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 CHF (Congestive Heart Failure), J91.8 for pleural effusion in diseases classified elsewhere (related to her CHF), I48.91 for atrial fibrillation, and E11.9 for type II diabetes. There is no need for additional procedure codes or the dyspnea code (R06.02) as the primary procedures and conditions are already accurately coded.

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