Determine whether physician query is appropriate

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Determine whether a physician query is appropriate in order to assign codes appropriately for this physician case. If so, what query(ies) should be made? OPERATIVE REPORT Preoperative Diagnosis: Chronic adenotonsillitis and plugged myringotomy tube Postoperative Diagnosis: Same Procedure(s) Performed: Tonsillectomy and tympanostomy tube replacement This 9-year-old child has had several recurrences of severe tonsillitis. Has been prescribed multiple courses of antibiotics without success. He has also had a recent bout of otitis with drainage from the right ear. Patient was brought to the OR and both ears examined. There was a moderate amount of debris obstructing the right tube and the tube was removed and a new tube inserted. Following this, the nasopharynx was examined with hypertrophic adenoidal tissue noted. The tonsils were enlarged as well and a tonsillectomy was performed. The patient was returned to the recovery room in satisfactory condition.

Reference no: EM133795582

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