dropout but otherwise was functioning well.  This was consistent with a small area of fraying of the lead with the  bulk of the lead intact. The leads were then tightened and then  reinterrogated with otherwise good function noted, normal impedances,  and then the excess lead was placed behind the generator in the pocket.  Then the pocket was irrigated out again with Vancomycin antibiotic  solution and, once both pockets had been irrigated out, the wound was  closed in multiple layers and the skin was ultimately closed with  staples at both sites. The patient then had the wounds cleaned off and  dressed and the patient was then rolled supine and extubated and brought  back to the recovery room alert and moving all extremities.


•    Based on your review of the operative report, what is the objective of the procedures performed today?
•    Based on your review of the operative report, what two approaches are used for this report?
•    Based on your review of the operative report, identify the two codes needed to reflect the work performed on the leads.
•    Identify the code that would be used to report the insertion of the pulse generator.
•    Identify the code for the interrogation of the pacemaker. 

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