chapter4
chapter4
Chapter 4 ICD-10-CM Coding Chapters 1–11 Anesthesia: General. Indications: This is a 69-year-old
woman who has had progressive hearing loss |2| over the last 10–15 years. Hearing aids are not useful
for her. She is a candidate for cochlear implant by FDA standards. The risks, benefits, and alternatives of
procedure were described to the patient, who voiced understanding and wished to proceed. Procedure:
After properly identifying the patient, she was taken to the main operating room, where general
anesthetic was induced. The table was turned to 180 degrees and a standard left-sided postauricular
shave and injection of 1% lidocaine plus 1:100,000 epinephrine was performed. The patient was then
prepped and draped in a sterile fashion after placing facial nerve monitoring probes, which were tested
and found to be working well. At this time, the previously outlined incision line was incised and flaps
were elevated. A subtemporal pocket was designed in the usual fashion for placement of the device. A
standard cortical mastoidectomy was then performed and the fascial recess was opened exposing the
area of the round window niche. The lip of the round window was drilled down exposing the round
window membrane. At this time, the wound was copiously irrigated with Bacitracin containing solution
and the device was then placed into the pocket. A 1 mm cochleostomy was then made and the device
was then inserted into the cochleostomy with an advance-off stylet technique. A small piece of
temporalis muscle was then packed around the cochleostomy and the wound was then closed in layers
using 3-0 and 4–0 Monocryl and Steri-Strips. A standard mastoid dressing was applied. The patient was
returned to the anesthesia, where she was awakened, extubated, and taken to the recovery room in
stable condition. _____________________________________________________________ |1| Report
the postoperative diagnosis. |2| The diagnosis is documented as the indication for the surgery.
_____________________________________________________________ What diagnosis/es code(s)
are reported? ICD-10-CM Code: H90.3 Rationale: The patient has bilateral sensorineural hearing loss.
From the Index to Diseases and Injuries, look for Loss (of)/ hearing (see also Deafness). Look for
Deafness/ senso