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As you have learned in your readings, even the best CAC programs require human oversight. For this Assignment, you will review five cases followed by the results from the CAC program for each case. NOTE: All procedures utilize CPT coding. You are to determine if the codes generated by the CAC program are accurate or not. Specify what the correct ICD-10-CM and CPT codes are. PREOPERATIVE DIAGNOSIS: Acute respiratory failure, intracranial hemorrhage POSTOPERATIVE DIAGNOSIS: Acute respiratory failure, intracranial hemorrhage PROCEDURE PERFORMED: Tracheostomy ANESTHESIA TYPE: General ESTIMATED BLOOD LOSS: 10 mL HISTORY: This is a 58-year-old female who presented with acute respiratory failure and intracranial hemorrhage. She has been on the ventilator and unable to support her ventilation without a mechanical ventilator. She is unable to be weaned from a ventilator and thus in need of a tracheostomy. The risks and benefits were explained to the family, and they consented to the procedure. PROCEDURE: The patient was brought to the operating room and had preoperative antibiotics given prior to any incision. She had come down with the ET-tube, and this was hooked up to the ventilator by the anesthesia staff. She was prepped and draped in normal sterile fashion, and the anatomic landmarks of the thyroid cartilage and sternal notch were identified, as well as the cricothyroid membrane. About 1 fingerbreadth below the cricothyroid membrane, incision was made down to the level of the subcu tissue. Bovie electrocautery was used to dissect down through the platysma. Any venous bleeders were identified and tied off with silk suture. We then had good exposure of the trachea. We identified the third tracheal ring. We had the ICU staff deflate the balloon and we placed stay sutures laterally on both sides of the third tracheal ring. This was carried down from skin to the tracheal ring back up to the skin. We then reinflated the balloon and then when we were ready we deflate the balloon again and made a square incision around the third tracheal ring and removed this portion in a square fashion. We brought our ET-tube out proximally just proximal to this and used a tracheal spreader to dilate the trachea. We then placed a #8 Shiley tracheostomy tube without any difficulty, and the balloon was inflated. We then hooked our tracheostomy to the ventilator and received good end tidal C02. The patient was oxygenating at 100%, and her tidal volumes were equivalent to what they were preop with the ET-tube. There were no signs of bleeding, and good hemostasis was achieved. The skin around the tracheostomy incision was closed in running fashion, and the tracheostomy was secured in four places with nylon suture. The Vicryl stay sutures were secured to the chest wall with Steri-Strips. The patient tolerated the procedure well and was taken to ICU in stable condition. CAC Results: J96.00 Acute respiratory failure I61.9 Nontraumatic intracranial hemorrhage, unspecified 31603 Tracheostomy Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Determine the most accurate ICD-10-CM and CPT code(s) and modifier(s), if appropriate. You may not need all of the spaces provided.

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