CPC Chapter 9- Respiratory Practical Review Flashcards
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.
There is one CPT® code and one ICD-10-CM code reported. A tracheostomy is the creation of an opening into the trachea to provide a passage for air. This is a planned procedure to create a new breathing passage. Look in the CPT® for Tracheostomy/Planned. The reason for the procedure is malignant neoplasm glottis. Look in the Table of Neoplasms for Neoplasm, neoplastic/glottis/Malignant Primary column.
CPT 31600
ICD-10 C32.0
CASE 2
PREOPERATIVE DIAGNOSIS: Left vocal cord tumor.
PREOPERATIVE DIAGNOSIS: Left vocal cord tumor.(Report this diagnosis if no further positive findings 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?
There is one CPT® code and one ICD-10-CM code reported. The documented procedure is a direct laryngoscopy with removal of a tumor. To report the correct CPT® laryngoscopy code you need to know the type of laryngoscope used, the site of the surgery, and whether a microscope was used. The diagnosis is vocal cord tumor. Use the main term Tumor to guide you in reporting the correct ICD-10-CM code.
CPT 31541
ICD-10 D49.1
CASE 3
Preoperative Diagnosis
- Loculated left pleural effusion, chronic
Postoperative Diagnosis
- 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?
There is one CPT® code and one ICD-10-CM diagnosis code reported. The documented procedure is an attempted ultrasound guided thoracentesis. A thoracentesis is a puncture of the pleural cavity/space with a needle or catheter to aspirate pleural fluid. The use of ultrasound indicates imaging guidance was used. Use a HCPCS Level II modifier to indicate which side of the body the procedure was performed. The reason for the procedure is pleural effusion. Pleural effusion is defined as an abnormal amount of fluid in the pleural space. The documentation doesn’t indicate if the pleural effusion is caused by an underlying disease such as tuberculous. If cancer cells are present in the fluid, it is known as malignant (cancerous) pleural effusion. There isn’t documentation to indicate this is malignant pleural effusion.
CPT 32555-LT
ICD-10 J90
CASE 4
Preoperative Diagnosis:
- Mass, right upper lobe.
Postoperative Diagnosis:
- 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?
There is one CPT® code and one ICD-10-CM code reported. The procedure is performed by Video-Assisted Thoracoscopic Surgery - VATS. A single lobe from the right lung is removed. The diagnosis is carcinoma, right upper lobe. Refer to the ICD-10-CM Table of Neoplasms.
CPT 32663-RT
ICD-10 C34.11
CASE 5
Preoperative Diagnoses
- Sarcoid of lymph nodes(Diagnosis if no further positive findings are found in the operative note.)
- New onset paratracheal adenopathy(Diagnosis if no further positive findings are found in the operative note.)
Postoperative Diagnoses
- Sarcoid of lymph nodes
- 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?
There is one CPT® code and two ICD-10-CM codes reported. The documented procedure is a mediastinotomy. In the CPT® locate Mediastinotomy and select the code by the surgical approach. The diagnoses are listed in the Postoperative diagnosis. The first diagnosis is Sarcoid. Sarcoid is a disease where granulomas form in the lymph nodes, lung, skin and other areas. In the Alphabetic Index locate Sarcoid and you’re directed to see also Sarcoidosis. The Sarcoidosis is of the lymph nodes. The second diagnosis is for adenopathy. The adenopathy is localized to the lymph gland.
CPT 39000
ICD-10 D86.1, R59.0
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 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?
There is one CPT® code and two ICD-10-CM codes reported. The documented procedure is a laparoscopic bilateral pelvic lymphadenectomy. In the CPT® index locate Laparoscopy/Lymph System/Lymphadenectomy for your code choices. Thediagnosis is cancer of the penis that has metastasized to the inguinal lymph nodes. The patient is being treated for the metastatic cancer. Be sure to check the sequencing guidelines for the diagnoses (Section I.C.2.l.2) this will determine the order of the diagnoses. Refer to the ICD-10-CM Table of Neoplasms for the two diagnosis codes and look for Neoplasm, neoplastic/lymph, lymphatic channel NEC/gland (secondary)/inguina, inguinal/Malignant Secondary (column). Next, look for Neoplasm, neoplastic/penis/Malignant Primary (column).
CPT 38571
ICD-10 C77.4, C60.9
CASE 7
Preoperative Diagnosis: Recurrent pleural effusion, stage II right lung cancer.
Postoperative Diagnosis: Recurrent pleural effusion, stage II 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?
There is one CPT® code and two ICD-10-CM codes reported. The documented procedure is a Video Assisted Thoracoscopy (VATS). Pleurodesis was performed to treat the pleural effusion. This is a procedure in which an irritant (such as talc powder) is instilled in the space between the visceral and parietal pleura which causes the membranes around the lungs to stick together. This prevents fluid buildup in the space between the membranes. The treatment is directed at the recurrent pleural effusion. In the CPT® look for Pleurodesis/Thoracoscopic. Use a HCPCS Level II modifier to indicate which side of the body the procedure is performed. The reason for the procedure is pleural effusion and is listed first. Pleural effusion is defined as an abnormal amount of fluid in the pleural space. In the Alphabetic Index look for Effusion/pleura, pleurisy, pleuritic, pleuropericardial. The documentation doesn’t indicate if the pleural effusion is caused by an underlying disease such as tuberculous. If cancer cells are present in the fluid, it is known as malignant (cancerous) pleural effusion. There isn’t any documentation to indicate this is malignant pleural effusion. The patient also has stage IV right lung cancer. Use the Table of Neoplasms and locate Neoplasm, neoplastic/lung/Malignant Primary column.
CPT 32650-RT
ICD-10 J90, C34.91
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:
There are two CPT® codes and one ICD-10-CM code reported. The documented procedure is a Bronchoscopy. There are two different procedures; a biopsy and multiple washings and brushings via bronchoscopy. The biopsy procedure is more work intensive and would be sequenced first. This is a multiple procedure situation and l requires the appropriate modifier on the second procedure. The diagnosis is cancer of the right lung and bronchus intermedius. This is considered a neoplasm of contiguous sites of the lung with the bronchus. Refer to the ICD-10-CM Table of Neoplasms. In the Table of Neoplasms, look for Neoplasm, neoplastic/lung/overlapping lesion/Malignant Primary (column),
CPT 31625, 32623-51
ICD-10 C34.81
CPT® codes: For this case, report two surgical bronchoscopy codes. The first code to report is for removing the samples of bronchial tissue for study. In the CPT® Index, look for Bronchoscopy/Biopsy, referring you to 31625–31629, 31632, 31633. Code 31625 is the correct code, since there is no documentation about going through the bronchial wall (transbronchial) to take the biopsies. The second code is indexed under Bronchoscopy/Brushing/Protected brushing, referring you to code 31623. Append modifier 51 to this code to indicate an additional procedure code was performed at the same surgical session by the same physician.
ICD-10-CM code: The tumor was located between the right upper and right middle lobes, overlapping sites. In the ICD-10-CM Alphabetic Index, look for Carcinoma - see also Neoplasm, by site, malignant. In the Table of Neoplasms, look for Neoplasm, neoplastic/lung/overlapping lesion/Malignant Primary (column), which guides you to code C34.8-. In the Tabular List, the 5th character is 1 for the right lung. The complete code is C34.81.
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?
There are two CPT® codes and two ICD-10-CM codes reported. The first procedure is a surgical thoracoscopy. As in Case 7, it is performed by Video-Assisted Thoracoscopic Surgery - VATS. The difference is this is a wedge resection of the lung rather than a pleurodesis. In the CPT® Index look for Thoracoscopy/Surgical/with Therapeutic Wedge Resection. Use a HCPCS Level II modifier to indicate which side of the body the procedure is performed. The second procedure is an exploratory (diagnostic) bronchoscopy. These procedures are totally separate because two different scopes are used for different purposes. In the CPT® Index locate Bronchoscopy/Exploration. Review the code choices. This code needs a modifier to indicate two separate and distinct services are reported at the same operative session. The first diagnosis code is for the pneumothorax. This is considered traumatic because of the MVA. In the ICD-10-CM Alphabetic Index locate Pneumothorax/traumatic. Also, code an external cause code for the motor vehicle accident (MVA). In the ICD-10-CM External Cause to Injuries look for Accident/transport/pedestrian/on foot/collision (with)/car. Do not forget to use the 7th character to complete the code.
CPT 32666-LT, 31622-59
ICD-10 S27.0XXA, V03.90XA
CPT® codes: There are two procedure codes to report for this case, because two distinct surgical approaches were used as were two different scopes. The first procedure to report is the surgical thoracoscopy (VATS), removing a wedge of the left lung through an endoscope. In the CPT® Index, look for Thoracoscopy/Surgical/with Therapeutic Wedge Resection of Lung, which guides you to codes 32666 and 32667. Code 32667 is an add-on code for additional resections. Because only one resection was documented, 32666 is the most appropriate code. The second procedure code to report is a diagnostic bronchoscopy, which was performed to examine the bronchus due to concern for trauma in that area. In the CPT® Index, look for Bronchoscopy/Exploration, which guides you to code 31622, 31634, 31647, 31651. There is no mention of any surgical interventions, making 31622 the correct code. Modifier 59 is appended to code 31622 because it is designated as a “separate procedure” code. CPT® guidelines indicate modifier 59 is reported on a CPT® code designated as a separate procedure when reported with another CPT® code.
CASE 10
Preoperative diagnosis:
1. Chronic hyperplastic rhinosinusitis
2. Allergies
3. Status post-prior polypectomy and sinus surgery
Postoperative diagnosis:
- Intranasal and sinus polyps
- 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
- 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?
There are two CPT codes and three ICD-10-CM codes reported. The Operative Procedure indicates the procedures were performed through an endoscope and they are nasal/sinus surgical endoscopies.
- The first CPT® code is the ethmoidectomy with polyps removed anteriorly and posteriorly. In the index, look for Nasal Sinuses/Endoscopy/Ethmoidectomy. Check the listing of codes and you will see a code for ethomoidectomy, total; however, if you look further you will see another code that includes total ethmoidectomy and sphenoidotomy. This is considered a bilateral procedure and you will need to determine the correct modifier.
- The second code is the endoscopic removal of the maxillary sinus tissue. In the index look for Nasal Sinuses/Maxillary/Antrostomy. This code will need a modifier for bilateral procedure and a modifier for an additional procedure performed during the same surgical session.
The ICD-10-CM codes are based on the Postoperative Diagnosis. List first the nasal cavity polyps; in the Alphabetic Index locate Polyps/nasal (mucous)/cavity. The second diagnosis is for sinus polyps; in the Alphabetic Index locate Polyps/sinus/sphenoidal. The third diagnosis is for chronic hyperplastic rhinosinusitis. This is chronic sinus inflammation and found by looking in the Alphabetic Index for Sinusitis (accessory) (chronic) (hyperplastic) (nasal) (nonpurulent) (purulent).
CPT 31259-50, 31267-50-51
ICD-10 J33.0, J33.8, J32.9
