Question

OPERATIVE REPORT PATIENT: Mara Bell Lee PHYSICIAN: Randy Greenfield, MD PREOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause. POSTOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause. PROCEDURES PERFORMED: 1. Diagnostic thoracentesis. 2. Four-quadrant pleural biopsy. 3. Pleural drainage with a small catheter temporary chest tube. PROCEDURE: With the usual Betadine scrub to the area marked by ultrasound, the area was anesthetized with approximately 15 cc of 1% lidocaine, and then a small-caliber needle, #21 gauge, was inserted into the space. Fluid was removed for appropriate bacteriological, hematological, and chemical analyses. Once this was accomplished, a larger tube with a Cope pleural biopsy needle was inserted into the space, and four quadrants were biopsied and sent for appropriate pathological specimens. Once that was accomplished, the space was entered with the use of a small-caliber temporary chest tube from the Cope, as well as the pneumothorax set, and 1.5 liters of bloody fluid was removed. A small bandage was then attached. There was no pain involved, and the chest x-ray will be taken afterward to assure ourselves that we had a reasonable effect without any ill consequences. CPT Codes: Answer, ____________________ (two codes)

          OPERATIVE REPORT
PATIENT: Mara Bell Lee
PHYSICIAN: Randy Greenfield, MD
PREOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
POSTOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
PROCEDURES PERFORMED:
1. Diagnostic thoracentesis.
2. Four-quadrant pleural biopsy.
3. Pleural drainage with a small catheter temporary chest tube.

PROCEDURE:
With the usual Betadine scrub to the area marked by ultrasound, the area was anesthetized with approximately 15 cc of 1% lidocaine, and then a small-caliber needle, #21 gauge, was inserted into the space. Fluid was removed for appropriate bacteriological, hematological, and chemical analyses. Once this was accomplished, a larger tube with a Cope pleural biopsy needle was inserted into the space, and four quadrants were biopsied and sent for appropriate pathological specimens. Once that was accomplished, the space was entered with the use of a small-caliber temporary chest tube from the Cope, as well as the pneumothorax set, and 1.5 liters of bloody fluid was removed. A small bandage was then attached. There was no pain involved, and the chest x-ray will be taken afterward to assure ourselves that we had a reasonable effect without any ill consequences.

CPT Codes: Answer, ____________________ (two codes)

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