Mignon0908
Guest
Description of procedure / Findings:
After reviewing the informed consent and the risk and benefits the patient was brought to the operating room placed supine position with all the pressure points adequately padded. Bilateral lower extremities assist are in place, adequate IV access obtained and general tracheal anesthesia induced without difficulty. Foley catheter and A-line are placed under sterile condition. Patient received antibiotics within 30 minutes of initiation of the procedure. He is flipped into the left lateral decubitus with the right chest exposed that is prepped and draped in the usual sterile fashion. Timeout confirms the patient's name procedure laterality as well as the availability for the material for the operation. A one cm incision in created in the 9th costal space at posterior axillary line and carried down with the electrocautery through the Scarpa fascia muscle and entered into the pleural space. Diagnostic thoracoscopy demonstrates a large pleural and a large tumor occupying more than 50% of the pleural space. This is multilobulated. It appeared that had a stuck to the diaphragm. The tumor is heavy and due to the large size decision was made to proceed with a left thoracotomy. A 7 intercostal space anterolateral and extending to posterior thoracotomy was performed. Muscles were divided and went into the pleural space. I was able to place the right rib retractors and expose the lower portion of the tumor that was attached to the diaphragm. Part of the lower lobe was attached to it so I utilized an Endo GIA to encircle staple and divide and freed up from the lateral aspect of the right lower lobe. When further assessed the tumor extension noticed that this invaded the entire middle lobe and upper lobe. I mobilized the posterior mediastinal pleura with the Bovie electrocautery. Despite efforts I concluded that this was not a resectable tumor and less a pneumonectomy will be performed. Due to prior conversations with the patient that this would not be an option I decided to take further biopsies as I do not believe that this is the natural behavior of a solitary fibrous tumor but rather a more sarcomatoid type of tumor. Further biopsies were obtained and submitted for permanent staining. I also noticed that there was a small area on the pleura that appeared to have an implant and utilizing the Bovie I scored the pleura and perform a pleural biopsy of approximately 4 cm. This was also submitted to the pathology lab. Due to the recurrent effusions the patient experienced a decided to perform a talc pleurodesis. 9 g of intrapleural talc where successfully distributed through the chest cavity diaphragm lung parenchyma and the tumor itself. Adequate hemostasis was confirmed. After removing the rib spreaders I noted that the right 8 rib had a an area of fracture. Therefore, I decided to proceed with rib plating to provide support and aligned healing to the rib. The universal plate was selected and a total 6 self locking screws were utilized to secure the rib. Excessive irrigation of the chest cavity with warm saline was carried away. Vista seal is sprayed over the staple line. T the thoracotomy was closed with total of 4-0 Ethibond sutures in figure-of-eight's. Muscle layers were reapproximated with 0 Vicryl. wound wounds were thoroughly irrigated pat dry and closed in layers with 0 Vicryl, 2-0 Vicryl, 4-0 Monocryl. Surgical glue was applied and small island dressing applied as well. 4 x 4 and transparent dressings were placed onto the chest tube site.
The patient is flipped into the supine position, a diagnostic flexible bronchoscopy is performed evaluating the airway. This demonstrates normal endobronchial anatomy, no endobronchial tumor lesions. A bronchoalveolar lavage from the right lower lobe lobe is obtained by instilling aliquots of 20 cc of normal saline and recovering into a mucous trap. This is submitted to the microbiology lab.Thereafter, a therapeutic bronchoscopy with aggressive washing, irrigation and suctioning of the airway is performed at every segment and subsegment to remove any presence of mucous plugs or blood clots assuring a complete airway recanalization.
The cpt codes that I coded are:
-32097
-32098 -xs
-21811
-31645
-31624
-32650 is not coded because it was converted to open.
-32560 it state that it is [Misuse of Column Two code with Column One code] however, the description says the instillation, is via chest tube/catheter, agent for pleurodesis.
My question is are codes correct or should I add an unlisted procedure code for the pleurodesis.
Thanks in advance for your help.
After reviewing the informed consent and the risk and benefits the patient was brought to the operating room placed supine position with all the pressure points adequately padded. Bilateral lower extremities assist are in place, adequate IV access obtained and general tracheal anesthesia induced without difficulty. Foley catheter and A-line are placed under sterile condition. Patient received antibiotics within 30 minutes of initiation of the procedure. He is flipped into the left lateral decubitus with the right chest exposed that is prepped and draped in the usual sterile fashion. Timeout confirms the patient's name procedure laterality as well as the availability for the material for the operation. A one cm incision in created in the 9th costal space at posterior axillary line and carried down with the electrocautery through the Scarpa fascia muscle and entered into the pleural space. Diagnostic thoracoscopy demonstrates a large pleural and a large tumor occupying more than 50% of the pleural space. This is multilobulated. It appeared that had a stuck to the diaphragm. The tumor is heavy and due to the large size decision was made to proceed with a left thoracotomy. A 7 intercostal space anterolateral and extending to posterior thoracotomy was performed. Muscles were divided and went into the pleural space. I was able to place the right rib retractors and expose the lower portion of the tumor that was attached to the diaphragm. Part of the lower lobe was attached to it so I utilized an Endo GIA to encircle staple and divide and freed up from the lateral aspect of the right lower lobe. When further assessed the tumor extension noticed that this invaded the entire middle lobe and upper lobe. I mobilized the posterior mediastinal pleura with the Bovie electrocautery. Despite efforts I concluded that this was not a resectable tumor and less a pneumonectomy will be performed. Due to prior conversations with the patient that this would not be an option I decided to take further biopsies as I do not believe that this is the natural behavior of a solitary fibrous tumor but rather a more sarcomatoid type of tumor. Further biopsies were obtained and submitted for permanent staining. I also noticed that there was a small area on the pleura that appeared to have an implant and utilizing the Bovie I scored the pleura and perform a pleural biopsy of approximately 4 cm. This was also submitted to the pathology lab. Due to the recurrent effusions the patient experienced a decided to perform a talc pleurodesis. 9 g of intrapleural talc where successfully distributed through the chest cavity diaphragm lung parenchyma and the tumor itself. Adequate hemostasis was confirmed. After removing the rib spreaders I noted that the right 8 rib had a an area of fracture. Therefore, I decided to proceed with rib plating to provide support and aligned healing to the rib. The universal plate was selected and a total 6 self locking screws were utilized to secure the rib. Excessive irrigation of the chest cavity with warm saline was carried away. Vista seal is sprayed over the staple line. T the thoracotomy was closed with total of 4-0 Ethibond sutures in figure-of-eight's. Muscle layers were reapproximated with 0 Vicryl. wound wounds were thoroughly irrigated pat dry and closed in layers with 0 Vicryl, 2-0 Vicryl, 4-0 Monocryl. Surgical glue was applied and small island dressing applied as well. 4 x 4 and transparent dressings were placed onto the chest tube site.
The patient is flipped into the supine position, a diagnostic flexible bronchoscopy is performed evaluating the airway. This demonstrates normal endobronchial anatomy, no endobronchial tumor lesions. A bronchoalveolar lavage from the right lower lobe lobe is obtained by instilling aliquots of 20 cc of normal saline and recovering into a mucous trap. This is submitted to the microbiology lab.Thereafter, a therapeutic bronchoscopy with aggressive washing, irrigation and suctioning of the airway is performed at every segment and subsegment to remove any presence of mucous plugs or blood clots assuring a complete airway recanalization.
The cpt codes that I coded are:
-32097
-32098 -xs
-21811
-31645
-31624
-32650 is not coded because it was converted to open.
-32560 it state that it is [Misuse of Column Two code with Column One code] however, the description says the instillation, is via chest tube/catheter, agent for pleurodesis.
My question is are codes correct or should I add an unlisted procedure code for the pleurodesis.
Thanks in advance for your help.