Assign CPT codes and modifiers to operative reports
OPERATION
1. Right upper lung lobectomy.
2. Mediastinal lymph node dissection.
ANESTHESIA
1. General endotracheal anesthesia with dual-lumen tube.
2. Thoracic epidural.
OPERATIVE PROCEDURE IN DETAIL: After obtaining
informed consent from the patient, including a thorough explanation
of the risks and benefits of the aforementioned procedure, the
patient was taken to the operating room, and general endotracheal
anesthesia was administered with a dual-lumen tube. Next, the
patient was placed in the left lateral decubitus position, and his
right chest was prepped and draped in the standard surgical
fashion. We used a #10-blade scalpel to make an incision in the
skin approximately 1 fingerbreadth below the angle of the scapula.
Dissection was carried down in a muscle-sparing fashion using Bovie
electrocautery. The 5th rib was counted, and the 6th interspace was
entered. The lung was deflated. We identified the major fissure. We
then began by freeing up the inferior pulmonary ligament, which was
done with Bovie electrocautery. Next, we used Bovie electrocautery
to dissect the pleura off the lung. The pulmonary artery branches
to the right upper lobe of the lung were identified. Of note was
the fact that there was a visible, approximately 4 x 4-cm mass in
the right upper lobe of the lung without any other metastatic
disease palpable. As mentioned, a combination of Bovie
electrocautery and sharp dissection was used to identify the
pulmonary artery branches to the right upper lobe of the lung.
Next, we began by ligating the pulmonary artery branches of the
right upper lobe of the lung. This was done with suture ligature in
combination with clips. After taking the pulmonary artery branches
of the right upper lobe of the lung, we used a combination of blunt
dissection and sharp dissection with Metzenbaum scissors to
separate out the pulmonary vein branch of the right upper lobe of
the lung. This likewise was ligated with a 0 silk. It was
stick-tied with a 2-0 silk. It was then divided. Next we dissected
out the bronchial branch to the right upper lobe of the lung. A
curved Glover was placed around the bronchus. Next a TA-30 stapler
was fired across the bronchus. The bronchus was divided with a
#10-blade scalpel. The specimen was handed off. We next performed a
mediastinal lymph node dissection. Clips were applied to the base
of the feeding vessels to the lymph nodes. We inspected for any
signs of bleeding. There was minimal bleeding. We placed a
#32-French anterior chest tube, and a #32-French posterior chest
tube. The rib space was closed with #2 Vicryl in an interrupted
figure-of-eight fashion. A flat Jackson-Pratt drain, #10 in size,
was placed in the subcutaneous flap. The muscle layer was closed
with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed
by 4-0 Monocryl in a running subcuticular fashion. Sterile dressing
was applied. The instrument and sponge count was correct at the end
of the case. The patient tolerated the procedure well and was
transferred to the PACU in good condition.
The procedure was performed by incision on the right chest and the mass was identified and dissected. Then it was followed by the dissection of the lymph node in the mediastinum. Here the open approach is used to dissect the mass. Hence,
1. Right Upper lung Lobectomy
CPT code: 32663-RT
2. Mediastinal Lymph node dissection
CPT code: 32674.
Assign CPT codes and modifiers to operative reports OPERATION 1. Right upper lung lobectomy. 2. Mediastinal...
Assign the appropriate CPT and ICD-10-CM codes and modifiers. OPERATION 1. Right upper lung lobectomy. 2. Mediastinal lymph node dissection. ANESTHESIA 1. General endotracheal anesthesia with dual-lumen tube. 2. Thoracic epidural. OPERATIVE PROCEDURE IN DETAIL: After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube. Next, the patient was placed in the...
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services codes and icd 10 codes? PRE CASE 9-12 Operative Report, Tracheostomy 1. S 2 H 3. incise in a horiznntal fashion through the skin. Cautery dissmction WRS USed to Cauterize between the strapmuscles down to the ievaid the thyroid isthmus. The patient had a very thin neck but surprisinol wide and thick thyroid isthmus, approximately 1 inch wide Bu dissection was used to dissect between 1he thyroid isthmus, and it was divided and tied off. Bleeders were all well...