Using the coding techniques described in this chapter, carefully read through the case study and determine the most accurate CPT code(s) and HCPCS code(s) and modifier(s), if appropriate.
PROCEDURE: Needle-localized biopsy, right breast
DESCRIPTION OF PROCEDURE: After proper consent was obtained, the patient (48-year-old female) was brought to the operating room and placed on the table in a supine position. Patient was given 2 mg of midazolam HCL, IV, titrated during the procedure; the nurse monitored Davida’s vital signs for a total of 15 minutes.
The right breast area was prepped and draped in a sterile manner. Plain Marcaine 0.5% solution was injected for local anesthesia in the perioperative region. A curvilinear incision was made medial to the insertion site of the wire, as the wire was noted to pass medially in the breast. The preoperative localization films were reviewed, noting that the clip was posterior to the wire. The dissection was carried out with cautery to remove a core of tissue around the wire, being more generous on the posterior aspect around the wire and especially near the end of the wire, taking a very generous area of tissue posteriorly; in fact, it was all the way down to the pectoralis fascia at that site. The specimen was removed, noting that the wire was within the mid portion of removed tissue with a large amount of surrounding tissue. This was submitted for radiographic analysis and the wire was noted to be within the large specimen. However, the clip could not be visualized. For this reason, the operative area was inspected with fluoroscopy with diligence and there was no evidence of any residual clip within the right breast tissue or within the drapes around the right breast. The Ray-Tec sponge was also evaluated with fluoroscopy and direct inspection and no clip was noted. The suction canister and tubing were also evaluated with fluoroscopy and no clip was noted. At this point, due to the generous size of the biopsy specimen, decision was made to not blindly remove any further breast tissue. I suspect that the clip may have become stuck to a Ray-Tec sponge or other instrument during this procedure and came out of the wound and fell out of the field of dissection. The operative area was irrigated, noted to hemostatic, and closed in layers using interrupted #3-0 Vicryl suture to close deep dermis and running #4-0 subcuticular Vicryl suture to close the skin. Benzoin, Steri-Strips, and sterile gauze dressings were placed. The patient had her sedation stopped and she was taken to the recovery area.
Trending nowThis is a popular solution!
Step by stepSolved in 2 steps
still waiting on my answers to my questions
still waiting on my answers to my questions
- A 42year old female presents to your consulting room with a history of vague left breast symptoms. Your physical examination revealed nothing concrete. List two radiological examinations you will request and why b. а. How will you prepare this patient for the radiological investigations? List two contraindications for one of your modalities с.arrow_forwardAfter reading the following three (3) scenarios, you are required to complete the attached request forms, patient label and record the clinical notes for collection and post collection procedures of each. Patient details such as address / Medicare number etc., should be made up by the student and be recorded on the request form. Please include the following pre-test criteria Appropriate times to collect - Impact of medications -Timing of last dose - Required fasting times -How to protect the integrity of the specimen cenario 3 : Miss Jasmine Knights ( DOB - 20/01/2009) attends your clinic early this morning with her mother with a request for Vitamin C. Jasmine has fasted and besides water she has not had anything to eat since 9pm last night. Jasmine's mother informs you that Jasmine normally take a multivitamin supplement every morning, but it has been withheld today.arrow_forwardThe nurse is caring for a patient who has recently returned to the unit after hip replacement surgery. The physician has prescribed heparin 2500 units bid subQ. Pharmacy has provided heparin 5,000 units/mL. How many mL (s) should the parent administer per dose? Which size syring will be most accurate to use to administer this medication? What size needle should you use (gauge & lenght)? Where will you administer this medication( preferred site)arrow_forward
- The patient was a 44 year-old male with a past medical history significant for hypertension, non-insulin-dependent diabetes, high cholesterol, and heavy smoking (2 packs/day). He presented to the emergency room with complaints of chest pain and was found to have suffered a myocardial infarction (heart attack). A cardiac catheterization on hospital day 3 showed three arterial occlusions, and he underwent a triple-bypass on hospital day 5. On day 7, he developed septic shock with acute respiratory and renal failure, requiring intubation. He had a fever at that time of 39.3° C and two blood cultures were obtained. A chest x-ray showed left lung pleural effusion and a chest tube was inserted to drain the effusion. On day 11, pus was leaking from the sternal wound. Cultures derived from the wound and from the chest tube grew the organism noted in figures 1 and 2. A Kirby-Bauer disk diffusion assay is shown in figure 3. Figure 1: Organism under 1000x !! 200 Figure 2: Organism grown on 5% BAP…arrow_forward"A client has to receive intravenous fluid, Normal saline (NS) 1500 ml in 24 hours. Using an ordinary IV giving set, calculate the number of drops to be given per minute. Show the steps of Calculation For the toolbar, press ALT+F10 (PC) or ALT+FN+F10 (Mac). BIU A v 2 v I. 出D白Q 5d三言山 x X次 Paragraph Arial 14pxarrow_forwardChesabell is 10 weeks pregnant,G1 Po, came in the clinic for pre natal check-up. Nurse Jeric asked regarding the medications she is taking. Chesabell said that she was taking folic acid 400 micrograms 1 tab daily, multivitamins 1 tab daily and vitamin C 500 mg twice daily for the past 3 days without consulting her Physician. Drug Study Generic Name Route, Dosage & availability mechanism of Action Indication Contraindication Special Precaution Side effects Nursing Responsibilities Brand Name: Classification: Adverse effects:arrow_forward
- The patient was a 44 year-old male with a past medical history significant for hypertension, non-insulin-dependent diabetes, high cholesterol, and heavy smoking (2 packs/day). He presented to the emergency room with complaints of chest pain and was found to have suffered a myocardial infarction (heart attack). A cardiac catheterization on hospital day 3 showed three arterial occlusions, and he underwent a triple-bypass on hospital day 5. On day 7, he developed septic shock with acute respiratory and renal failure, requiring intubation. He had a fever at that time of 39.3° C and two blood cultures were obtained. A chest x-ray showed left lung pleural effusion and a chest tube was inserted to drain the effusion. On day 11, pus was leaking from the sternal wound. Cultures derived from the wound and from the chest tube grew the organism noted in figures 1 and 2. A Kirby-Bauer disk diffusion assay is shown in figure 3. Figure 1: Organism under 1000x ANG 2 ALLEY CO ALE S Co H Feren bete…arrow_forwardDiscuss with regards to pre-clinicalresearch the binding of similar drug targets between SARS-CoV-2 and pharmacotherapy. A diagram/image can be used in conjuction with your explination. Reference your asnwers if obtained from the internet.arrow_forwardDescribe the proper protocol for the identification of a. an Out patient b. an In patientarrow_forward
- Question: Can you make a list of NURSING DIAGNOSIS related to the given case scenario below? Title: Care of pregnant clients with Human Immunodeficiency Virus Focus Area: Obstetric Nurse Station Margerie Ramos, a 32-year-old female, who, on her 34th week of pregnancy was transferred to the hospital after coming from a prenatal clinic and reported to be experiencing continuous regular contractions for almost 2 days. This is her third pregnancy. The labor and delivery team were planning to admit her to observe and monitor her baby through a fetal Non-Stress Test and to exclude complications associated with preterm labor. The patient previously agreed to a scheduled repeat C-section since she already had two prior ones. Upon admission, the patient verbalized, “I'm cold, I feel so hot.” Temperature was taken, T=38.5 C. She also reported to be having diarrhea for 3 days now. She weighs 55kgs and has a BP of 120/80 mmHg. She was also observed to be coughing a few times during the…arrow_forwardMake a summary of each diagnostic procedure using this format. Name of the Description Indication Contraindication Nursing procedure Responsibilities 3. Aspiration Diagnostic Procedures 3.1 Biopsy 3.2 Lumbar puncture 3.3 Thoracentesis 3.4 Paracentesis 4. Laboratory Tests 4.1 Blood specimen 4.2 Urine 4.3 Culture and sensitivity 4.4 Stool examinationarrow_forwardA nurse is caring for for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client? WBC 1,400/mm3 RBC 4.3 x 10^12/L HgB 12.1 g/dL Hct 36.5% Platelets 170,000/mm3 albumin 4.5 g/dL The client has an increased risk for bleeding The client should receive an erythropoiesis stimulating agent The client has increased risk of infection The client should receive a diet with an increased proteinarrow_forward
- Phlebotomy EssentialsNursingISBN:9781451194524Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)Publisher:JONES+BARTLETT PUBLISHERS, INC.Gould's Pathophysiology for the Health Profession...NursingISBN:9780323414425Author:Robert J Hubert BSPublisher:SaundersFundamentals Of NursingNursingISBN:9781496362179Author:Taylor, Carol (carol R.), LYNN, Pamela (pamela Barbara), Bartlett, Jennifer L.Publisher:Wolters Kluwer,
- Fundamentals of Nursing, 9eNursingISBN:9780323327404Author:Patricia A. Potter RN MSN PhD FAAN, Anne Griffin Perry RN EdD FAAN, Patricia Stockert RN BSN MS PhD, Amy Hall RN BSN MS PhD CNEPublisher:Elsevier ScienceStudy Guide for Gould's Pathophysiology for the H...NursingISBN:9780323414142Author:Hubert BS, Robert J; VanMeter PhD, Karin C.Publisher:SaundersIssues and Ethics in the Helping Professions (Min...NursingISBN:9781337406291Author:Gerald Corey, Marianne Schneider Corey, Cindy CoreyPublisher:Cengage Learning