Help Code CPT/modifiers/ICD-10-Cm Codes LOCATION: Outpatient, Hospital PATIENT: Frank…

Help Code CPT/modifiers/ICD-10-Cm Codes LOCATION: Outpatient, Hospital PATIENT: Frank Beeker SURGEON: Gregory Dawson, M.D. PREOPERATIVE DIAGNOSIS: Abnormal chest x-ray showing a 5 centimeter mass in the left lobe. POSTOPERATIVE DIAGNOSIS: Normal airways, with the mass being in the left upper lobe INDICATIONS: Abnormal chest x-ray showing a 5 centimeter mass in the left lobe. PROCEDURES PERFORMED: Fiberoptic bronchoscopy with transbronchial biopsy, bronchial washings, bronchial brushings and bronchioalveolar lavage. The patient was monitored throughout the procedure electrocardiographically. All we saw was sinus tachycardia with heart rates up to the 130’s. The bulk of the heart rates were in the 110’s. Blood pressures were variable, anywhere from a high of 169/112 to the lowest one recorded of 132/83. The bulk was in the 150’s. 02 saturations were variable, mostly in the 90’s. At a brief time, when there was some bleeding, the 02 saturation dropped to 86% at its lowest but that was for 2 minutes as per the printout, then went back up to the 90’s. The rest of the time it was in the 90’s. This was a patient maintained on 6 liters a minute. There was no pneumothorax post-procedure by fluoroscopic exam. Bleeding was present with the procedure only. Bleeding stopped by the time we finished the procedure. DESCRIPTION OF PROCEDURE: Once the local anesthesia was applied to the right naris, the bronchoscope was introduced through the right naris. The right naris, posterior pharynx, epiglottis, vocal cords, trachea and carinal were all within normal limits. In the right and left lung, all segments were patent and entered. No masses were seen. The mass in question was noted under fluoroscopy in the left upper lobe, anterior segment. The area was biopsied, brushed, and washed. At that point fluoroscopy showed the brush tip and the forceps tip to be in the midst of the mass. Multiple brushings and washings were taken as well as bronchioalveolar lavage and transbronchial and bronchial biopsies were done of the left upper lobe. However, the biopsies provoked a fair amount of bleeding, obscuring vision, so only three specimens were obtained. All bleeding stopped by the time we finished the procedure. The patient was then transported to the room for recovery, in good condition. Pathology Report Later Indicated: No cytologic evidence of malignancy and benign mass of the lung.