Chapter 9: Practical Application
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? - Answer 31600
C32.0
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. Th - Answer 31541
D49.1
reoperative 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? - Answer 32555
J90
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 - Answer 32663-RT
C34.11
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:
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? - Answer 31600
C32.0
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. Th - Answer 31541
D49.1
reoperative 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? - Answer 32555
J90
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 - Answer 32663-RT
C34.11
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:
