AAPC Chapter 9 Q & A's

A patient presents to the 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?

32551

A patient with chronic 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:?

32560, J93.81

A 45 year old presents with acute pericarditis. The surgeon makes a small incision between 2 ribs and enters 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?

32659

Which CPT code(s) describes VATS therapeutic wedge resection of the left upper lobe followed by left upper lobectomy?

32663

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 of lungs (physician C)?

32850, 32856, 32853

A patient with adenocarcinoma of the larynx has developed cervical adenopathy and is undergoing an excisional biopsy of the right cervical node. An incision is made above the clavicle and dissection taken down into the muscle. Blunt dissection was used to work the way down to the node, which was firm and white. The entire node was taken, and the wound was closed. What CPT code is reported?

38510

An operative report lists excisional bilateral biopsies of deep cervical nodes and biopsy of right deep axillary nodes as the procedures performed. The pathology report comes back confirming lymphadenitis. What CPT codes are reported?

38510-50, 38525-51-RT

A patient has a mass in her left axillar 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?

38525

A patient is seen in the OR for removal of a hepatic adenoma which has invaded the diaphragm. The resection of the diaphragm portion of the mass was repaired with primary sutures. What CPT code is reported for the diaphragmatic mass resection?

39560

A 4 month old infant presents to the physician with cold-like symptoms, coughing, and wheezing. The infant is diagnosed with bronchiolitis due to RSV. How is this condition coded?

J21.0

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?

J33.9

What is the ICD-10-CM code for a patient who presents with enlarged tonsils and adenoids for the 4th time in a year?

J35.3

A final diagnosis for a patient in the ER is COPD with acute bronchitis due to echovirus. How is the diagnosis coded?

J44.0, J20.7

What is the ICD-10-CM code selection for a patient with COPD presenting with an acute bronchitis?

J44.0, J20.9

A patient presents with wheezing and shortness of breath. After evaluating the patient, the provider determines the patient is suffering from an exacerbation of his asthma. The provider orders nebulizer treatments to be administered in his office. According to the ICD-10-CM guidelines for coding signs and symptoms, what is/are the correct ICD-10-CM code(s)?

J45.901

What is the ICD-10-CM code for a child with an acute exacerbation of hay fever asthma?

J45.901

What ICD-10_CM code is reported for spontaneous pneumothorax?

J83.83

What ICD-10-CM code is reported for pyopneumothorax with fistula?

J86.0

What is the term for removal of part of the lymph system?

Lymphadenectomy

What portion of the thoracic cavity lies between the lungs and contains the heart?

Mediastinum

Which option is TRUE regarding reporting codes for cytomegaloviral pneumonitis in ICD-10-CM?

1 code is used to report both the pneumonia and the cytomegaloviral disease.

Most nasal passageways have how many turbinates present on the lateral wall of each nasal cavity?

3

What CPT code(s) is/are reported for extensive excision of 7 nasal polyps?

30115

Johnny has a penny removed from his left nostril in the provider's office. What CPT code is reported?

30300

A thoracotomy procedure was performed for repair of hemorrhage and lung tear. What CPT code is reported?

32110

What CPT code is reported with a major thoracotomy for post-op hemorrhage following an endoscopic uuper lobectomy?

32120

A 55 year old female smoker presents with cough, hemoptysis, slurred speech, and weight loss. Chest xray 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?

32408-RT, C34.11

Which CPT code describes a pneumonectomy?

32440

A surgeon performs a high thoracotomy with resection of a single lung segment on a 57 year old who is currently a heavy cigarette smoker who had present with a 6 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

32484, C34.10, F17.210

A 78 year old patient with bilateral lower lobe lung cancer has been in the hopsital for 7 days with a tunneled chest tube in place to drain fluid from the pleural space. The chest tube currently inserted between the 4th and 5th intercostal space on the left side. There's a bad infection at insertion site. The provider removes this chest tube and inserts another chest tube between 5th and 6th intercostal space on the left side to continue fluid drainage. The tube placed today is just the same as the 1 they removed only sterile. What CPT and ICD-10-CM codes are reported?

32550, 32552-51, T85.79XA, C34.31, C34.32

What is also referred to as the windpipe?

Trachea

What ICD-10-CM codes are reported for postoperative pulmonary edema due to fluid overload from an infusion?

T80.89XA, J81.1, Y63.0

What is the ICD-10-CM code selection for a patient with whooping cough who presents with pneumonia?

A37.91

Where does the exchange of o2 and co2 take place within the lungs?

Alveoli

Case 3 Preoperative Diagnosis: Loculated left pleural effusion, chronic. Postoperative Diagnosis: Loculated left pleural effusion, chronic. Procedure Performed: Attempted, ultrasound guided thoracentesis. Description of Procedure: The patient was prepped and draped in the sitting position. Using ultrasound guidance and 1% lidocaine, the thoracic catheter was introduced into the pleural space where we encountered very thick fibrous type pleura. 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 Code: 32555-LT ICD-10-CM Code: J90

Case 5 Preoperative Diagnoses: 1.Sarcoid of lymph nodes 2.New onset paratracheal adenopathy Postoperative Diagnoses: 1.Sarcoid of lymph nodes 2.New onset paratracheal adenopathy Procedure Performed: Mediastinotomy. 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. 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. 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 Code: 39000 ICD-10-CM Code: D86.1, R59.0

What is the ICD-10-CM code fore acquired lymphedema?

I89.0

What is the largest single mass of lymphatic tissue?

spleen

What is another name for the larynx?

voice box

An indirect endoscopic procedure of the larynx means the larynx is viewed:

with mirrors

Can bronchoscopy codes be coded together by a physician, and if yes, how? Are multiple procedures reported with modifier 51?

yes, report multiple procedures with modifier 51 (if required by payer)

Can a diagnostic thoracoscopy be billed with video-assisted thoracoscopic surgery (vats) under certain circumstances?

*** no, a diagnostic thoracoscopy is always included in surgical vats

A 20 year old male presents to the ED with chest pain and shortness of breath. Chest x-ray reveals a pneumothorax. The patient gives a history of no recent trauma; patient smokes 2 packs of cigarettes a day. The ED physician documents a diagnosis of spontaneous tension pneumothorax. What is the ICD-10-CM code selection?

****J93.0

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?

30450

Patient is a mouth-breather. He is diagnosed with inflamed inferior turbinates and a superficial ablation is performed. What CPT code is reported?

30801

A 14 year old boy presents at the ED experiencing uncontrolled epistaxis. Through the nares, the ED provider packs his entire nose via an anterior approach with extensive packaging of medicated gauze. In approximately 15 minutes, the nosebleed stops. What CPT and ICD-10-CM codes are reported?

30903-50, R04.0

A patient with a diagnosis of chronic sphenoidal sinusitis undergoes a bilateral sinusotomy. While the provider examines the diseased sphenoid sins, she takes a biopsy of the sphenoidal masses and removes the mucosa with several polyps. Transseptal sutures are placed and the intraoral incision is closed in a single layer. The nose is packed and external nasal dressings are placed. What CPT and ICD-10-CM codes are reported?

31051-50, J32.3, J33.8

Which code(s) describe(s) bilateral endoscopic nasal procedure to diagnose breathing problems?

31231

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?

31267

The pulmonologist in a multispecialty group refer a patient to the otolaryngologist because he thinks that the shortness of breath the patient is experiencing may be due to sinusitis laryngopharyngeal reflux (LPR). The otolaryngologist decides to perform a rigid bilateral nasal endoscopy to get a better look at what is going on in the sinuses and a flexible laryngoscope to determine if LPR is contributing to the problems because he couldn't get adequate visualization on manual exam. 1st the bilateral nasal endoscopy is performed and the otolaryngologist diagnosis chronic pansinusitis. Next a flexible fiberoptic laryngoscope is introduced nasally and the larynx and trachea are inspected. The diagnosis is chronic laryngitis/ tracheitis and LPR. He prescribes Singulair and Nexium and proposed endoscopic surgery will be considered in the future if the current treatment doesn't fully take care of the problems experienced by the patient. What CPT and ICD-10-CM codes are reported for this procedure?

31575, 31231-59, J32.4, J37.1

How many lobes are in both lungs combined?

5

Which of the following is not 1 of the 4 organs of the lymph system?

Bone Marrow

A patient with right arm and shoulder pain, and a droopy eyelid is referred to a pulmonologist after the discovery of an abnormality in the right upper lobe on a recent chest x-ray. The pulmonologist orders a CT scan and determines the patient has a Pancoast tumor. What ICD-10-CM code is used to report this?

C34.11

What is the ICD-10-CM code fore primary malignant thymoma?

C37

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 Code: 31259-50, 31267-50-51 ICD-10-CM Codes: J33.0, J33.8, J32.9

Case 2 Preoperative Diagnosis: Left vocal cord tumor. Postoperative Diagnosis: Left vocal cord tumor. Name of Procedure: Direct laryngoscopy with microscope, removal of tumor. Anesthesia: General. Complications: None. Specimens: Left vocal cord tumor to pathology. Blood Loss: Less than 10 ml. Technique: Patient was brought to 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 was performed with no abnormal findings other than the above-described tumor. The scope was suspended, and using the operating microscope 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. 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. It was fairly soft. What CPT® and ICD-10-CM codes are reported for this procedure?

CPT Code: 31541 ICD-10-CM: D49.1

Case 1 Preoperative Diagnosis: Malignant neoplasm glottis. Postoperative Diagnosis: Malignant neoplasm glottis. 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 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 Code: 31600 ICD-10-CM Code: C32.0

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. What CPT® and ICD-10-CM codes are reported?

CPT Code: 31625, 31623-51 ICD-10-CM Codes: C34.81

Case 3 Preoperative Diagnosis/Indication: Traumatic pneumothorax/hemothorax |1|/pleural effusion Postoperative Diagnosis: Decompressed pneumothorax/drained hemothorax/drained pleural effusion Procedure: Chest thoracostomy with indwelling tube Procedure: After consent was obtained, the patient was then placed supine with the ipsilateral arm above his head. After donning cap, mask, sterile gown, and gloves, the patient's left chest wall from mid-clavicular line to posterior axillary line and from axilla to costophrenic line was scrubbed thoroughly with chlorhexidine solution and allowed to dry. Sterile drapes were applied covering the patient's upper torso including face. Landmarks were identified between the 4th and 5th intercostal space. 10 ccs of 2% Lidocaine with epinephrine were widely infiltrated subcutaneously for local analgesia. Using a 10-blade scalpel, the skin and subcutaneous tissues were incised parallel to the rib margins to a length of approx 3 cm. Hemostats were then used to dissect bluntly to the intercostal musculature. The parietal pleura was then punctured with large Kelly clamps and the jaws were opened widely to allow an immediate escape of air. An 18 French chest tube with trocar was introduced into the pleural space to a level of 2 cm at the skin. The trocar was removed as the tube was advanced into position. The skin was approximated first, via 2-0 silk sutures in a horizontal mattress above and below the chest tube, then, the suture ends were tied around the indwelling tube. |2| The tube was then placed to suction. Sterile petrolatum gauze was placed at the skin junction and covered with sterile 4x4's. The site was then taped with pressure tape and secured. The Pleuravac |3| was checked and no air leak indicated. The patient tolerated the procedure well. There were no complications. Follow-up CXR has been ordered for placement. |1| Traumatic pneumothorax with hemothorax are coded together. |2| Chest tube was placed and left in for suction. |3| Pleurovac is used for water seal suction. What CPT® and ICD-10-CM codes are reported?

CPT Code: 32551-LT ICD-10-CM Codes: S27.2XXA, J90

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 thoracic 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 Code: 32650-RT ICD-10-CM Codes: J90, C34.91

Case 1 Preoperative Diagnosis: Hypoxia Shortness of breath Postoperative Diagnosis: Small cell carcinoma right lower lobe |1| Procedure: Surgical VATS, anatomic resection of the right lower lobe Description of Procedure: After getting the appropriate consent for the operation and administering general anesthesia and intubation, the patient was placed in a full left lateral decubitus position with the table flexed at 30 degrees at the level between the nipples and the umbilicus to have better exposure of the right intercostal spaces. A 10-mm zero-degree thoracoscope was inserted in the right pleural cavity through a port site placed in the sixth intercostal space on the midaxillary line. Two additional port sites were placed in the fifth intercostal space on the posterior and anterior midaxillary line, respectively. The port sites were chosen with a possible thoracotomy in mind. The VATS exploration immediately revealed a mass in the base of the right lung. We wedge biopsied the mass and sent it to pathology for frozen section. |2| Results from pathology revealed small cell carcinoma so we proceeded with an anatomic resection of the mass. |3| We were able to thorascocopically remove the mass via anatomic resection of the right lower lobe |4| without having to open the thoracic cavity. Green load endoscopic stapling was used to retract the right lower wedge, which was bagged and sent to pathology. Inspection of the lung revealed normal pulmonary parenchyma. After closing the port sites and inserting a chest tube, the patient was extubated and was transferred to the surgical intensive care unit for observation. |1| Malignancy found in right lower lobe of lung. |2| Diagnostic VATS biopsy performed and sent to pathology. |3| Results came back from pathology and a decision is made in the same-surgical session to perform a surgical VATS. |4| Lobectomy performed. What CPT® and ICD-10-CM codes are reported for this procedure?

CPT Code: 32663-RT ICD-10-CM Code: C34.31

Case 4 Preoperative Diagnosis: Mass, right upper lobe. Postoperative Diagnosis: Carcinoma, right upper lobe. 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. 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. 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. What CPT® and ICD-10-CM codes are reported?

CPT Code: 32663-RT ICD-10-CM: C34.11

Case 9 Preoperative Diagnosis: Pedestrian in a MVA involving a car, left pneumothorax. Postoperative Diagnosis: Pedestrian in a MVA involving 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 endotracheal 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 into 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?

CPT Code: 32666-LT, 31622-51 ICD-10-CM Codes: S27.0XXA, V03.90XA

Case 6 Preoperative Diagnosis: Grade 3 squamous cell carcinoma of penis with inguinal lymphatic metastasis. Postoperative Diagnosis: 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 saphenous 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 was 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 Code: 38571 ICD-10-CM Codes: C77.4, C60.9

Case 2 Preoperative Diagnosis: Left upper lobe mass PET positive lesion Intractable back pain Postoperative Diagnosis: Lung cancer left upper lobe Procedure: Mediastinotomy, bronchoscopy Finding: Frozen section revealed a positive malignancy and compression of the left upper lobe bronchus |1| found by bronchoscopy. Procedure: Patient was brought to the OR and placed in supine position. IV sedation and general anesthesia were administered per the anesthesia department. A single lumen endotracheal tube was placed per anesthesia, and the neck was prepped in standard fashion using ChloraPrep sterile towels, sheets and drapes. A standard linear incision was made over the trachea and was used to dissect down to through the pretracheal fascia without difficulty. |2| After extensive dissection and ligation of a few dense adhesions, we were able to identify two large lymph nodes in level 4 in the paratracheal region. Both were biopsied |3| extensively. The initial lymph node was found to be a reactionary lymph node; however, the second demonstrated a malignant process on frozen section. With the diagnosis in hand, we opted to terminate the mediastinotomy at that time. Hemostasis was obtained. The wound was closed and the layer of skin was closed with subcuticular. Bronchoscopy demonstrated copious amounts of clear white secretions. |4| No evidence of purulent drainage was noted. The right bronchus was cannulated first and found to be free of any endobronchial lesions or unexpected pathology. However, the left main stem bronchus led us to a bronchiole that appeared to be compressed likely due to the malignancy in the left upper lobe lesion. The bronchus leading to left lower lobe and lingula appeared to be free of this compression. Again, copious amounts of clear secretions were noted and were removed with suction. |5| At that point, the bronchoscopy was terminated. The ET tube was removed without difficulty. The patient tolerated the procedure well and was taken to the recovery room. |1| Malignant based on pathology. |2| A cervical approach (neck) was used as the report states a linear incision was made over the trachea portion of the neck. |3| Two lymph nodes were biopsied. |4| Diagnostic bronchoscopy with secretions removed with suction. |5| Secretions removed with suction. What CPT® and ICD-10-CM codes are reported?

CPT Codes: 39000, 31622-51 ICD-10-CM Code: C34.12

What is the major muscle used during respiration?

Diaphragm

What protects the trachea from food or liquids entering?

Epiglottis

Where is the mediastinum located?

between the 2 lungs