The code description "tube thoracostomy" is not clearly stated in the documentation, but CPT crosswalk for a 'tube placement" followed by "chest" leads the coder to CPT 32551. CPT 32550 describes the insertion of a catheter that allows the patient to drain pleural fluid in an outpatient setting. Moderate sedation can be separately billed but only by the provider administering the medication. The 193 series is circumstantial (e.g., spontaneous, acute). Even though the term
"recurrent" is not used, it does describe the background of the patient's condition and so would fall into the other specified diagnosis rather than unspecified.

To calculate the total number of units, it is important to understand that anesthesia time is measured in 15-minute intervals (or in fractions thereof). In this scenario, take the total number of minutes spent on the procedure (105) and divide it by 15. The total number of time units is 7. The time units are then added to the base unit (10) for a total of 17 units.

The diaphragm separates the thoracic cavity from the abdominal cavity by means of skeletal muscle. When the diaphragm contracts, air is drawn into the lungs. It therefore plays a key role in respiration. The mediastinum is surrounded by loose connective tissue and contains several anatomical structures including the heart. Connective tissue is distributed throughout the body to form tendons, ligaments, cartilage, and fat.

A goiter is an abnormal enlargement of the thyroid gland. The removal of that gland is a thyroidectomy, represented by CPT codes 60240-60271. CPT 60270 is selected based on the approach used. CPT codes 21602 and 32900 are obtained by using the coding crosswalk for resection ofthe chest wall and describe the removal of a tumor and one or more ribs. CPT 32140 is a thoracotomy, which involves pulling apart the ribs to reach and remove a lung cyst.

A central nervous system assessment is comprised of multiple screenings that are reported with CPT codes 96105-96146 and includes, but is not limited to, the following elements: use of standardized instruments for staging and rating clinical dementia: evaluation for behavioral symptoms using standardized screening instruments; and development, updating, revision, and/or review of an Advance Care Plan. A review of high-risk medications is also included in the central nervous system assessment; however, if in the same encounter a prescription is issued, the clinician should document and report the treatment with an appropriate E/M.