Question

NAME OF PROCEDURE: Fiberoptic bronchoscopy with biopsy, brushings and washings.

PREOPERATIVE DIAGNOSIS: Right upper lobe lung lesion.

POSTOPERATIVE DIAGNOSIS: Right upper lobe lung lesion.

MEDICATIONS GIVEN: Codeine 60 mg IM prior to procedure. Atropine 0.4 mg IM prior to procedure. Versed 3 mg given during procedure.

INDICATIONS FOR PROCEDURE: Patient is a 75-year-old white male, a farmer and a pipe smoker, who presents with a right upper lobe 4 cm lung lesion. Bronchoscopy is done to evaluate for lung cancer.

PROCEDURE: Consent was obtained after the risks and benefits including bleeding and pneumothorax were described to the patient and the patient agreed to proceed with the procedure. He was given Atropine and Codeine prior to going to the Bronchoscopy Suite.

Posterior pharynx and vocal cords are visualized and felt to be free of lesion or abnormality. Upper trachea was normal. Left side was normal. Mucosa was normal without erythema, edema, or excessive secretions. Right side had complete obstruction of the apical and posterior segments of the right upper lobe with a lobulated pink lesion that was biopsied x 6 with brushings x 2 and washings x 10 cc. He had good hemodynamic findings at the end of the procedure.

Bronchus intermedius was extrinsically narrowed. Right middle lobe appeared free of disease as well as the lower lobes; however, as stated before, the bronchus intermedius had extrinsic compression.

CONDITION DURING PROCEDURE: The patient's heart rate remained in the 50s. Blood pressure remained within normal limits. His saturations remained above 97% on 2 liters of supplemental oxygen. He tolerated the procedure well with minimal coughing. He was extubated and sent to the recovery room in satisfactory condition.

1. FILL IN THE BLANK.
   Enter the proper code(s) in the blank(s) provided. If a specific category of code is not applicable, please leave the box blank. When entering multiple codes in the same box, separate them with a comma and a space (i.e. E11.9, I10).
   1. Primary ICD-10-CM Code:
   2. Secondary ICD-10-CM Code(s):
   3. Z Code(s):
   4. External Cause of Morbidity Code(s):
   5. Primary CPT Code:
   6. Secondary CPT Code(s):
   7. HCPCS Code(s):

Answer 1

Primary diagnosis is the diagnosis or condition due to which the patient seeked medical services

ICD code for Right upper lobe lung lesion R 91.1

Secondary diagnosis is the condition that coexists with the primary condition or oocurs after admission which the patient have secondary to the primary condition

No secondary disease he had

CPT code for Fiberoptic bronchoscopy with biopsy, brushings and washings is 31622 and 31625