bennieyoung
Guru
I have 2 reports a day apart. There is so much going on that I'm not sure I'm coding it correctly. I don't know if I'm even close to getting it right. Can anyone help me with this?
My tentative coding is...first report...33465,33405,33430,33202 and second report...33530,33465,33020
Here are the reports...
First report...
PREOPERATIVE DIAGNOSIS: Aortic valve endocarditis with embolization and class IV congestive heart failure, severe mitral stenosis and insufficiency, status post repair, and severe tricuspid insufficiency.
POSTOPERATIVE DIAGNOSIS: Aortic valve endocarditis with embolization and class IV congestive heart failure, severe mitral stenosis and insufficiency, status post repair, and severe tricuspid insufficiency.Postoperative coagulopathy
PROCEDURE PERFORMED:
1. Reoperation aortic valve replacement with a 23 Inspiris bioprosthesis.
2. Mitral valve replacement with chordal sparing to the posterior leaflet with a #27 Magna bioprosthesis.
3. Initial tricuspid valve repair and subsequent tricuspid valve replacement with a 33 Magna bioprosthetic valve.
4. Right inferior wall ventricular lead tunneled to a separate pocket.
FINDINGS:
DESCRIPTION OF PROCEDURE: Patient presented with class IV heart failure, was found to have embolic lesions in the brain on MRI, which were subclinical, was presumed endocarditis with subsequent positive blood cultures. He had had previous episode of endocarditis and aortic valve replacement and mitral valve repair in 2016 with the same organism. He was consented for surgery after control of his extreme volume overload and persistent renal failure. It was felt his renal failure would not improve with the ongoing infection; therefore, he was brought to the operating room, intubated. Monitoring lines were placed. He was prepped and draped in sterile classical manner. Repeat sternotomy was performed. The right side of the heart was marsupialized, and the left internal mammary was identified and preserved. Previous vein graft to the circumflex was intact. After heparinization, he was cannulated. Bypass was begun. Cardioplegic arrest was obtained with antegrade cardioplegia, retrograde cardioplegia, topical hypothermia, and systemic cooling, all per del Nido protocol. Please see perfusion sheet for timing of additional cardioplegia. Initially, the aortic valve was inspected. There was a large vegetation, which was minimally adherent to the valve leaflets. There was no annular abscess. Because the valve was 5 years old, we decided to replace it. The valve was excised. The anulus was debrided. There was healthy annular tissue remaining. We then proceeded with exposing the mitral valve. There was a small vegetation that appeared on the anterior leaflet. It was sent to Pathology. We then excised the annular ring, debrided the anulus from a lot of pannus tissue, and excised the anterior leaflet. Posterior leaflet was preserved. It was debrided from pannus and any foreign material. LV chamber was copiously irrigated. Horizontal mattress sutures were placed, and a 27 Magna valve was sutured without difficulty. The atrium was closed in a 2-layer fashion with an LV sump placed across the valve. We went back and replaced the aortic valve with a supra-annular 23 mm Inspiris valve. The aortotomy was closed. We then exposed the tricuspid valve after securing caval tapes. It was a large valve with what appeared to be retraction of the leaflets into the dilated ventricle. Initially, I put a 34 ring around it. I came off bypass and was dissatisfied with the amount of residual regurgitation. For that reason, I went back on bypass, arrested the heart, and placed a 33 mm Magna valve without difficulty with interrupted 2-0 Ti-Cron pledgeted mattress sutures and Cor-Knots. The tissues were somewhat friable. After coming off, I saw a paravalvular leak down below the coronary sinus. For that reason, I went back on, re-exposed it without arresting the heart, and placed an external suture from outside the atrium below the cava, up through the anulus, and through the valve, and then I did a continuous running suture along that area, staying away from the coronary sinus and utilizing only the roof of the sinus maintaining that it was patent. I felt that this likely secured the leak as far as I could tell. The patient had been on pump for some time. We closed the atrium. Spontaneous cardiac activity was noted to resume. He was weaned from bypass with minimal difficulty. Repeat TEE revealed excellent function of the mitral and aortic valve and a mild paravalvular leak in the tricuspid. I felt that he would not tolerate additional time on pump, and for that reason, I felt that if it persisted I could either come back another time or try to plug that small leak with catheter-based techniques. Heparin was reversed with protamine.The patient was severely coagulopathic postoperative. The cannula was removed and oversewn. The CVP was quite low. Four pacing wires were placed. One ventricular pacing wire was placed on the inferior wall to avoid intravascular pacing leads as much as possible, and this was tunneled to the left subclavian area. Thymic fat and pericardium were partially closed but not completely as this was a reoperation. A large opening in the right pericardium to allow drainage into the right pleura was made. A large bore chest tube was placed there to avoid tamponade as well as 3 other Blake drains placed in the left pleura and the mediastinum. Sternum was closed in standard fashion. Patient was returned to ICU in critical condition.
second report...
PREOPERATIVE DIAGNOSIS: Persistent coagulopathy with likely pleural mediastinal blood collection.
POSTOPERATIVE DIAGNOSIS: Persistent coagulopathy with likely pleural mediastinal blood collection with evidence of central tricuspid valve regurgitation in the prosthetic valve of uncertain etiology.
PROCEDURE PERFORMED:
1. Mediastinal reexploration with evacuation of thrombus and evacuation of clot and blood.
2. Replacement of tricuspid valve and cardiopulmonary bypass with a 31 mosaic bioprosthesis.
FINDINGS:
DESCRIPTION OF PROCEDURE: Patient was brought to the operating room already intubated with indwelling monitoring lines. He was prepped and draped in sterile classical manner, remained hemodynamically stable. Repeat sternotomy was performed. Large amount of thrombus was found in both pleural cavities as well as free-flowing blood. This was evacuated. There was some bleeding from the chest tube wire insertion sites, which was controlled. No other obvious bleeding except for diffuse coagulopathy was noted. He had received multiple blood products through the night.
Transesophageal echo revealed what initially we felt was perivalvular tricuspid regurgitation as being central regurgitation in a bovine valve. This was difficult to explain and was too much to leave, and for that reason, I reheparinized and cannulated, went on bypass, arrested the heart, and removed the previous bioprosthesis and placed a porcine valve within the leaflets which would require less pressure to close. This was yet done with horizontal mattress sutures and Cor-Knots. The cross-clamp was removed. The right atrium was closed. He was weaned from bypass. Heparin was reversed with protamine. Coagulation factors were administered. The valve looked excellent. The sternum was reapproximated with same indwelling chest tubes. He was returned to ICU in critical condition.
My tentative coding is...first report...33465,33405,33430,33202 and second report...33530,33465,33020
Here are the reports...
First report...
PREOPERATIVE DIAGNOSIS: Aortic valve endocarditis with embolization and class IV congestive heart failure, severe mitral stenosis and insufficiency, status post repair, and severe tricuspid insufficiency.
POSTOPERATIVE DIAGNOSIS: Aortic valve endocarditis with embolization and class IV congestive heart failure, severe mitral stenosis and insufficiency, status post repair, and severe tricuspid insufficiency.Postoperative coagulopathy
PROCEDURE PERFORMED:
1. Reoperation aortic valve replacement with a 23 Inspiris bioprosthesis.
2. Mitral valve replacement with chordal sparing to the posterior leaflet with a #27 Magna bioprosthesis.
3. Initial tricuspid valve repair and subsequent tricuspid valve replacement with a 33 Magna bioprosthetic valve.
4. Right inferior wall ventricular lead tunneled to a separate pocket.
FINDINGS:
DESCRIPTION OF PROCEDURE: Patient presented with class IV heart failure, was found to have embolic lesions in the brain on MRI, which were subclinical, was presumed endocarditis with subsequent positive blood cultures. He had had previous episode of endocarditis and aortic valve replacement and mitral valve repair in 2016 with the same organism. He was consented for surgery after control of his extreme volume overload and persistent renal failure. It was felt his renal failure would not improve with the ongoing infection; therefore, he was brought to the operating room, intubated. Monitoring lines were placed. He was prepped and draped in sterile classical manner. Repeat sternotomy was performed. The right side of the heart was marsupialized, and the left internal mammary was identified and preserved. Previous vein graft to the circumflex was intact. After heparinization, he was cannulated. Bypass was begun. Cardioplegic arrest was obtained with antegrade cardioplegia, retrograde cardioplegia, topical hypothermia, and systemic cooling, all per del Nido protocol. Please see perfusion sheet for timing of additional cardioplegia. Initially, the aortic valve was inspected. There was a large vegetation, which was minimally adherent to the valve leaflets. There was no annular abscess. Because the valve was 5 years old, we decided to replace it. The valve was excised. The anulus was debrided. There was healthy annular tissue remaining. We then proceeded with exposing the mitral valve. There was a small vegetation that appeared on the anterior leaflet. It was sent to Pathology. We then excised the annular ring, debrided the anulus from a lot of pannus tissue, and excised the anterior leaflet. Posterior leaflet was preserved. It was debrided from pannus and any foreign material. LV chamber was copiously irrigated. Horizontal mattress sutures were placed, and a 27 Magna valve was sutured without difficulty. The atrium was closed in a 2-layer fashion with an LV sump placed across the valve. We went back and replaced the aortic valve with a supra-annular 23 mm Inspiris valve. The aortotomy was closed. We then exposed the tricuspid valve after securing caval tapes. It was a large valve with what appeared to be retraction of the leaflets into the dilated ventricle. Initially, I put a 34 ring around it. I came off bypass and was dissatisfied with the amount of residual regurgitation. For that reason, I went back on bypass, arrested the heart, and placed a 33 mm Magna valve without difficulty with interrupted 2-0 Ti-Cron pledgeted mattress sutures and Cor-Knots. The tissues were somewhat friable. After coming off, I saw a paravalvular leak down below the coronary sinus. For that reason, I went back on, re-exposed it without arresting the heart, and placed an external suture from outside the atrium below the cava, up through the anulus, and through the valve, and then I did a continuous running suture along that area, staying away from the coronary sinus and utilizing only the roof of the sinus maintaining that it was patent. I felt that this likely secured the leak as far as I could tell. The patient had been on pump for some time. We closed the atrium. Spontaneous cardiac activity was noted to resume. He was weaned from bypass with minimal difficulty. Repeat TEE revealed excellent function of the mitral and aortic valve and a mild paravalvular leak in the tricuspid. I felt that he would not tolerate additional time on pump, and for that reason, I felt that if it persisted I could either come back another time or try to plug that small leak with catheter-based techniques. Heparin was reversed with protamine.The patient was severely coagulopathic postoperative. The cannula was removed and oversewn. The CVP was quite low. Four pacing wires were placed. One ventricular pacing wire was placed on the inferior wall to avoid intravascular pacing leads as much as possible, and this was tunneled to the left subclavian area. Thymic fat and pericardium were partially closed but not completely as this was a reoperation. A large opening in the right pericardium to allow drainage into the right pleura was made. A large bore chest tube was placed there to avoid tamponade as well as 3 other Blake drains placed in the left pleura and the mediastinum. Sternum was closed in standard fashion. Patient was returned to ICU in critical condition.
second report...
PREOPERATIVE DIAGNOSIS: Persistent coagulopathy with likely pleural mediastinal blood collection.
POSTOPERATIVE DIAGNOSIS: Persistent coagulopathy with likely pleural mediastinal blood collection with evidence of central tricuspid valve regurgitation in the prosthetic valve of uncertain etiology.
PROCEDURE PERFORMED:
1. Mediastinal reexploration with evacuation of thrombus and evacuation of clot and blood.
2. Replacement of tricuspid valve and cardiopulmonary bypass with a 31 mosaic bioprosthesis.
FINDINGS:
DESCRIPTION OF PROCEDURE: Patient was brought to the operating room already intubated with indwelling monitoring lines. He was prepped and draped in sterile classical manner, remained hemodynamically stable. Repeat sternotomy was performed. Large amount of thrombus was found in both pleural cavities as well as free-flowing blood. This was evacuated. There was some bleeding from the chest tube wire insertion sites, which was controlled. No other obvious bleeding except for diffuse coagulopathy was noted. He had received multiple blood products through the night.
Transesophageal echo revealed what initially we felt was perivalvular tricuspid regurgitation as being central regurgitation in a bovine valve. This was difficult to explain and was too much to leave, and for that reason, I reheparinized and cannulated, went on bypass, arrested the heart, and removed the previous bioprosthesis and placed a porcine valve within the leaflets which would require less pressure to close. This was yet done with horizontal mattress sutures and Cor-Knots. The cross-clamp was removed. The right atrium was closed. He was weaned from bypass. Heparin was reversed with protamine. Coagulation factors were administered. The valve looked excellent. The sternum was reapproximated with same indwelling chest tubes. He was returned to ICU in critical condition.