Chapter 4 Homework (Respiratory System)

The left lung has three lobes while the right lung has two.

FALSE

What questions should be answered before assigning codes for laryngoscopies?

First what is the purpose of the laryngoscopy, which one is present in laryngoscope or was being used is flexible fibreroptic,direct, indirect.Lastly is stroboscopy was used.

Removal of pebble from a child's nasal passage, performed in the physician's office. What is the appropriate CPT code?

30300

A patient is seen with difficulty breathing due to deviated nasal septum. The surgeon performs a submucous resection of the septum

30520

Preoperative Diagnosis: Deviated nasal septum, chronic maxillary sinusits, turbinate hypertrophy, nasal obstruction Postoperative Diagnosis: Deviated nasal septum, chronic maxillary sinusits, turbinate hypertrophy, nasal obstruction Procedures Performed: 1. Septoplasty, 2. Nasal endoscopy, with bilateral maxillary antroscopy, removal of maxillary polyp 3. Submucous resection of the inferior turbinates, bilaterally This 26-year-old woman was seen by ENT service for complaints of chronic sinusitis and difficulty breathing through the nose. She was noted to have a severely deviated septum toward the right with turbinate hypertrophy, nasal obstruction (CT scans confirmed this, as well as obstruction of the ostiomeatal complexes with mucosal thickening. A decision for the above-stated procedure was then made after she had failed conservative care. The patient was brought to the operative suite, given general anesthetic, and properly prepped and draped. 5% cocaine pledgets were placed in each nasal chamber. 1% lidocaine with 1:100.000 epinephrine was injected into the caudal columnar region into the septum, as well as the middle uncinate middle turbinate region. Then, with the #1 scalpel blade, an incision was made along the left caudal columnar region in the septum, down to the mucoperichondrium. The mucoperichondrium was carefully elevated off the nasal septum cartilage, exposing a portion of the deviation. The contralateral portion was also freed up. With a Seiler knife, a portion of the deviation was removed. A large septal spur, touching the lateral wall, was carefully freed up and removed. After the patient exhibited a much improved nasal septum, a piece of cartilage was morcellized and inserted between the septal mucosa layers, and the submucosa was closed with 4-0 plain suture in interrupted form. Attention was then brought to the middle turbinates, which were found to be lateralized. A decision to medialize them was made by placing 4-0 Vicryl to the left middle turbinate, sent through the right middle turbinate, back to the septum, and tied off on the left side. Next, with the scope, the left nasal chamber was examined. The natural os was located. With the frontal probe, it was further enlarged with microbiter straight shot and back-biters. There was a moderate amount of mucosal thickening around this opening, just on the inside. After it was widely patent and cleaned out, attention was brought to the right side. The right os was located in a similar fashion and widely enlarged with the microbiter straight shot and back-biters. Again, a moderate amount of mucosal thickening was noted around this opening. When this was completed, attention was brought to the inferior turbinates. The inferior turbinates were infractured and clamped with a Carmel clamp for five minutes, then submucosal resection was performed in the usual fashion. The rods of the turbinates were then cauterized with suction cautery. This was repeated in a similar fashion bilaterally. Silastic splints were sewn into place along the septum with 3-0 Ethilon, and tampons coated in Bactroban were inserted into both nasal chambers. The oral cavity was suctioned of all serosanguineous debris, and the patient exhibited good hemostasis. She recovered from the anesthetic and was transferred to the recovery room in stable condition. What is the appropriate CPT code(s)?

30520, 31267-50, 30140-50

A patient is seen in the Emergency Department for epistaxis. Physician performs an anterior packing of right nasal passage

30901-RT

Left nasal endoscopy for control of epistaxis. What is the appropriate CPT code?

31238-LT

Bilateral nasal endoscopy with total ethmoidectomy. What is the appropriate CPT code?

31255-50

Surgeon performs a left endoscopic anterior and posterior ethmoidectomy.

31255-LT

A patient was diagnosed with squamous cell carcinoma of the larynx. The surgeon performed a supraglottic laryngectomy with radical neck dissection to remove the metastasis to the lymph nodes.

31368

Procedure: Direct microlaryngoscopy under general anesthesia Diagnosis: Dysphonia Operative Report A 40-year-old patient was taken to the OR where, under general anesthesia, the Jako laryngoscope was inserted with the operating microscope to perform a laryngoscopy. The vocal cords were found to be normal on both sides, with no evidence of nodules or granuloma formation. The entire endolarynx was well visualized. Moreover, there was no evidence of subglottic stenosis, and, as the patient was awakening, vocal cord mobility appeared to be normal. The procedure was terminated, and the patient awakened and was taken to the recovery room in good condition with stable vital signs. What is the appropriate CPT code?

31526

With the use of an operating microscope, the surgeon performs a direct laryngoscopy for removal of a piece of a toothpick.

31531

Thoracoscopy (VATS) with resection of upper right lobe of lung. What is the appropriate CPT code?

32663-RT

Flexible laryngoscopy with laser destruction of a lesion, vocal cord. What is the appropriate CPT code?

31572

Flexible laryngoscopy performed for removal of a dime lodged in the patient's larynx. What is the appropriate CPT code?

31577

PREOPERATIVE DIAGNOSIS: Persistent upper lobe infiltrate POSTOPERATIVE DIAGNOSIS: Persistent upper lobe infiltrate PROCEDURE: Bronchoscopy The patient was brought to the endoscopy suite and anesthesia was administered. After the patient was placed in supine position, the fiberoptic bronchoscope was passed through the left nostril without difficulty. The upper airway, vocal cords, and upper trachea were unremarkable. Examination of the left bronchial tree demonstrated no abnormalities. The left upper lobe also appeared normal. The mucosa surrounding the left upper lobe appeared normal. The rest of the left bronchial tree was unremarkable. Next, we obtained brush specimens from the left upper lobe to send to cytology. We obtained bronchial washings from the left upper lobe as well and sent it to cytology. The patient tolerated the procedure well. What is the appropriate CPT code?

31623-LT

Flexible bronchoscopy with cell washings, brushings, and biopsy of the right side.

31625-RT, 31623-RT

Preoperative Diagnosis: Left upper lobe lung mass Postoperative Diagnosis: Left upper lobe lung mass Operations: Flexible bronchoscopy with transbronchial biopsy and bronchial washings and brushings. Indications for Procedure: The patient recently was diagnosed with a left upper lobe lung mass. The PET scan was negative in his mediastinum. The patient was brought to the operating room and placed in supine position on the operating table. After general endotracheal anesthesia was performed, the Olympus bronchoscope was placed in the ET tube down and into the patient's trachea. The carina was observed. The right lobe appeared free of lesions. The bronchoscope was then removed and placed in left main bronchus. The main stem and lower lobe was inspected and found to have no irregularities. The left upper lobe was then examined. Bronchial washings were obtained and sent for cytology. Using fluoroscopic guidance to ensure that we were in the appropriate segment, the tip of the bronchoscope was placed into the posterior segment of the left upper lobe of the bronchus and bronchial brushings were obtained. After this, the transbronchial biopsy forceps were used to biopsy this area. Three samples were obtained for frozen section and three samples were obtained for permanent section. After removing the last specimen, the bronchoscope was removed. The patient was extubated in good condition and sent to recovery. What is the appropriate CPT code(s)?

31628-LT, 31623-LT

Bronchoscopy with excision of lesion. What is the appropriate CPT code?

31640

Bronchoscopy for removal of tumor using argon plasma coagulation. What is the appropriate CPT code?

31641

Bronchoscopy with EBUS-guided transbronchial sampling of two mediastinal lymph nodes. What is the appropriate CPT code?

31652

Percutaneous drainage of pleural cavity via indwelling catheter, with imaging. What is the appropriate CPT code?

32557

PREOPERATIVE DIAGNOSIS: Recurrent right malignant pleural effusion POSTOPERATIVE DIAGNOSIS: Recurrent right malignant pleural effusion PROCEDURE PERFORMED: Right thoracoscopic pleurodesis FINDINGS: The patient had approximately 2 L of straw-colored pleural fluid. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed in the supine position, and was administered a general endotracheal anesthesia through a double-lumen endotracheal tube. The patient was then placed in the left lateral decubitus position with the right side up. The patient's skin was prepped, and she was draped in the usual sterile fashion. An incision was made in the midclavicular line, and the chest was entered. Finger probe was swept in the pleural cavity, and there were no lung adhesions. The patient had approximately 2 L of straw-colored fluid evacuated. A trocar was then placed into the chest cavity, and a 30-degree laparoscope was inserted. There was no lung injury noted. The patient had two additional 15 mm ports placed in a triangulating fashion. These were placed under visualization of the thoracoscope. A Bovie scratch pad was then used to mechanically pleurodesis the parietal pleura. The patient had what appeared to be adequate abrasions to most of the surfaces of the thoracic cavity. The lung was inspected; again, no injuries were identified. A 36-French chest tube was then placed into the apex through the inferior and medial most trocar site. The thoracic fascia was then reapproximated in O-Polysorb interrupted fashion. The skin was closed with staples. The chest tube was secured with a O-Polysorb suture. The chest tube was secured to a pleurovac. The patient's wounds were infiltrated with 0.5 percent Marcaine with epinephrine with a total of 10 mL being injected. The patient tolerated the procedure well. She was transported to the recovery room in satisfactory condition. What is the appropriate CPT code?

32650-RT

MATHING

Larynx-Voice box Esophagus-Structures leads from throat to stomach Bronchus-Major air passages of lungs Pharynx-Connects mouth to esophagus Ethmoid- A bone in the nose

matching

Pneumonectomy-Removal of entire lung Lobectomy-Remove of one lobe of the lung Bilbectomy- Removal of two lobes of the lung Wedge resection-Removal of small,wedge-shaped portion of the lung Segmental resection- Removal of large portion of the lung lobe, larger than wedge

Brushings of tissue is another method of specimen collection.

TRUE

The patient is experiencing sinus blockages in the area between the eye sockets. These sinuses are called (frontal or ethmoid).

ethmoid

The patient has pleural fluid that must be removed. The physician would most likely perform a (pneumocentesis or pneumonectomy) to remove the fluid

pneumocentesis