Adrenalectomy Operative Report

Keywords are Highlighted (With Coder Notes)

A 51 year old woman presented with

Diagnosis: Secondary - Type of Hypertension

 hypertension, Primary Term or Subterm?

 (malignant, renovascular) Type of Hypertension

           Unprovoked hypokalemia - You won't find "unprovoked in the ICD-9 Manual" See the Internet Link for more info 

           Primary hyperaldosteronism - Is there also Secondary? Is it a different Code?

An image study was performed with computed tomographic scan.

Operation:

Bilateral Is the CPT Code unilateral or bilateral?

Adrenalectomy  was performed with excision of adenoma by the way of retroperitoneoscopic approach. - What does this mean? What is the approach?

A specially designed Step’s trocar system with the cannula and blunt-tip obturator through a radially expandable sleeve was applied to make it quicker and safer during setting up of the first port.

The operation took 175 and 150 minutes respectively. Blood loss was less than 100 ml. There were no complications during and after the four and five days of hospital stay. Blood pressure was restored within normal range and the patient is free from medicine before leaving the hospital.

Note: Most Likely a general surgeon would perform this operation, NOT an endocrinologist.