Use the CPT, ICD-9-CM, and ICD-10-CM manuals to assign the appropriate procedure, modifier, and diagnosis codes to the following case scenario.
Preoperative Diagnosis: Right Pneumothorax
Postoperative Diagnosis: Same
Procedure Performed: Placement of anterior chest tube (Thoracostomy)
Procedure: the Patient was draped and prepped in the usual manner. The area was infiltrated with 1% lidocaine. A 1-cm incision was made in the second intercoastal space about 7 cm to the right of the midline in the anterior chest and a 20-F chest tube was passed. Good tidal volume was confirmed. The chest tube was anchored using 1-0 silk. The area was dressed, and the chest tube was placed on suction. The patient tolerated the procedure well. Complications-none.
CPT Code: __________
ICD-9-CM Code: ___________
ICD-10-CM Code: ___________
32551
To assign the appropriate procedure, modifier, and diagnosis codes to the given case scenario, you can refer to the CPT, ICD-9-CM, and ICD-10-CM manuals. Let's break down the information provided and find the relevant codes:
1. Preoperative Diagnosis: Right Pneumothorax
This indicates that the patient has a pneumothorax on the right side prior to the procedure.
ICD-9-CM Code: For ICD-9-CM, you would look for the code that represents right pneumothorax. As of October 1, 2015, ICD-9-CM codes are no longer used for reporting purposes.
ICD-10-CM Code: For ICD-10-CM, you would look for the code that represents right pneumothorax. The appropriate code is J93.11 - Pneumothorax, right side.
2. Postoperative Diagnosis: Same
This indicates that the pneumothorax on the right side remains after the procedure.
ICD-9-CM Code: Not applicable.
ICD-10-CM Code: Same as the preoperative diagnosis - J93.11 - Pneumothorax, right side.
3. Procedure Performed: Placement of anterior chest tube (Thoracostomy)
The procedure performed was the placement of an anterior chest tube (thoracostomy).
CPT Code: In the CPT manual, you would look for the code that represents the placement of the anterior chest tube. The appropriate code is 32551 - Tube thoracostomy, includes water-seal (eg, for abscess, hemothorax, empyema), when placed without imaging or guidance.
4. Modifier: Modifier codes may be used to provide additional information about the procedure performed. The information provided does not indicate the need for a modifier code in this case.
Therefore, the codes for the given case scenario would be:
CPT Code: 32551
ICD-9-CM Code: Not applicable
ICD-10-CM Code: J93.11