Chapter 9
Tracheal bifurcation
Where in the respiratory system is the carina located?
32440
Which CPT® code describes a pneumonectomy?
32663
Which CPT® code(s) describes VATS therapeutic wedge resection of the left upper lobe followed by left upper lobectomy?
31086
What CPT® code is reported for a frontal sinusotomy, nonobliterative, with osteoplastic flap, brow incision?
32320
What CPT® code is reported for open decortication and parietal pleurectomy?
30115
What CPT® code(s) is/are reported for extensive excision of seven nasal polyps?
32445, 32540-51
What CPT® codes are reported for an extrapleural pneumonectomy as well as empyemectomy performed during the same surgical session?
T80.89XA, J81.1, Y63.0
What ICD-10-CM codes are reported for postoperative pulmonary edema due to fluid overload from an infusion?
Mediastinum
What anatomical cavity or compartment contains all of the thoracic viscera except the lungs?
Trachea
What is also referred to as the "Windpipe?"
voice box
What is another name for the larynx?
J45.901
What is the ICD-10-CM code for a child with an acute exacerbation of hay fever asthma?
C37
What is the ICD-10-CM code for primary malignant thymoma?
J44.0, J20.9
What is the ICD-10-CM code selection for a patient with COPD presenting with an acute bronchitis?
A37.91
What is the ICD-10-CM code selection for a patient with whooping cough who presents with pneumonia?
Lymphadenectomy
What is the term for removal of part of the lymph system?
32850, 32856, 32853
A 27 year-old girl has been on the lung transplant list for months and today she will be receiving a LT and RT lung from an individual involved in an MVA. This person was DOA at the hospital and is an organ donor. The donor pneumonectomy was performed by physician A, the backbench work by physician B and the transplant of both lungs into the prepped and waiting patient by physician C. What is the correct coding for the removal (physician A), preparation (physician B) and insertion (physician C) of the lungs?
30906-50
A 43 year-old female is seen in the emergency room with severe epistaxis. She said this is a common occurrence for her during the cold dry months of winter and this is why she is here for the third time this week. Extensive bilateral posterior cautery and packing is again required to control the hemorrhage. What CPT® code is reported for the procedure? (Note: Do not code the E/M)
32659
A 45 year-old presents with acute pericarditis. The surgeon makes a small incision between two ribs and enters the thoracic cavity. An endoscope is introduced and the pericardial sac is examined by direct visualization. Using an instrument introduced through the endoscope, the surgeon creates an opening in the pericardial sac for drainage purposes. What CPT® code is reported?
32405-RT, 77002-26, C34.11
A 55 year-old female smoker presents with cough, hemoptysis, slurred speech and weight loss. Chest X-ray done today demonstrates a large, unresectable right upper lobe mass, and brain scan is suspicious for metastasis. Under fluoroscopic guidance in an outpatient facility, a percutaneous needle biopsy of the right lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemoradiotherapy is planned. What CPT® and ICD-10-CM codes are reported?
32663
A 65 year-old patient is complaining of difficulty breathing. Patient is scheduled for a diagnostic VATS (Video-assisted thoracoscopic surgery). Under general anesthesia he was placed in left lateral decubitus position and a thoracoscope was inserted through a port site. The VATS exploration immediately revealed a mass of the right upper lobe. A biopsy was performed and sent to pathology. Results from pathology revealed small cell carcinoma. The decision was made to perform VATS and remove the upper lobe of the right lung. What CPT® code(s) is (are) reported?
32550, 32552-51, T85.79XA, C34.31, C34.32
A 78 year-old patient with bilateral, lower lobe lung cancer has been in the hospital for seven days with a tunneled chest tube in place to drain fluid from the pleural space. The chest tube currently is inserted between the 4th and 5th intercostal space on the left side. There is a very bad infection at the insertion site. The provider removes this chest tube and inserts another chest tube between the 5th and 6th intercostal space on the left side to continue fluid drainage. The tube placed today is just the same as the one removed, only sterile. What CPT® and ICD-10-CM codes are reported?
J44.0, J20.7
A final diagnosis for a patient in the ER is COPD with acute bronchitis due to echovirus. How is this diagnosis coded?
38525
A patient has a mass in her left axilla that is a suspected recurrence of lymphoma. She has a left axillary node excisional biopsy. The lymph node biopsied is under the pectoralis minor. What CPT® code is reported?
31267
A patient is seen in the endoscopy suite for a diagnostic maxillary sinusotomy. During the sinusotomy, the provider observes some diseased tissue which needs to be removed. The provider decides to perform a maxillary antrostomy with tissue removal. Bleeding is controlled. The patient tolerated the procedure well. What CPT® code(s) is/are reported?
32551
A patient presents to the emergency department (ED) with a sucking chest wound. The ED provider on duty performs an immediate tube thoracostomy in order to restore normal breathing to the patient before rushing him to surgery for another provider to address other injuries. What CPT® code is reported by the ED provider?
J33.9
A patient presents to the physician with persistent stuffiness and facial pain. The physician documents a diagnosis of nasal polyps. What ICD-10-CM code is reported?
31571, J38.5
A patient with laryngeal spasms undergoes therapeutic injection of the vocal cords. Topical anesthesia is administered to the oral cavity, pharynx and larynx. Using an operating microscope, a direct laryngoscope is inserted into the patient's mouth. The interior larynx is examined and the surgeon injects the vocal cords at two sites with glycerin. What CPT® and ICD-10-CM codes are reported?
31561, J38.02
A patient with partial vocal cord paralysis requires bilateral removal of the arytenoids cartilage to improve breathing. The laryngoscope with operating microscope is inserted. Adequate visualization is established and the arytenoid cartilage is exposed by excision of the mucosa overlying it. What diagnosis and procedure codes are reported for this procedure?
32560, J93.81
A patient with recurrent pneumothoraces presents for chemopleurodesis. Under local anesthesia a small incision is made between the ribs. A catheter is inserted into the pleural space between the parietal and pleural viscera. Subsequently, 5g of sterile asbestos free talc was introduced into the pleural space via the catheter. What CPT® and ICD-10-CM codes are reported?
30450
A patient's nose was hit with a baseball during a high school baseball game. At that time reconstruction was performed with local grafts. Patient returns now as an adult, discontent with the bony prominence along the bony pyramid and flat look of the tip of the nose. He underwent major repair with osteotomies and nasal tip work. What CPT® code is reported?
94640, J38.5
A returning 2 year-old child is seen in the pediatrician's office with stridor and a bark like cough. The pediatrician examines the child quickly and determines the child has stridulous croup. The child is given a nebulizer breathing treatment in the office to improve PO2 levels. Medication used is breathable Epinephrine. What CPT® and ICD-10-CM codes are reported?
39010
A surgeon performed a transthoracic median sternotomy for exploration of the space around the lung sacs and for drainage of fluid, caused by pneumonia. What is/are the appropriate code(s) for this scenario?
32484, C34.10, F17.210
A surgeon performs a high thoracotomy with resection of a single lung segment on a 57 year-old who is currently a heavy smoker who had presented with a six-month history of right shoulder pain that radiates to the chest. An apical lung biopsy had confirmed lung cancer. What CPT® and ICD-10-CM codes are reported?
32110
A thoracotomy procedure was performed for repair of hemorrhage and lung tear. What CPT® code is reported?
With mirrors
An indirect endoscopic procedure of the larynx means the larynx is viewed:
CPT: 31600 ICD: C32.0
CASE 1 Preoperative diagnosis: Malignant neoplasm glottis Postoperative diagnosis: Malignant neoplasm glottis(Diagnosis to report for the procedure.) Procedure: An incision is made low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage. A tracheostomy(This is the performed procedure.) tube is inserted and secured with sutures. The patient tolerated the procedure well and was sent to recovery without complications. What are the CPT® and ICD-10-CM codes reported?
CPT: 31259-50, 31267-50-51 ICD: J33.0, J33.8, J32.9
CASE 10 Preoperative diagnosis: 1. Chronic hyperplastic rhinosinusitis 2. Allergies 3. Status post-prior polypectomy and sinus surgery Postoperative diagnosis: 1. Intranasal and sinus polyps 2. Chronic hyperplastic rhinosinusitis Operative procedure: Left sinusotomy (three or more sinuses) including: • Nasal and sinus endoscopy • Endoscopic intranasal polypectomy • Endoscopic total sinus ethmoidectomy • Endoscopic sphenoidotomy • Endoscopic nasal antral windows, middle meatus, and inferior meatus • Endoscopic removal of left maxillary sinus contents Right sinusotomy (three or more sinuses) including: • Nasal and sinus endoscopy • Endoscopic intranasal polypectomy • Endoscopic total sinus ethmoidectomy • Endoscopic sphenoidotomy • Endoscopic nasal antral windows, middle meatus, and inferior meatus • Endoscopic removal of right maxillary sinus contents Specimens sent to pathology: 1. Left ethmoid and sphenoid contents for routine and fungal cultures 2. Right maxillary contents for routine and fungal cultures 3. Left intranasal ethmoid, sphenoid, and maxillary specimens for pathology 4. Right ethmoid, sphenoid, maxillary, and right intranasal contents for pathology Findings: Complete nasal obstruction by polyps obscuring of all of the normal landmarks. The right middle turbinate was found and preserved. The residual body of the left middle turbinate was found and preserved. There was thickened hyperplastic mucosa throughout the sinuses with some polyps in the sinuses, and the majority of the sinus cavities were filled with glue-like mucopurulent debris. At the end of the case there were no visible polyps, the airway was clear, and the debris had been removed. Procedure: The patient was taken to the operating room, placed in the supine position, and general endotracheal anesthesia was obtained adequately. A pharyngeal pack was placed. The nose was infiltrated with Xylocaine with epinephrine, and cottonoids soaked in 4% cocaine were placed. The procedure was performed in a similar manner bilaterally. The cottonoids were removed. The 30-degree, wide-angle sinus telescope with Endo-scrub and the Stryker Hummer device were used to remove the polyps starting anteriorly and working posteriorly. This led to visualization of the middle turbinates. The middle meati disease was removed. The area of the uncinate process and infundibulum was shaved away and forceps were used to remove portions of bone particle. Using blunt dissection, the agger nasi cells, ethmoid and sphenoid sinuses were entered and the contents removed with forceps and suction. The inferior turbinates were infractured; a mosquito clamp was placed through the lateral nasal wall into the maxillary sinuses through the inferior meatus. That opening was opened with forward and backward biting forceps, sinus endoscopy was performed, and inspissated mucus and debris cleaned out of the sinuses. In a similar manner the sinuses were opened from the middle meatus and the sinuses cleaned. Like before, the ethmoid, sphenoid, and maxillary sinuses were cleaned of debris, and inspissated mucus was suctioned from the frontal recesses. The patient was then suctioned free of secretions, with adequate hemostasis noted. Gelfilm was soaked, rolled, and placed in the middle meati. Telfa gauze was infused with Bacitracin, folded and placed in the nose. Vaseline gauze was placed between the folds of Telfa. The pharyngeal pack was removed. He was suctioned free of secretions, with adequate hemostasis noted, and the procedure terminated. He tolerated it well and left the operating room in satisfactory condition. What are the CPT® and ICD-10-CM codes to report?
CPT: 31541 ICD: D49.1
CASE 2 PREOPERATIVE DIAGNOSIS: Left vocal cord tumor. PREOPERATIVE DIAGNOSIS: Left vocal cord tumor.(Report this diagnosis if no further positive finding are found in the operative note.) NAME OF PROCEDURE - Direct laryngoscopy with microscope, removal of tumor.(Indication of type of laryngoscopy being performed.) ANESTHESIA: General. COMPLICATIONS: None. SPECIMENS: Left vocal cord tumor to pathology.(Tumor was sent to pathology.) BLOODLOSS: Less than 10 ml. TECHNIQUE: Patient was brought into the operative suite and comfortably positioned on the table. General endotracheal anesthesia was induced. The bed was turned 90 degrees clockwise. The alveolar guard was placed over the upper alveolus to protect the teeth. Appropriate drapes were placed. The anterior laryngoscope was inserted and direct laryngoscopy(Placement of the direct laryngoscope.) was performed with no abnormal findings other than the above-described tumor. The scope was suspended, and using the operating microscope(Operating microscope is used.) the anterior vocal cord tumor was removed. The mucous membrane posterior to the tumor was carefully incised and Reinke's space was entered. Careful dissection allowed mucous membrane elevation off of the anterior vocal cord up to the commissure, with what appeared to be complete excision of the tumor.(Removal of the tumor.) Minimal bleeding was noted. The area was sprayed with Cetacaine spray. The scope was gently removed. The teeth were evaluated and found to be free of injury. The drapes and instruments were removed. The patient was returned to anesthesia for care, allowed to awaken, extubated, and transported in stable condition to the recovery room. The patient tolerated the procedure well. FINDINGS: Patient is a pleasant 77-year-old white female with a history of the above-noted diagnoses. Operative findings included an otherwise normal larynx with the exception of the left anterior vocal cord tumor.(This is confirmation to report a tumor on the vocal cord.) It was fairly soft. What CPT® and ICD-10-CM codes should be used for this procedure?
CPT: 32555-LT ICD: J90
CASE 3 Preoperative Diagnosis 1. Loculated left pleural effusion, chronic Postoperative Diagnosis 1. Loculated left pleural effusion(Report this diagnosis for this procedure.), chronic Procedure Performed: Attempted, ultrasound guided thoracentesis Description of Procedure: The patient was prepped and draped in the sitting position. Using ultrasound guidance(Imaging guidance is performed.) and 1% lidocaine, the thoracic catheter was introduced into the pleural space where we encountered very thick fibrous type pleura.(The placement of the catheter in the pleural cavity to perform the thoracentesis.) The catheter was advanced, and we were unable to aspirate fluid. The catheter was removed. Sterile dressings were applied. Chest x-ray will be obtained for follow-up. Patient tolerated the procedure well. What are the CPT® and ICD-10-CM codes for this procedure?
CPT: 32663-RT ICD: C34.11
CASE 4 Preoperative Diagnosis: 1. Mass, right upper lobe. Postoperative Diagnosis: 1. Carcinoma, right upper lobe.(Report this diagnosis if no further positive findings are found in the operative report.) Procedure Performed: VATS, right superior lobectomy. Description of Procedure: Under general anesthesia, after a double-lumen tube intubation, the right lung was collapsed and the right side up is oriented so the patient is in the left lateral decubitus position. We prepped and draped the patient in the usual manner and gave antibiotics. Then two 1 cm incisions were made along the posterior and mid axillary line at the ninth and seventh intercostal spaces. The lung was deflated and a camera was inserted.(VATS.) A longer (6 cm) incision was made along the fourth intercostal space anteriorly. We then freed up some adhesions at the top of the lung, both in the superior area away from the tumor and in the anterior mediastinal area. The tumor seemed to be in the right upper lobe.(Tumor is in the right lung.) The dissection began by ligating the superior pulmonary vein and its branches, and the upper lobe was freed up. The small fissure was incomplete, and I proceeded with the lobectomy. The pulmonary artery branches were then ligated. The bronchus was ligated, as well. The superior branches to the upper lobe were ligated with Endo GIA. The lobe was freed up and sent to pathology. The wound was then closed in layers. A chest tube was placed to suction, and the patient was sent to recovery in stable condition. Pathology confirmed carcinoma.(Indication to report the right lobe of the lung as cancerous.) What are the procedure and diagnosis codes for this procedure?
CPT: 39000 ICD: D86.1, R59.0
CASE 5 Preoperative Diagnoses 1. Sarcoid of lymph nodes(Diagnosis if no further positive findings are found in the operative note.) 2. New onset paratracheal adenopathy(Diagnosis if no further positive findings are found in the operative note.) Postoperative Diagnoses 1. Sarcoid of lymph nodes 2. New onset paratracheal adenopathy Procedure Performed: Mediastinotomy(Indication of what procedure is being performed.) Description of Procedure: The patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia was administered by the anesthesia department. The neck was prepped in standard fashion with betadine scrub, sterile towels and drapes. A standard linear incision was made over the trachea.(Procedure performed with the anterior cervical approach.) We were able to dissect down the pretracheal fascia into the mediastinum without difficulty. The extensive adenopathy was immediately apparent just below the innominate artery on the right paratracheal side. One exceedingly large lymph node was identified and biopsied extensively.(Biopsy performed.) The specimen was sent to pathology. Hemostasis was obtained without difficulty. The region was infused with a marcaine, lidocaine, and epinepherine mixture. The wound was closed in layers. The skin was closed with subcutaneous stitches and covered with Dermabond. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?
CPT: 38571 ICD: C77.4, C60.9
CASE 6 Preoperative Diagnosis: 1. Grade 3 squamous cell carcinoma of penis with inguinal lymphatic metastasis Postoperative Diagnosis 1. Grade 3 squamous cell carcinoma of penis with inguinal lymphatic metastasis Procedure Performed: Laparoscopic bilateral pelvic lymphadenectomy Description of Procedure: The patient is placed in supine position with thigh abduction. A 1.5 cm incision was made 2 cm distally of the lower vertex of the femoral triangle. The second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions. The last trocar was placed 2 cm proximally and 6 cm laterally from the first port. Radical endoscopic bilateral pelvic lymphadenectomy was performed.The main landmarks-adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly, were well visualized. The retrograde dissection using a harmonic scalpel was started distally near the vertex of the femoral triangle towards the fossa ovalis, where the saphena vein was identified, clipped, and divided, towards the femoral artery laterally. After the procedure, one can identify the skeletonized femoral vessels and the empty femoral channel, showing that the lymphatic tissue in this region was completely resected. The surgical specimen was removed through the first port incision. A suction drain was placed to prevent lymphocele, and were kept until the drainage reached 50 ml or less in 24 hours. Patient tolerated the procedure well and was transferred to recovery in stable condition. What CPT® and ICD-10-CM codes are reported?
CPT: 32650-RT ICD: J90, C34.91
CASE 7 Preoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Postoperative Diagnosis: Recurrent pleural effusion, stage IV right lung cancer. Procedure Performed: Video-assisted thoracoscopy, lysis of adhesions, talc pleurodesis Procedure: Patient was brought to the operating room and placed in supine position. IV sedation and general anesthesia were administered, per the anesthesia department. A double-lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the right side up. The chest was prepped in the standard fashion with ChloraPrep, sterile towels, sheets, and drapes. A small incision is made between two ribs and a standard port placement was utilized to gain access to the tho-racic cavity. The endoscope is inserted into the chest cavity. We had excellent isolation of the lung; however, we had poor exposure because there were a number of fibrous adhesions, a few were actually very dense. We immediately evacuated approximately 700 ml of fluid; however, once we entered the chest we encountered a number of loculated areas. We did not break down the adhesions. We gained enough exposure to do a complete talc pleurodesis. After lysing of adhesions, we were confident that we had access to the entire thoracic cavity. Eight grams of talc were introduced into the right thoracic cavity and strategically placed under direct vision. The chest tubes were then placed. The wounds were closed in layers. The patient tolerated the procedure well and was taken to the recovery room in stable condition. What are the CPT® and ICD-10-CM codes reported?
CPT: 31625, 31623-51 ICD: C34.81
CASE 8 Preoperative Diagnosis: Carcinoma, right lung and bronchus intermedius. Procedure Performed: Bronchoscopy. DESCRIPTION OF PROCEDURE: Two liters of oxygen were supplied nasally. The right nostril was anesthetized with two applications of 4% lidocaine and two applications of lidocaine jelly. The posterior pharynx was anesthetized with two applications of Cetacaine spray. The Olympus PF fiberoptic bronchoscope was introduced into the patient's right nostril. The posterior pharynx, epiglottis, and vocal cords were normal. The trachea and main carina were normal. The entire tracheobronchial tree was then visually examined and the major airways. No abnormalities were noted on the left side. There was, however, extrinsic compression of the posterior segment of the right upper lobe. There also appeared to be a submucosal tumor involving the bronchus intermedius between the right upper lobe and right middle lobe. Multiple washings, brushings, and biopsies were taken from the right upper lobe bronchus and bronchus intermedius. The specimens were sent for cytology and routine pathology. The patient tolerated this without complications. The CPT® and ICD-10-CM codes to report are:
CPT: 32666-LT, 31622-51 ICD: S27.0XXA, V03.90XA
CASE 9 Preoperative Diagnosis: Pedestrian in a MVA involving a car, left pneumothorax. Postoperative Diagnosis: Pedestrian in a MVA involved a car, left pneumothorax. Procedure: Bronchoscopy, left VATS, wedge resection. Procedure: Patient was brought into the operating room and placed in supine position. IV sedation and general anesthesia was administered, per the anesthesia department. A single lumen endotrachial tube was placed for bronchoscopy, per anesthesia. Due to the nature of the trauma, we were interested in ruling out a bronchial tear. The bronchoscope was introduced in the mouth and passed into the throat without difficulty. There was no evidence of sanguineous drainage or bronchial trauma noted to the left mainstem. There were copious amounts of secretions noted and removed without difficulty. The right mainstem was also cannulated and found to be free of unexpected trauma. The bronchoscopy was terminated at that time. A double lumen endotracheal tube was placed, per anesthesia. The position was confirmed by bronchoscopy. The patient was placed in the decubitus position with the left side up. The chest was prepped in standard fashion with Betadine, sterile towels, sheets, and drapes. A small incision is made along the upper boarder of the fourth rib just below the intercostal space and a standard port placement was utilized to gain access to the thoracic cavity. An endoscope was inserted into the chest cavity. Initially we had excellent exposure with good isolation of the lung. We identified a large bleb at the apex of the lower lobe of the left lung, which was likely to be the source of the chronic air leak. We removed the area of the large bleb at the apex with a wedge resection using thoracoscopic green load for therapeutic correction of the patient's pneumothorax. The wounds were closed in layers. Chest tubes were placed. The patient tolerated the procedure well and was taken to the recovery room. What are the CPT® and ICD-10-CM codes reported?
Yes: Report multiple procedures with modifier 51 (if required by the payer)
Can bronchoscopy codes be coded together by a physician, and if yes, how? Are multiple procedures reported with modifier 51?
5
How many lobes are there in the lungs?
Z
In ICD-10-CM, codes for Factors Influencing Health Status and Contact with Health Services begin with which letter?
30300
Johnny has a penny removed from his left nostril in the provider's office. What CPT® code is reported?
30801
Patient is a mouth-breather. He is diagnosed with inflamed inferior turbinates and a superficial ablation is performed. What CPT® code is reported?
