through the case study and determine the most accurate procedure
code(s) and modifier(s), if appropriate.
WESTON HOSPITAL
591 Chester Road • Masters, FL 33955
PATIENT: SCHERINI, STEPHANIE
ACCOUNT/EHR #: SCHEST001
DATE: 11/09/22
Diagnosis: Chronic obstructive lung
disease
Procedure: Lung transplant, single, with
cardiopulmonary bypass
Surgical Team: Marion M. March, MD,
primary; Fredrick Avatar, MD; Gene Lavelle, MD
Anesthesia: General
PROCEDURE: Pt is a 37-year-old female
brought into the OR, placed on the table, and draped in sterile
fashion. Anesthesia was administered. At thoracotomy, the left lung
was removed by dividing the left main stem bronchus at the level of
the left upper lobe. The two pulmonary veins and single pulmonary
artery were divided distally. An allograft left lung was inserted.
The recipient left main stem bronchus and pulmonary artery were
re-resected to accommodate the transplant. The recipient pulmonary
veins were opened into the left atrium. An end-to-end anastomosis
of the recipient’s respective structures (pulmonary artery, main
stem bronchus, and left atrial cuffs) was made to the similar donor
structures. Two chest tubes were inserted. Bronchoscopy was
performed in the OR. Cardiopulmonary bypass was successfully
completed.
Patient tolerated the procedure well and was taken to the
recovery room.
Be sure to list the codes, one code per box, in the correct
sequence, from top to bottom, and in the proper row.
Capitalization, punctuation, and spacing can impact whether or not
your answer is correct. Follow coding best practices. Please list
modifiers with the code they relate to as necessary. Include a
hyphen in between the code and the modifier. Example
Procedure: 43846-74 or for Anesthesia: 00797-P2.
Determine the most accurate CPT code(s) and necessary
modifier(s) for the transplantation. TIP: Don't forget your
Anesthesia code with modifier.
The number of spaces provided does not indicate the number of
codes required to accurately report this encounter.
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