CHAPTER 15 REVIEW

Operative Note Preoperative Diagnosis: Right pneumothorax Postoperative Diagnosis: Right spontaneous pneumothorax Procedure Performed: Placement of anterior chest tube The patient was draped and prepped in the usual manner. The area was infiltrated with 1 percent Lidocaine. A 1 cm incision was made in the second intercostal space about 7 cm to the right of the midline in the anterior chest and a 20F chest tube was passed. Good tidal volume was confirmed. The chest tube was anchored using 1-0 silk. The area was dressed and the chest tube placed on suction. The patient tolerated the procedure well. Complications: none. What CPT ® and ICD-10-CM codes are reported?

32551, J93.83

A physician performed an aspiration via thoracentesis on a patient in observation status in the hospital. The patient has advanced right lung cancer with malignant pleural effusion. Later the same day, due to continued accumulation of fluid, the patient was returned to the procedure room and the same physician performed a repeat thoracentesis. What CPT ® and ICD-10-CM codes are reported?

32554, 32554-76, C34.91, J91.0

In the ICD-10-CM codebook, what is the category for asthma?

J45

What is an extranasal approach?

Making an incision in the area of the face that will give the best access to the nasal sinus cavity.

What is a direct laryngoscopy?

The insertion of an instrument into the mouth to view the larynx and vocal cords directly

The ENT performs a diagnostic nasal endoscopy bilaterally, followed by right partial ethmoidectomy and removal of tissue from the maxillary sinus bilaterally. The diagnosis is chronic sinusitis of the ethmoid and maxillary sinuses.

31254-RT, 31267-50, J32.8

A 71 year-old patient presents to the outpatient clinic at the local hospital with COPD, congestive heart failure, and hypertension. After a comprehensive evaluation, the physician adjusts to the patient's hypertension medication due to the hypertension being uncontrolled. The patient's other conditions were stable. The patient is to follow-up in two weeks. What ICD-10-CM codes are reported?

I11.0, I50.9, J44.9

In the ASC, a patient undergoes drainage of a right nasal abscess. The physician makes an incision into the nasal mucosa and then inserts a hemostat into the abscess to allow drainage of the pus. After successful decompression, the patient's right nasal cavity is packed with Telfa. Once recovered, the patient is instructed to follow up in two days. What CPT ® and ICD-10-CM codes are reported?

30000, J34.0

A patient with acute maxillary sinusitis is seen in the outpatient surgery department. Procedure performed is a therapeutic injection of the turbinates. Documentation stated that the right and left inferior nasal turbinates were injected for treatment of the sinusitis. What CPT ® and ICD-10-CM codes are reported?

30200, J01.00

A patient presented to the hospital outpatient pulmonary clinic for asthma follow-up. During the encounter, the physician performed an expanded problem focused history and exam with moderate decision making for this established patient. The documentation supported a low-level E/M for the facility. Later in the evening, the patient suffered an acute asthma attack and went to the ER in the same hospital for treatment. What modifier is used to indicate multiple E/M services occurred on the same date?

27

An ENT specialist performed surgery at an ASC on a 5 year-old who stuck a foam hair roller up her nose. It was decided to remove the roller by lateral rhinotomy because of the position and depth of the foam roller in the nose. What CPT ® and ICD-10-CM codes are reported?

30320, T17.1XXA

A child was admitted for an obstructed airway. The physician scheduled a flexible laryngoscopy. Finding nothing, he progressed to the trachea, then to the bronchial tubes. A biopsy was taken for an abnormal bronchial lesion and a lodged tiny Lego toy was found and removed. What CPT ® and ICD-10-CM codes are reported?

31635, 31625, T17.908A, J98.09

A 26 year-old male patient with left lower-lobe bronchial cancer has an obstructed bronchus in the left lower lobe of the lung. Airway is viewed using a flexible bronchoscope introduced through the oral airway, following administration of conscious sedation. Fluoroscopic guidance assists in identifying the obstruction. A laser probe is introduced through the scope to eradicate and relieve the tumor obstruction. What CPT ® and ICD-10-CM codes are reported?

31641, C34.32

Previous bronchoscopy showed two suspicious lesions in the main bronchus. Laser photoresection is planned for destruction of these lesions because bronchial washings obtained previously showed carcinoma in situ of the main bronchus. Following general anesthesia, in the hospital same-day surgery area, with a high-frequency jet ventilator, a rigid bronchoscope is inserted and advanced through the larynx to the main bronchus. The area is treated with laser photoresection. What CPT ® and ICD-10-CM codes are reported?

31641, D02.20

A patient is respirator dependent and has a tracheostomy in need of revision due to redundant scar tissue formation surrounding the site. Under general anesthesia and establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using a layered closure. What CPT ® and ICD-10-CM codes are reported?

31830, L90.5, Z43.0, Z99.11

A 55 year-old female smoker presents with cough, hemoptysis, slurred speech, and weight loss. Chest X-ray demonstrates a large, unresectable right upper-lobe mass, and brain scan is suspicious for metastasis, but has not been confirmed. After administration of conscious sedation, and under fluoroscopic guidance, a needle biopsy of the lung lesion is performed for histopathology and tumor markers. A diagnosis of small cell carcinoma is made and chemotherapy and radiation therapy are planned. What CPT ® and ICD-10-CM codes are reported?

32405, 77002, C34.11

A 66 year-old woman had breast cancer removed three years ago via a right partial mastectomy. She presented to her provider with lumps in her right axilla. The surgeon performs an incisional deep biopsy of the axillary lymph nodes bilaterally. What CPT ® and ICD-10-CM codes are reported?

38525-50, R59.0, Z85.3

The provider performs a left cervical lymphadenectomy and left superficial axillary lymphadenectomy for enlarged lymph nodes. The pathology report shows malignant lymphoma for both the axillary and cervical lymph nodes. What CPT ® and ICD-10-CM codes are reported?

38720-LT, 38740-LT, C85.98

This 60 year-old patient was admitted to hospital outpatient surgery for a biopsy of an anterior mediastinal mass. A standard cervical mediastinoscopy was performed and a biopsy was taken. The pathology report indicated lymphoma. What CPT ® and ICD-10-CM codes are reported?

39401, C85.92

A patient was seen in the hospital outpatient department with a chronic cough and shortness of breath. Documentation recorded in the chart states rule out emphysema. What is the patient's diagnosis?

Chronic cough, shortness of breath

The parents of a 6 month-old male bring their child to the local emergency department. Symptoms are seal-like-sounding cough and hoarseness. After workup, it is determined that the child has croup. Report the ICD-10-CM code(s).

J05.0

A patient with chronic sinusitis was in the hospital outpatient surgery department. Procedures performed were bilateral endoscopic sinusotomies, anterior and posterior ethmoidectomies, and sphenoidectomy with debridement removal in all areas. The postoperative diagnosis was sinusitis of the maxillary, ethmoid, and sphenoid sinuses. Report the ICD-10-CM code(s).

J32.8

The respiratory disease, emphysema is located in the ICD-10-CM codebook in category:

J43

In the emergency department, a 10 year-old male is seen for wheezing attacks over the past three days. His mother stated that breathing treatments were not effectively helping the attacks. The ED physician documented the patient as having childhood asthma with acute exacerbation. Report the ICD-10-CM code(s).

J45.901

A patient was seen in the hospital outpatient department with complaints of chronic coughing and wheezing. The documentation in the medical record indicated, "suspect asthma." Report the ICD-10-CM code(s).

R05, R06.2