SOLVED468

CASE 1 (Process 1: CPT) Preoperative diagnosis: Tracheal stenosis, subglottic Postoperative diagnosis: Same Procedure performed: Fiber-optic bronchoscopy Surgeon: Stine, Frank, MD Indications: Tracheal stenosis Details of the procedure, and potential risks and alternatives, were explained, and patient consent was obtained. Medications: Xylocaine spray was applied to the throat and Xylocaine gel placed in the nostrils. The patient received 50 mcg of fentanyl and 8 mg of Versed intravenous. Procedure: The bronchoscope was placed orally once sufficient sedation was obtained. The vocal cords were visualized, and the patient appeared to have some right true vocal cord weakness. Just below the vocal cords, in the subglottic area, scar tissue was noted and moderate narrowing of the upper trachea with almost complete closure of the airway on exhalation. Airways were immediately examined. The trachea; carina; right upper-, middle-, and lower-lobe bronchi; and left main stem bronchus and upper- and lower-lobe bronchi were examined and found to be normal and without significant mucosal abnormalities. The patient tolerated the procedure well. No specimens were collected. Based on the documentation, what is (are) the correct code(s) for this case?
SCIENCE
HEALTH SCIENCE
NURSING

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