Do any of these instructional notes apply to this scenario?
EXCLUDES: Lung removal with bronchoplasty (32501)
Code also decortication (32320)
Code also excision of chest wall tumor, when performed (21601-21603)
Documentation:
PREOPERATIVE DIAGNOSIS: Mass of lung
POSTOPERATIVE DIAGNOSIS: Carcinoma of the right lung
OPERATION PERFORMED: Bronchoscopy and right upper lobectomy
The patient was brought into the operating room, and after the
administration of anesthesia, the patient was prepped and draped in the usual sterile fashion. The patient was placed in the left lateral decubitus
position. A thoracotomy incision was made. This exposed the chest
muscles, which were incised and retracted. The fourth and fifth ribs were
visualized and transected to allow entrance to the chest. A tumor mass was
noted. This mass measured 7.0 cm in diameter, involving the right lung
upper lobe. The mass was excised in its entirety, and a biopsy of the mass
was taken and sent for frozen section. The frozen section revealed
squamous cell carcinoma. Nodes were then dissected around the pulmonary
artery and the trachea. The nodes were sent for frozen section. The nodes
were identified as negative per pathology. Saline was irrigated into the
chest. It was noted that the liver and diaphragm appeared to be normal with
no lesions seen. After verification that the sponge count was correct, chest
tubes were placed for drainage. The surgical wound was closed in layers
with chromic catgut and nylon. The patient tolerated this portion of the
procedure well.
The patient was then placed in the supine position for the bronchoscopy.
The patient was still under anesthesia. A flexible fiberoptic bronchoscope
was inserted. Patient bronchi were noted bilaterally. The scope was
withdrawn. The patient was awakened and sent to the recovery area in
stable condition.
a. Yes
b. No