1-Ambulatory Surgery Center Report Patient history: This 34-year-old male patient was in an accident five years ago, and
Posted: Sun Apr 17, 2022 3:32 pm
1-Ambulatory Surgery Center Report Patient history: This
34-year-old male patient was in an accident five years ago, and at
that time had a permanent tracheostomy due to the extent of the
injury. He now presents with scar tissue in the area of the
tracheostomy. Preoperative and postoperative diagnosis: Redundant
scar tissue surrounding a tracheal stoma Procedure: Repair of the
tracheal stoma The patient was placed under general anesthesia, and
the airway was established for proper ventilation during the
procedure. An incision was made to resect the redundant scar tissue
that had formed around the tracheal stoma. The skin was
reanastomosed and closed in sutured layers. Blood loss was minimal.
The patient was sent to the recovery area in satisfactory
condition. CPT code(s):
2-Endoscopy Report Preprocedure diagnosis: Rule out
malignant lesion of right upper lobe of bronchus Postprocedure
diagnosis: Pending pathology report Procedure: Under conscious
sedation, this 82-year-old female was sedated. The airway was
anesthetized, and a flexible bronchoscope has advanced through the
oral cavity through the larynx using fluoroscopic guidance. The
bronchus was viewed, and a lesion was identified. A biopsy of the
tissue was taken from the right upper lobe of the bronchus. No
other lesions were visualized. Bleeding was found to be minimal,
and the scope was removed. The tissue sample was sent to pathology.
The patient was sent to the recovery area in stable condition. CPT
code(s)
3-Procedure Note This 32-year-old female was brought to the
emergency department by her sister with right-side chest pain.
Patient states that pain is between 9 and 10 on the pain scale. She
has been having shortness of breath for the last four hours. She
was fine yesterday except for a little fatigue. The pain started
when she woke up this morning. A chest x-ray showed some suspicious
area at the left base. At this time it was determined that a
percutaneous needle biopsy of the left lung should be completed.
This procedure was performed, and the patient is resting. CPT
codes:
4-Preoperative diagnosis: Foreign body in bronchus Postoperative
diagnosis: Foreign body in bronchus Procedure: Removal of a foreign
body in the bronchus of the left lung via scope The patient was
consciously sedated, and a bronchoscope was introduced into the
left nasal passage. There were no abnormal structures noted as the
scope was placed into the left bronchial tree. In the left
bronchial tree, there was a foreign body, and the bronchial tree
appeared slightly inflamed. The foreign body was removed and sent
to pathology for inspection. The scope was removed, and the patient
tolerated the procedure and was sent to recovery in stable
condition. CPT code(s):
34-year-old male patient was in an accident five years ago, and at
that time had a permanent tracheostomy due to the extent of the
injury. He now presents with scar tissue in the area of the
tracheostomy. Preoperative and postoperative diagnosis: Redundant
scar tissue surrounding a tracheal stoma Procedure: Repair of the
tracheal stoma The patient was placed under general anesthesia, and
the airway was established for proper ventilation during the
procedure. An incision was made to resect the redundant scar tissue
that had formed around the tracheal stoma. The skin was
reanastomosed and closed in sutured layers. Blood loss was minimal.
The patient was sent to the recovery area in satisfactory
condition. CPT code(s):
2-Endoscopy Report Preprocedure diagnosis: Rule out
malignant lesion of right upper lobe of bronchus Postprocedure
diagnosis: Pending pathology report Procedure: Under conscious
sedation, this 82-year-old female was sedated. The airway was
anesthetized, and a flexible bronchoscope has advanced through the
oral cavity through the larynx using fluoroscopic guidance. The
bronchus was viewed, and a lesion was identified. A biopsy of the
tissue was taken from the right upper lobe of the bronchus. No
other lesions were visualized. Bleeding was found to be minimal,
and the scope was removed. The tissue sample was sent to pathology.
The patient was sent to the recovery area in stable condition. CPT
code(s)
3-Procedure Note This 32-year-old female was brought to the
emergency department by her sister with right-side chest pain.
Patient states that pain is between 9 and 10 on the pain scale. She
has been having shortness of breath for the last four hours. She
was fine yesterday except for a little fatigue. The pain started
when she woke up this morning. A chest x-ray showed some suspicious
area at the left base. At this time it was determined that a
percutaneous needle biopsy of the left lung should be completed.
This procedure was performed, and the patient is resting. CPT
codes:
4-Preoperative diagnosis: Foreign body in bronchus Postoperative
diagnosis: Foreign body in bronchus Procedure: Removal of a foreign
body in the bronchus of the left lung via scope The patient was
consciously sedated, and a bronchoscope was introduced into the
left nasal passage. There were no abnormal structures noted as the
scope was placed into the left bronchial tree. In the left
bronchial tree, there was a foreign body, and the bronchial tree
appeared slightly inflamed. The foreign body was removed and sent
to pathology for inspection. The scope was removed, and the patient
tolerated the procedure and was sent to recovery in stable
condition. CPT code(s):