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Coding suggestions: Preliminary Discussion: The patient has confirmed open fractures of both the left ulna and left radius shafts. Each fracture must be coded separately using the most specific available ICD-10 codes. Both fractures are initial encounters for open fractures, unspecified type. Primary Codes: S52.202B: Unspecified fracture of shaft of left ulna, initial encounter for open fracture type I or II, or unspecified. S52.302B: Unspecified fracture of shaft of left radius, initial encounter for open fracture type I or II, or unspecified. Alternate Codes: S52.225B: Nondisplaced transverse fracture of shaft of left ulna, initial encounter for open fracture type I or II, or unspecified. S52.325B: Nondisplaced transverse fracture of shaft of left radius, initial encounter for open fracture type I or II, or unspecified. Next 5 Most Relevant Codes: S52.234B: Nondisplaced oblique fracture of shaft of right ulna, initial encounter for open fracture type I or II, or unspecified. S52.232B: Displaced oblique fracture of shaft of left ulna, initial encounter for open fracture type I or II, or unspecified. S52.222B: Displaced transverse fracture of shaft of left ulna, initial encounter for open fracture type I or II, or unspecified. S52.322B: Displaced transverse fracture of shaft of left radius, initial encounter for open fracture type I or II, or unspecified. S52.365B: Nondisplaced segmental fracture of shaft of radius, left arm, initial encounter for open fracture type I or II, or unspecified.

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PREOPERATIVE DIAGNOSIS Right pleural effusion; suspected malignant mesothelioma POSTOPERATIVE DIAGNOSIS Right pleural effusion; suspected malignant mesothelioma PROCEDURE Right VATS pleurodesis and pleural biopsy ANESTHESIA General anesthesia via double-lumen endotracheal tube FINDINGS Right pleural effusion with scattered firm nodules throughout the right pleura and diaphragmatic surface SPECIMENS Pleural biopsies for pathology and microbiology ESTIMATED BLOOD LOSS Minimal FLUIDS 1.2 L crystalloid; 1.9 L pleural fluid drained INDICATIONS A 66-year-old male presented with recurrent right pleural effusion, shortness of breath, and prior biopsy results suggestive of mesothelioma. Risks, benefits, and alternatives of right VATS pleurodesis and pleural biopsy were discussed; the patient and family opted to proceed. PROCEDURE IN DETAIL After informed consent, the patient was positioned and intubated with a double-lumen tube. The right thorax was prepped and draped. A 10 mm port was placed, and the pleural fluid was drained. Multiple firm nodules were palpated. An additional port was placed anteriorly for further drainage and pleural biopsies. Notably, nodules on the diaphragmatic surface appeared to possibly extend beyond the pleura. Following drainage, two cans of talc were sprayed for pleurodesis. The lung was reinflated, and a 32 French chest tube was placed. Incisions were closed, and the patient was extubated and transferred to recovery in stable condition. Dr. X was present for the entire procedure. Instrument and sponge counts were correct x2.
Results
Coding suggestions: Preliminary Discussion: The patient has a confirmed right pleural effusion. Malignant mesothelioma is suspected but not yet confirmed, so it should not be coded. The patient also presents with shortness of breath, which warranted treatment. Primary Codes: J90: Pleural effusion, not elsewhere classified Alternate Codes: R06.02: Shortness of breath J91.8: Pleural effusion in other conditions classified elsewhere J94.8: Hydrothorax (pleura) Next 5 Most Relevant Codes: J94.9: Pleural condition, unspecified C45.0: Mesothelioma of pleura C38.4: Malignant neoplasm of pleura D38.2: Neoplasm of uncertain behavior of pleura S27.9: Injury; intrathoracic, initial encounter

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