Submit your answers to the following case studies in a Word Document. There is no need to copy and paste the operative note itself, just the answers and any questions you might have had during the coding process. See below for format: Chapter 10 Case 1: Operative Report Additional Information: Review this Upper Airway EndoscopyLinks to an external site. to get a picture of the procedure itself. PREOPERATIVE DIAGNOSIS: Dyspnea and hypoxia POSTOPERATIVE DIAGNOSIS: Creamy secretions in bilateral airways PROCEDURE: Upper airway endoscopy INDICATION: Rule out Valley Fever and pneumonia Informed consent was obtained from the patient and family. They understand the risks and benefits associated with the procedure, mortality, morbidity, and gave informed consent. PROCEDURE: The fiberoptic bronchoscope was passed through the oral cavity. The vocal cords were well visualized. There is normal trachea. Some creamy secretions are seen in the bronchi. Creamy secretions in the right lower lobe bronchus and left lower lobe bronchus were seen and were drained and suctioned into a canister for cytology, AFB, fungal, Gram stains, culture, legionella, and mycoplasma. No endobronchial lesions, hemorrhage, or mass was seen. The patient tolerated the procedure well, without complication. ICD-10-PCS Code: ________________________ Chapter 11 Procedure Report Case #3 Additional Information: Inferior vena cava filter placement is described hereLinks to an external site., along with an explanatory video for patients, by a surgeon. (When you land on the page, it is in the top right corner). This one is an actual procedure and pretty interesting, also IVC placement procedureLinks to an external site.. NOTE: Do not code ultrasound or fluoroscopy on this case. PROCEDURE: Ultrasound and fluoroscopy-guided infrarenal IVC filter placement INDICATION: Acute onset right lower extremity DVT, status post ORIF for tibial plateau fracture approximately 6 weeks ago. Clot extends from upper thigh to pelvis. Significant right lower extremity swelling. Catheter directed thrombolysis requested. Prophylactic retrievable IVC filter placement required in preparation. PROCEDURE DETAIL: The patient’s right neck was prepped and draped in sterile fashion. Ultrasound was used to locate and selectively cannulate the right internal jugular vein approximately 2 cm above the clavicle. A 21-gauge needle was directed into the vein and 018 antegrade guidewire placed. The guidewire was directed through the right atrium into IVC. The IJ puncture site and tract were further dilated and a 10 French introducer sheath advanced into the lower IVC near the caval bifurcation over the 035 guidewire. A cavogram was performed in the AP projection. Cavogram shows the IVC to be normal course and caliber with brisk antegrade flow. No clot was identified in the cava. Reflux into the right iliac system demonstrates findings consistent with known clot in this location. No anomalous flow patterns or developmental variants. Renal inflow was identified at the L1-L2 level. A retrievable Bard G2 IVC filter was then deployed. Filter was positioned in an infrarenal location at the L2 level. A post deployment cavogram was performed showing satisfactory filter position and alignment with brisk flow across the filter. Patient tolerated procedure without complication or adverse effect. Continuous cardiac monitoring was provided. Ongoing antibiotic coverage was maintained. ICD-10-PCS Code: _________________________
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