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March 25, 2024

Instructions: Assign ICD-10-PCS codes to the following case. PREOPERATIVE DIAGNOSIS: Right-sided thyroid mass consistent

Instructions: Assign ICD-10-PCS codes to the following case. PREOPERATIVE DIAGNOSIS: Right-sided thyroid mass consistent with papillary thyroid carcinoma with probable paratracheal node metastasis POSTOPERATIVE DIAGNOSIS: Right-sided thyroid mass consistent with papillary thyroid carcinoma with probable paratracheal node metastasis PROCEDURE NAME: Total thyroidectomy and right paratracheal node dissection INTRAOPERATIVE FINDINGS: Evidence of scarred-down right thyroid mass to the right recurrent laryngeal nerve and pathologically enlarged right paratracheal node inferiorly to thyroid gland. INDICATIONS: This patient originally presented has an enlarged left posterior triangle node. A CT scan of the area has been also consistent with a possible paratracheal node metastasis on the right side with a thyroid mass as the probable source. Informed consent was obtained for total thyroidectomy and paratracheal node dissection.

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