Icd 10 code for tertiary hyperparathyroidism

M132 Module 05 Coding Assignment

1. Case Study #1

PREOPERATIVE DIAGNOSIS: Tertiary hyperparathyroidism.

POSTOPERATIVE DIAGNOSIS: Tertiary hyperparathyroidism.

OPERATION PERFORMED: Subtotal parathyroidectomy.

ANESTHESIA: General. Fifteen mL of 0.5% Marcaine with epinephrine for local anesthesia.

DESCRIPTION OF OPERATION: The patient was intubated with the nerve monitor endotracheal tube. A shoulder roll was placed and the neck was prepped and draped in the usual manner. A transverse cervical incision was made, and local anesthesia was infiltrated prior to the incision and as we finished the closure. The initial incision was deep and beyond platysma. Crossing anterior jugular vein branches were doubly ligated with 2-0 silk ties and divided. The superior subplatysmal flap was brought to the thyroid notch and the inferior flap to the sternal notch. Strap muscles were divided at the midline and separated.

The right strap muscles were lifted off the right thyroid gland and mobilized slowly the right thyroid gland medially. The nerve at the base of the neck was identified. There were two inferior thyroid artery branches that were ligated with 2-0 silk ties and divided. Middle thyroid vein was ligated with 2-0 silk tie and divided. The thyroid gland was mobilized medially. The right upper parathyroid gland was found at the mid aspect of the posterior thyroid gland. It was intrathyroidal. It was slowly removed from the thyroid gland, clipped the feeding vessels and the right upper parathyroid gland was totally excised. The nerve was noted to be functional at the end of this excision.

The superior vascular bundle was doubly ligated with 2-0 silk ties and divided allowing for further mobilization of the gland medially. We were unable to find a parathyroid gland at that level. We then subsequently freed the lower pole of the thyroid gland and we started identifying the thymus tissue and pulled it out of the chest. There was a right neck lymph node that was submitted for frozen section and this was benign. We then identified a right lower parathyroid gland. I clipped the distal half and this was confirmed to be parathyroid tissue. The proximal half of the parathyroid gland was left intact.

The left strap muscles were lifted off the left thyroid gland. The middle thyroid vein was ligated with 3-0 silk ties and divided and the thyroid gland was then mobilized medially. The nerve was found at the base of the neck and traced towards the larynx. The left upper parathyroid gland was identified, found to be posterior to the mid aspect of the thyroid gland, and it measured 1.5 x 0.8 cm. We freed it from the nerve and from the thyroid gland and this was confirmed to be parathyroid tissue. The small vascular pedicles were clipped and the left upper parathyroid gland removed. The nerve was noted to be functional at this point.

We ligated the superior thyroid vascular pedicle. This was done with 2-0 silk ties x2 and with a 3-0 silk suture ligature. We mobilized the gland medially, and not finding any parathyroid tissue superiorly, we then addressed our attention inferiorly where the thymus was pulled out and we identified a left inferior parathyroid gland. This was found to be anterior to the nerve. This gland was noted to be 1.1 x 0.9 x 0.8 cm. This was removed in its entirety. The vascular pedicles were clipped. At this point, both nerves were noted to be functional, and with assurance of hemostasis, we commenced closure. Running 4-0 Vicryls were used to approximate the strap muscles at the midline, interrupted 4-0 Vicryls were used to approximate the platysma, 5-0 Monocryl was used for the subcuticular skin closure. Local anesthesia was infiltrated. Dermabond was placed. The patient tolerated the procedure well. Sponge and needle counts were correct. Blood loss was minimal. The patient was taken to recovery room, extubated and in stable condition.

ICD-10-PCS Code: Click here to enter text.

2. Case Study #2

PREOPERATIVE DIAGNOSIS: Obstructive jaundice.

POSTOPERATIVE DIAGNOSIS: Pancreatic head mass.

SURGICAL PROCEDURES: EUS with FNA.

After informed consent was obtained, the patient received sedation with IV 10 mg Versed and IV 200 mcg of fentanyl for adequate sedation. The linear echoendoscope was first passed through the mouth down the esophagus to the extent of the duodenal bulb. The scope could not pass beyond the duodenal bulb into the descending duodenum due to the nature of her anatomy. The celiac axis was first scanned from the stomach and was grossly normal with no lymphadenopathy seen. The body and tail of the pancreas were scanned from the stomach at which point that the pancreatic duct was seen to be very irregular in nature and also dilated to approximately 5-6 mm. The parenchyma appeared very atrophic as well of the pancreas in the body and tail. No lymphadenopathy seen near. The scope was then advanced to the duodenal bulb through the pylorus into the duodenal bulb at which point a pancreatic head mass was seen. This mass appeared was very vague to differentiate from the normal pancreatic parenchyma, but appeared to be roughly 3 x 2 cm when scanned from the duodenal bulb. There appeared to be no invasion of the superior mesenteric artery and no invasion of the portal vein. There was seen a clean plane between these 2 structures. The percutaneous drain appeared to be extending into this mass. From the duodenal bulb, 3 biopsies were taken with the 22-gauge FNA needle. Three passes made through the duodenal wall of the pancreatic head lesion and sent for cytology, and cell block. There was maybe one 2 mm lymph nodes seen at this level, but again no definite vascular invasion was seen. The scope was then removed and the procedure complete.

ANESTHESIA TYPE: Conscious sedation.

ESTIMATED BLOOD LOSS: Minimal.

SPECIMENS REMOVED: FNA of the pancreatic head mass x3 with a 22 gauge needle through the duodenal wall.

FINDINGS: Pancreatic head mass measuring roughly 3 x 2 cm. Local collaterals seen, but no apparent invasion of the confluence, the portal vein or the superior mesenteric artery. Unable to pass the scope into duodenum for a full evaluation of this lesion.

COMPLICATIONS: None.

RECOMMEND: Await cytology results.

ICD-10-PCS Code: Click here to enter text.

3. Case Study #3

Code only the biopsy for this procedure.

PROCEDURE: Right heart cardiac catheterization and endomyocardial biopsy

procedure.

REASON FOR PROCEDURE: The patient is status post orthotopic cardiac

transplantation and is undergoing hemodynamic evaluation and surveillance

allograft biopsy for rejection.

The patient was admitted to the catheterization lab. His right neck was prepped

and draped in the usual sterile fashion. Using 2% lidocaine the skin was

anesthetized. Using the Seldinger technique, the right internal jugular vein

was easily entered. Good blood flow was obtained. A short sheath was placed

over a wire. The wire was removed. Through the sheath, the Swan was floated to

the right atrium, right ventricle, pulmonary artery, pulmonary capillary wedge

positions. Pressure was measured. PA saturation and thermodilution cardiac

output was measured. The Swan was withdrawn using a wire for guidance. The

short sheath was exchanged for a long biopsy sheath with its tip in the right

ventricle. The wire was removed through the biopsy sheath. A bioptome was

placed and endomyocardial biopsy specimens from the right ventricle were obtained. The biopsy sheath and bioptome were removed and good hemostasis was obtained using manual compression. The patient tolerated the procedure well. There were no complications. He was discharged from the catheterization lab in good condition.

Mean right atrial pressure 12. RV 32/10. PA 37/14. Mean PA 25. Pulmonary

capillary wedge pressure 18. Cardiac output 3.78. Cardiac index 2.18. PA

saturations 16%.

IMPRESSION: Mild pulmonary hypertension with lower PA saturation. Patient's

creatinine today is 1.4 and he may be significantly volume depleted, but overall

stable. Allograft biopsy results pending.

ICD-10-PCS Code: Click here to enter text.

4. Case Study #4

PREOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage.

POSTOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage.

PROCEDURE PERFORMED: Tracheostomy.

ANESTHESIA TYPE: General.

ESTIMATED BLOOD LOSS: 10 mL.

HISTORY: This is a 58-year-old female who presented to the trauma center several days ago with isolated head trauma. She has been on the ventilator and unable to support her ventilation without a mechanical ventilator. She is thus unable to be weaned from a ventilator and thus in need of a tracheostomy. She also is unable to swallow and thus will need a PEG placement. Due to the fact that there is no endoscope functioning at this time we have decided to do the PEG at a later time. The risks and benefits were explained to the family and they consented to the procedure.

PROCEDURE: The patient was brought to the operating room and had SCDs placed prior to induction of anesthesia. She had preoperative antibiotics given prior to any incision. She had come down with the ET-tube and this was hooked up to the ventilator by the anesthesia staff. She was prepped and draped in normal sterile fashion and the anatomic landmarks of the thyroid cartilage and sternal notch were identified, as well as the cricothyroid membrane. About 1 fingerbreadth below the cricothyroid membrane, incision was made down to the level of the subcu tissue. Bovie electrocautery was used to dissect down through the platysma. Any venous bleeders were identified and tied off with silk suture. Right angles were used and a suture ligature was placed with silk suture around the end of the isthmus and this was transected in the midline. We then had good exposure of the trachea. We identified the third tracheal ring. We had the ICU staff deflate the balloon and we placed stay sutures laterally on both sides of the third tracheal ring. This was carried down from skin to the tracheal ring back up to the skin. We then reinflated the balloon and then when we were ready we deflate the balloon again and made a square incision around the third tracheal ring and removed this portion in a square fashion. We brought our ET-tube out proximally just proximal to this and used a tracheal spreader to dilate the trachea. We then placed a #8 Shiley tracheostomy tube without any difficulty and the balloon was inflated. We then hooked our tracheostomy to the ventilator and received good end tidal C02. The patient was oxygenating at 100% and her tidal volumes were equivalent to what they were preop with the ET-tube. There were no signs of bleeding and good, hemostasis was, achieved. The skin around the tracheostomy incision was closed in running fashion and the tracheostomy was secured in four places with nylon suture. The Vicryl stay sutures were secured to the chest wall with Steri-Strips. The patient tolerated the procedure well and was taken to ICU in stable condition.

ICD-10-PCS Code: Click here to enter text.