BACHELOR IN SCIENCE IN NURSING Study Guide - Lumbar Puncture, Cleft Lip And Cleft Palate, Pneumonectomy

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 The scope was withdrawn.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

Which of these first modifying term(s) apply to the scenario? (Check all

that apply.)

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. Biopsy

b. Diagnostic

c. Exploration

d. Tumor

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