What procedure(s) will you need to code? (Check all that apply.)
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 pper lobe. The mass was excised in its entirety, and a biopsy of the mass vas taken and sent for frozen section. The frozen section revealed quamous 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 The scope was withdrawn.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. Bronchoscopy
b. Lobectomy
c. Excision
d. Biopsy
What procedure(s) will you need to code? (Check all that apply.)
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 pper lobe. The mass was excised in its entirety, and a biopsy of the mass vas taken and sent for frozen section. The frozen section revealed quamous 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. Bronchoscopy
b. Lobectomy
c. Excision
d. Biopsy
