missaw3
New
I am very new to coding for different bronchoscopies and I wanted to post this report and see if I could get some feedback as to whether or not the community thinks I am doing this correctly.
I coded the following reports as: 31652 and 31624. DX: R59.1 and R91.8.
Description: Patient was brought to the OR and intubated with size#9 endotracheal tube. Airway inspection was done using regular bronchoscope and abundant mucoid secretions were found in the airways but beyond that no mucosal abnormalities/endobronchial lesions were found in trachea, carina, right side (right upper lobe, bronchus intermedius, right lower lobe inspected up until segmental level), left side (left upper lobe, lingula, left lower lobe ).
Next, scope was switched to EBUS scope and after entering right mainstem bronchus, right pulmonary artery was visualized. Then scope was medially turned to visualize large subcarinal lymph node, station 7. 6 passes were made from this location. Next scope was withdrawn to trachea and left main stem bronchus was entered and large subcarinal lymph node was again visualized via this approach. 4 additional passes were made from this location. On ROSE, all the passes showed"bronchial epithelial cells". Next right pulmonary artery was visualized again and next to it,Right Interlobar(11R) lymph node was visualized and 6 passes made. On ROSE, 2 passes showed"lymphocytes"and the rest showed"bronchial epithelial cells".
Next, the scope was switched back to regular fiberoptic scope and airway inspection was done. Dried blood clots were visualized. Some areas of dark were seen which was suctioned out. No active bleeding seen. In right lower lobe bronchus, balloon of EBUS scope was seen wedged which was easily retrieved by forceps. Next, scope was wedged in the anterior segment of right upper lobe, and 60 mL saline was instilled and 15 mL clear return was obtained which was sent for microbiology.
Patient tolerated the procedure well.
Impression and Plan
Diagnosis
Mediastinal and hilar lymphadenopathy, lung lesions.
I coded the following reports as: 31652 and 31624. DX: R59.1 and R91.8.
Description: Patient was brought to the OR and intubated with size#9 endotracheal tube. Airway inspection was done using regular bronchoscope and abundant mucoid secretions were found in the airways but beyond that no mucosal abnormalities/endobronchial lesions were found in trachea, carina, right side (right upper lobe, bronchus intermedius, right lower lobe inspected up until segmental level), left side (left upper lobe, lingula, left lower lobe ).
Next, scope was switched to EBUS scope and after entering right mainstem bronchus, right pulmonary artery was visualized. Then scope was medially turned to visualize large subcarinal lymph node, station 7. 6 passes were made from this location. Next scope was withdrawn to trachea and left main stem bronchus was entered and large subcarinal lymph node was again visualized via this approach. 4 additional passes were made from this location. On ROSE, all the passes showed"bronchial epithelial cells". Next right pulmonary artery was visualized again and next to it,Right Interlobar(11R) lymph node was visualized and 6 passes made. On ROSE, 2 passes showed"lymphocytes"and the rest showed"bronchial epithelial cells".
Next, the scope was switched back to regular fiberoptic scope and airway inspection was done. Dried blood clots were visualized. Some areas of dark were seen which was suctioned out. No active bleeding seen. In right lower lobe bronchus, balloon of EBUS scope was seen wedged which was easily retrieved by forceps. Next, scope was wedged in the anterior segment of right upper lobe, and 60 mL saline was instilled and 15 mL clear return was obtained which was sent for microbiology.
Patient tolerated the procedure well.
Impression and Plan
Diagnosis
Mediastinal and hilar lymphadenopathy, lung lesions.