A 66-year-old female with CHF, atrial fibrillation, and type II diabetes was admitted with right pleural effusion demonstrated on x-ray, as well as shortness of breath and dyspnea on exertion. A video-assisted thoracic surgery (VATS) pleurodesis was performed. A 10-mm port was placed and the effusion was drained by placing a sucker into the port site. An additional anterior port was then placed in similar fashion and the effusion was drained with a sucker. A 32 curved chest tube was placed and secured with nylon. The other port site was also closed. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code for a video-assisted thoracic surgery (VATS) pleurodesis is 32650. The ICD-10-CM codes accurately reflect the patient's conditions: I50.9 for congestive heart failure (CHF), J91.8 for pleural effusion in conditions classified elsewhere (related to CHF), I48.91 for unspecified atrial fibrillation, and E11.9 for type II diabetes mellitus without complications. There is no need for additional procedure codes or modifiers as the description provided does not indicate the necessity for additional specific procedural codes beyond 32650, nor does it specify complications or additional conditions that would require the use of modifiers or additional codes.

A 66-Year-Old Female with CHF, Atrial Fibrillation, and Type II