online solution: This is an authentic coding case for an Outpatient Clinic ca

This is an authentic coding case for an Outpatient Clinic case Please review the documentation of the patient encounter and code the case. You may use ICD-10-CM including External Cause Codes, CPT, and HCPCS codes. (There is 10 codes total) PREOPERATIVE DIAGNOSIS:  POSTOPERATIVE DIAGNOSIS: Intractable epilepsy.  OPERATION PERFORMED: Replacement of a VNS generator for vagal nerve stimulator with intraoperative interrogation of device.   ANESTHESIA:  POSTOPERATIVE DIAGNOSIS: Intractable epilepsy.  INDICATIONS: The patient is a woman with a long history of intractable epilepsy with a vagal nerve stimulator implant in place. The generator was nearing the end of its lifespan and she was recommended to undergo replacement of generator.  FINDINGS AT SURGERY: No abnormalities other than expected postop changes.  DESCRIPTION OF PROCEDURE: The patient was brought to the Operative Suite. General anesthesia was induced. An endotracheal tube was placed . Lines were placed. The left chest was sterilely prepped and draped. The old incision was infiltrated with local anesthetic. A skin incision was made with a #1 0blade. Bovie hemocautery was used to dissect through subcutaneous fat and to open the fibrotic capsule around the old generator. The generator was brought out of the chest area. The Allen wrench was used to remove the leads from the old generator. The new generator was obtained . It was a model 104, and it was attached to the leads with the Allen wrench. The new generator was then placed in the subcutaneous pouch and anchored with a 2-0silk suture. The wound was irrigated with bacitracin irrigation. The computer wand was placed in a sterile sleeve and the generator was interrogated and programmed with the patient code and date. Lead impedance was tested and found to be okay. The wound was closed with 3-0Vicryl suture and running subcuticular 4- 0 Monocryl suture with Steri-Strips and a sterile dressing over that. The patient was transported to the recovery area in stable condition .  CHIEF COMPLAINT End of battery life for generator  HISTORY OF PRESENT ILLNESS: 65 y.o. female right handed who presents to clinic today for Pre-Op Evaluation for replacement of VNS generator. with mental retardation and intractable epilepsy. The patient currently reports their pain is a level 0/10  BP 120/78 Pulse64 Temp(Src) 35.9 oc (96. 7 oF) (Temporal) Resp 16 Past Medical History DiagnosisGERD (gastroesophageal reflux disease) MR (mental retardation) Seizures Arthritis Glaucoma Osteoporosis Pseudophakiaof both eyes Cornea edema left eye Past Surgical History Eye surgery Vagal nerve stimulation Vagal nerve stimulation Total knee arthroplasty RIGHT. Revision total knee arthroplasty RIGHT. Knee surgery RADICAL RESECTION RIGHT DISTAL FEMUR, REMOVAL RIGHT TKA, RIGHT KNEE ARTHRODESIS WITH AN INTRAMEDULLARY ROD FROM THE PROXIMALFEMUR DOWNTO THE DISTAL TIBIA  AllergiesTegretol (Carbamazepine) UNKNOWN  Current Outpatient Prescriptions  bisacodyl (DULCOLAX)5 MG Take 15 mg by mouth daily as EC tablet needed. bisacodyl (DULCOLAX)5 MG Take 5 mg by mouth. calcium carbonate-vitamin d 600- Take 1 Tablet by mouth 2 times 400MG-UNITTABS daily. clonazePAM(KLONOPIN)1 MG Take 1 mg by mouth 2 times tablet daily. Morning and@@ 5 pmdivalproex (DEPAKOTE)250 MG Take 750 mg by mouth 2 times EC tablet daily.docusate sodium (COLACE) `100 Take 100mg by mouth 2 times MG capsule daily. ketorolac (ACULAR LS) 0.4 % Place1 drop into the right eye 4 5 mL SOLN times daily.lamoTRigine (LAMICTAL)100 Take 125 mg by mouth 2 times MG tablet daily. levetiracetam (KEPPRA)1000 Take 1,500mg by mouth 2 times MG tablet daily. LORazepam (ATIVAN)2 MG/ML Inject4 mg as directed as injection meloxicam (MOBIC)15 MG Take 15 mg by mouth daily. tablet MINERAL OIL HEAVY As instructed. 3 drops into each ear @@ bedtime 3x weekMultiple Vitamins-Minerals Take 1 Tablet by mouth daily. (MULTIVITAMIN) WITH MINERALS) TABS ranitidine (ZANTAC)150MG Take 150mg by mouth nightly. tabletsenna (SENOKOT)8.6 MG Take 17.2 mg by mouth every TABS tablet evening.sodium chloride(MURO)5% ophthalmic ointment timolol(TIMOPTIC)0.5% ophthalmic solution travoprost, benzalkonium, (TRAVATAN) 0.004% ophthalmic solution No current facility-administered medications for this visit.  REVIEW OF SYSTEMS: Constitutional: No problems Eyes: Glaucoma ENT/Mouth: No problems Cardiovascular: Leg pain while walking and Swelling in hands or feet Respiratory: No problems Gastrointestinal: GERD Genitourinary: Incontinence Musculoskeletal: Arm or leg pain , Arm or leg weakness and Arthritisintegumentary: No problems Neurologic: Seizures Psychiatric: No problems Endocrine: No problems Hematologic/Lymphatic: No problems Allergic/Immunologic: No problems  PHYSICAL EXAMINATION: 2nd Cranial Nerve: blinks to threat 3rd, 4th, 6th Cranial Nerves: Dysconjugate gaze with opacification of cornea on left 5th Cranial Nerve: grimaces to touch7th Cranial Nerve: full and symmetrical facial movement8th Cranial Nerve: hears finger rub well bilaterally 9th, 10thCranial Nerves: Opens mouth to command 11th Cranial nerve: Kyphotic posture, head tilt to right12th Cranial nerve: normal tongue movement  Constitutional: well developed, well nourished, in no apparent distress and seated in wheelchair, right knee extendedEyes: Dysconjugate gaze, opacification on left cornea Head: normocephalic, atraumaticMouth/Throat: periodontal disease noted and moist mucus membranes Page 3 of 4 Neck: no adenopathy ,no palpable thyroid tissue and supple, no adenopathy, no JVD, no bruits, no thyromegalyChest: clear bilaterally Cardiac: normal rate and regular rhythm Vascular: no edema and compression hose in placeAbdomen: abdomen is soft without significant tenderness and bowel sounds presentGenital: exam deferredExtremities: deformities: right kneeLymph nodes: no lymphadenopathyMusculoskeletal: Decreased ROM right knee Neurologic: person and home is mental status awake, looking around, speech dysarthric, alert and oriented x Follows simple commands Skin: no rashes or significant lesions, no petechiae and no bruisingSensation: no decrease in sensation, arms and legs to touch  ASSESSMENT: End of battery life VNS generator  PLAN: replace VNS generator. has discussed the risks and benefits of this surgery with The patient understands and wishes to proceed. The consent is signed and on the chart. i has been instructed to be NPO after midnight. The patient has been provided with Cida Stat soap and instructed to shampoo and shower head to toe, both the night before surgery and the morning of surgery before coming to the hospital. Pre- and post operative teaching have been begun. The patient was educated on what level of pain to expect postoperatively and what pain management modalities to expect.  Discontinued Medications0.9% NaClinfusion 1307 Rate: 10mUhr Freq: CONTINUOUS Route: IV                 Health Science Science NursingHCMT 2025C

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