Forum - Questions & Answers

Nov 17th, 2013 - katejohnson 11 

ICD-9DX help

Can anyone help me out with the correct ICD-9DX code along with the CPT® service code? Thanks for the help in advance.

The patient, a 45-year-old male with ALS, has been experiencing severe shortness of breath of a progressive nature over the last several weeks. After discussion of all risks, the decision has been made to perform a tracheostomy on this patient. The patient was brought into the operating suite for this procedure and placed supine on the table. General anesthesia was given, and the patient was prepped and draped in the usual sterile fashion. A 2.5cm incision was made of the neck over the trachea. The trachea was carefully isolated from the surrounding structures after the tracheal rings were identified. The second ring was identified, and a tube was advanced after incision. The patient's breath sounds were checked and were adequate. The tracheostoma was packed with gauze, and the ties were secured. A chest x-ray will be done postoperatively to check for tube placement, but breath sounds were good when the patient went to the recovery room.



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