Wiki cpt help mediastinoscopy and wedge


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I'm thinking 32666 and 39400. What else?

The mediastinoscope was advanced into the pretracheal space and soft tissue dissection proceeded to the level of the carina. There was large bulky lymphadenopathy throughout. However, the lymph nodes all appeared anthracotic and relatively benign. Lymph nodes were harvested from station 7, stations 4R and 4L. These were all sent for frozen pathology. There was a large amount of gross sample. These were confirmed by the pathologist as negative for tumor.
Two small incisions were made in a line anterior to the scapula tip. One additional incision was made posterior to the scapula tip for access to the pleural space. The right lung was deflated and the left lung was preferentially ventilated. A thoracoscope was then advanced into the chest.

Entry into the chest was difficult as the patient's lung was noted to be densely adherent to the chest wall. This was true throughout the entire pleural space. Entry into the pleural space required an initial dissection that was extrapleural. The pleura was then divided under direct vision and the intrapleural space developed using a combination of blunt and sharp dissection and electrocautery dissection. The lung was freed up from the middle lobe up to the apex both anteriorly and posteriorly. The division of all of these adhesions took approximately 1-1/2 hours. Once this had been completed, the right upper lobe nodule was identified. It was wedge resected using green load Echelon Ethicon stapling device. It was placed into an EndoCatch bag and extracted via the posterior port site. It was sent for pathology where it was identified to be a well-differentiated adenocarcinoma.

At this point, the decision was made to stop the operation with just a wedge. This decision was made because of a number of factors.
1. The patient's lung remained densely adherent to the chest wall and dissection of the hilum would necessitate a thoracotomy. The patient had previously expressed a strong desire to be in the hospital as short a time as possible.
2. The patient's pulmonary function tests revealed that his lung function was 44% of predicted. Resection of his right upper lobe in its entirety would put him at under 40% predicted postoperative value which increases his risk of morbidity and mortality, especially in light of the thoracotomy.
3. The patient's tumor size was approximately 1 cm and was very well differentiated. There was no evidence of other disease on PET scan and his mediastinal lymph nodes were all negative.
I'd try appending a -22 to the wedge, due to the adhesions and time it took. You may need a -51 on the mediastinoscopy, depending on your payer.