Deck 9: Respiratory System

Question 1

Case
-T9-2A OPERATIVE REPORT, INTUBATION
LOCATION: Inpatient, Hospital
PATIENT: Russell Shergrud
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREPROCEDURE DIAGNOSIS: Acute respiratory failure
POSTPROCEDURE DIAGNOSIS: Acute respiratory failure
PROCEDURE PERFORMED: Intubation with a #8 endotracheal tube
The first attempt was with an 8.5 endotracheal tube, which just did not fit in the vocal cords. I was afraid of causing trauma, so we switched to a #8 endotracheal tube, which went in nicely. He had good return on the capnograph, and we eventually got O2 (oxygen) saturations up to 90%. It took 35 minutes to do that, to get his O2 stats back up from about 60% to over 90% once he was intubated.
I got here toward the middle of the respiratory arrest, so I do not think any sedation was given. A chest x-ray will be taken postprocedure to assure ourselves of a good placement.
T9-2A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 1

Professional Services: 31500 (Intubation, Endotracheal, Tube) [see rationale for alternate
code]
ICD-10-CM DX: J96.00 (Failure/failed, respiration/respiratory, acute)
Explanation: The service is an intubation conducted during an emergency as indicated by the statement "I got here toward the middle of the respiratory arrest." The emergency intubation is reported with 31500. It would also be acceptable to code this as critical care services (99291 for 30-74 minutes). If critical care codes are used, the intubation would not be reported separately because intubation is bundled into the critical care codes.
The diagnosis is as stated in the Postprocedure Diagnosis section of the report as acute respiratory failure and reported with J96.00.

Question 2

Case
-T9-2B PULMONARY FUNCTION STUDY
LOCATION: Outpatient, Hospital
PATIENT: Duane Scholl
PHYSICIAN: Gregory Dawson, MD
ENTRANCE DIAGNOSIS: Sarcoidosis, a nonsmoker, and gave good consistent effort
INTERPRETATION:
1. Flow volume loop has mild concavity toward the volume axis, well-preserved inspiratory limb, and reduced flow rates.
2. No significant change after bronchodilator.
3. Lung volumes are normal, without evidence of hyperinflation.
4. Single breath lung volumes are also normal, without hyperinflation.
5. There is no significant dynamic airway collapse (air trapping).
6. Transfer factor is quite reduced (to 52% of predicted), suggesting reduced alveolar capillary membrane surface area and/or V/Q mismatching.
7. Pre-bronchodilator flow rates have a pattern consistent with mild chronic obstructive pulmonary disease/emphysema.
8. Post-bronchodilator values show no significant change, and the same conclusion can be reached.
9. The MVV (maximum voluntary ventilation) is abnormal pre-bronchodilator and normal post-bronchodilator. Between that and a normal FEV1 (forced expiratory volume in one second), I expect a reasonably normal exercise tolerance.
10. Airway resistance is normal.
OVERALL IMPRESSION: Borderline lung volumes with slightly reduced DLCO (diffuse capacity of lungs for carbon monoxide) are consistent with diagnosis of sarcoid. Comparing this to studies done in the past, the DLCO at this time is just a little bit better than the one in October, slightly better than the one done in August, better than the one done in May of this year, and actually similar to what it was in April of this year. The plethysmographic TLC (total lung capacity) is almost identical to what it was in May of last year and slightly less than it was in October of this year. I do not think there is any significant change.
T9-2B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Answer 2

Professional Services:
94060-26 (Pulmonology, Diagnostic, Spirometry) 94727-26 (Pulmonology, Diagnostic, Functional Residual Capacity) 94729-26 (Pulmonology, Diagnostic, Carbon Monoxide, Diffusion Capacity) ICD-10-CM DX:
D86.9 (Sarcoidosis)
Explanation: Modifier -26 was added to each of the codes, as the directions indicated that only the physician portion of the service was being provided.
REPORT
Included in the spirometry (94060) service indicated in the report are:
1. Flow volume loop has mild concavity toward the volume axis, well-preserved inspiratory limb, and reduced flow rates.
2. No significant change after bronchodilator.
7. Pre-bronchodilator flow rates have a pattern consistent with mild chronic obstructive pulmonary disease/emphysema.
8. Post-bronchodilator values show no significant change, and the same conclusion can be reached.
9. The MVV is abnormal pre-bronchodilator and normal post-bronchodilator. Between that and a normal FEV1, I expect a reasonably normal exercise tolerance.
Included in the functional residual capacity (94727) service indicated in the report are:
3. Lung volumes are normal without evidence of hyperinflation (also known as: Functional Residual Capacity).
4. Single breath lung volumes are also normal, without hyperinflation.
The total gas volume service indicated in the report is not reported as it is included in 94727.
5. There is no significant dynamic airway collapse (air trapping).
Included in the Carbon Monoxide, Diffusion Capacity (94729) service indicated in the report is:
6. Transfer factor is quite reduced (to 52% of predicted), suggesting reduced alveolar capillary membrane surface area and/or V/Q mismatching.
The Resistance to Airflow service indicated in the report is not reported as it is included in 94727.
10. Airway resistance is normal.
The diagnosis is stated as sarcoidosis reported with D86.9/135.

Question 3

Case
-AUDIT REPORT T9.2 OPERATIVE REPORT, BRONCHOSCOPY
LOCATION: Outpatient, Hospital
PATIENT: Kevin Hendrickson
PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS: Hemoptysis
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: The patient was intubated prior to the procedure. Informed consent was obtained from the patient's wife, who agreed to the procedure. The bronchoscope was passed with an endotracheal tube, 8.5 size. Then Lidocaine was utilized for lubrication for the endotracheal tube. Video monitoring was utilized through endoscopic technique. With the bronchoscope into the endotracheal tube, the left upper, lingula, and lower lobe regions for the subsegmental branches were visualized. They were cleaned with cold saline. There were no endobronchial lesions on the left side. Then the right upper lobe bronchus to segmental branches was visualized, and there were no endobronchial lesions or bleeding from any particular segment. Then the right mid-lobe branches up to medial and lateral branches up to segmental branches were visualized, and no bleeding was noted and no endobronchial lesions either. Then right lower lobe bronchus up to subsegmental branches was visualized, including the superior segmental bronchus. The anterior segment of the left lower lobe was showing evidence of active bleeding after washing with all the saline. After cold saline irrigation, the bleeding was able to be controlled. Then local epinephrine was also administered to cause local vasoconstriction. Specimens were collected to send for cytology to rule out malignancy and also to rule out any infectious etiology. The procedure was uneventful. Bleeding seemed to be controlled with cold saline irrigation administrations.
PATHOLOGY REPORT LATER INDICATED: Bronchial wash; no cytologic evidence of malignancy
T9.2:
SERVICE CODE(S): 31628__________________
ICD-10-CM DX CODE(S): R04.2_____________
INCORRECT/MISSING CODE(S): ________________________________________

Answer 3

AUDIT REPORT T9.2 OPERATIVE REPORT, BRONCHOSCOPY Incorrect/Missing code(s): 31628, 31622, modifier -50
Explanation: The bronchoscopy was performed endotracheally through the intubation tube. This was done for exploration to find an answer for the patient's hemoptysis (R04.2). Washing were taken from the lung (cleaned with cold saline, cold saline irrigation), along with the collection of cytology specimens (31622). Modifier -50 indicates that these procedures were performed bilaterally.

Question 4

Case
-T9-1A NOCTURNAL POLYSOMNOGRAM
LOCATION: Outpatient, Hospital
PATIENT: Terry Cain
PHYSICIAN: Gregory Dawson, MD
The patient had a previous diagnosis of obstructive sleep apnea.
The four-stage study was started at 2200 hours and continued through 0600 hours the next day. This was done basically with CPAP (continuous positive airway pressure) titration. The patient had a total of 469.5 minutes in bed, 410 minutes asleep, a sleep latency of 3.5 minutes, and 153 arousals; had a heart rate of 89 while awake and 81 while asleep; and during the titration had 22 respiratory events. Because we have a previous diagnosis of obstructive sleep apnea, we are trying to find the adequate level of titration for him. The longest duration of any of these events was 32 seconds, the lowest O2 (oxygen) saturation was 87%, and the lowest heart rate was 74, showing some minor hypoxic and minor cardiac effects of these events. He had 91 myoclonic leg jerks, all associated with arousal. At home, the patient's CPAP is set at 9 cm (centimeter). This study showed that he requires much more pressure with the REM state than he does with the other stages of sleep. At 16 cm of pressure, it eliminated most all of the desaturations and respiratory events, but the patient complains at the higher pressure flows and does not like the airflow.
The previous study recommended an auto titrating device, and I think that would be quite valuable for this gentleman. I agree with that opinion.
IMPRESSION: This patient requires very low amounts of pressure, up to 16 cm during REM state. I would suggest an auto titration device or demand CPAP device be used on this particular patient to try and accommodate that particular variation in his needs.
T9-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 5

Case
-T9-1B OPERATIVE REPORT, TRACHEOSTOMY
This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.
LOCATION: Inpatient, Hospital
PATIENT: Duane Monsonbratten
PHYSICIAN: Gregory Dawson, MD
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS: Acute respiratory failure
POSTOPERATIVE DIAGNOSIS: Acute respiratory failure
PROCEDURE PERFORMED: Tracheostomy
ANESTHESIA: General
INDICATIONS FOR SURGERY: The patient is a 62-year-old Caucasian male who has pneumonia. The patient has been on a ventilator for over 2 weeks and appears to require long-term ventilator. The patient is undergoing tracheostomy for this purpose.
DESCRIPTION OF PROCEDURE: The patient was prepped and draped in the usual manner. A vertical incision was made along the anterior border of the neck. The patient has a very short neck; therefore, it made the operation much more difficult. Dissection was carried down to the trachea using Bovie cautery. The patient had multiple small vessels in the operative area that had to be either bovied or ligated with interrupted 3-0 silk sutures or stick tied with 3-0 silk sutures. After completion of the dissection down to the trachea, the first ring was identified; the second and third rings were also identified. 0 silk stay sutures were placed on either side of the trachea through the second and third rings. An incision was then made in the second and third rings, also creating a low pocket so that a #8 Shiley trach tube could be placed. After the opening was made, the endotracheal tube was pulled back so that the tracheostomy tube through the neck could be placed. Once it was in place, it was hooked to ventilation. The stay sutures were left in place. The tracheostomy tube was then tied around the trachea opening. The skin was injected with 0.5% Marcaine with epinephrine; a total of 8 cc was used. The patient tolerated the procedure and returned to the intensive care unit in stable condition.
T9-1B:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question 6

Case
-AUDIT REPORT T9.1 OPERATIVE REPORT, ETHMOIDECTOMY AND ANTROSTOMY
LOCATION: Outpatient, Hospital
PATIENT: Tony Flaur
PHYSICIAN: Gregory Dawson, MD
ATTENDING PHYSICIAN: Gregory Dawson, MD
PREOPERATIVE DIAGNOSIS:
1. Chronic sinusitis.
2. Nasal polyposis.
3. Septal deviation.
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED:
1. Bilateral image-guided intranasal antrostomy.
2. Bilateral image-guided total ethmoidectomy.
3. Bilateral image-guided intranasal sphenoidotomies.
ANESTHESIA:
General endotracheal anesthesia
DESCRIPTION OF PROCEDURE: Tony is a 34-year-old woman seen in the office and diagnosed with the above condition. Decision was made in consultation with the patient to take her to the operating room to undergo the above-named procedure.
Because of her septal deviation, we had to consent for her a possible septoplasty if access was not possible. She had a CT scan of the sinus performed on an outpatient basis. The images were reconstructed in the three-dimensional display that was used during stereotactic surgery.
She was admitted through the Same Day Surgery Program and taken to the operating room where she was administered a general anesthetic via intravenous injection.
She was then intubated endotracheally. The nose was decongested with 4 ml of 4% cocaine solution on nasal pledgets. A small amount of Afrin was also used. The patient was draped in the usual fashion. The three-dimensional ray was placed on the chest and positioned.We entered our fiducial points into the computer, and good accuracy was obtained.We then removed the patties from both sides of the nose and inserted the 4-mm endoscope. The right side had excellent access. The left side was extremely narrow.We felt, however, that we would be able to do this without septoplasty, so decision was made to proceed.We started initially with the right side of the nose. The uncinate process was injected with 15 mg/kg Lidocaine with Epinephrine.
Freer elevator was used to incise the uncinate process vertically. This was removed with a Wilde forceps. Curved tracking suction was used to identify the maxillary sinus ostium. Using the tracking microdebrider, and the backbiting forceps, we removed materials to enlarge the left maxillary sinus opening. The ethmoid air cells were then penetrated with the microdebrider, and we cleaned this out on both sides.
The ground lamella was penetrated with the aid of the navigator, and we cleaned out additional cells from this area. There was a lot of polypoid material.We moved superiorly along the fovea and cleaned out both anterior and posterior ethmoid air cells.
We then entered the sphenoid sinus and enlarged this. Packing from the left was then removed, and we placed the image-guided system into the nose. The curved tracking suction was used to identify the maxillary sinus ostium. This was enlarged with the microdebrider and the backbiting forceps. The posterior ethmoid air cells were entered in a similar fashion. We cleaned this out with the microdebrider using an image-guided system.We then entered the sphenoid sinus and enlarged this ostium.
This side of the nose was then packed with the same material. The material was removed from both sides of the nose, and a FloSeal was placed on either side. A mustache dressing was placed on the nose. The patient was then allowed to recover from the general anesthetic and taken to the Post Anesthesia Care Unit in stable condition. There were no complications during this procedure.
T9.1:
SERVICE CODE(S): 31201, 31020, 31050_________________________________
ICD-10-CM DX CODE(S): J33.9_________________________________________
INCORRECT/MISSING CODE(S): ______________________________________