KNLong
New
Wanting to coding 32659, Lt and I am trying to research to see if #2-4(procedure details) are included or if I can code them as well. Any help would be greatly appreciated.
Procedure:
1. Left VATS with pericardial window and evacuation of hemopericardium
2. Evacuation of left pleural effusion via VATS
3. Lysis of pleural adhesions
4. Open thoracostomy tube placement (24 French)
5. Left multilevel intercostal nerve block
Indication:
62-year-old male with paraplegia and recent diagnosis of severe aortic valve stenosis secondary to bicuspid aortic valve along with ascending aortic aneurysm. The patient underwent aortic valve replacement with a mechanical valve and replacement of his ascending aorta on January 26, 2021. The patient developed shortness of breath and intermittent chest pressure. Transthoracic echo as well as CT scan of the chest confirmed moderate sized bilateral pleural effusions as well as a moderate pericardial effusion without tamponade physiology. He presents today for definitive management.
Specimens:
-Left pleural fluid for cultures
-Pericardial fluid for cell count and cultures
Estimated blood loss: 5 mL
Blood replaced: None
Drains: 24 French Silastic chest tube in bilateral pleural spaces
Implants: None
Complications: None
Condition at the completion of the procedure: Stable
Intraoperative findings:
-500 mL of serosanguineous fluid removed from the right pleural space
-600 mL of serosanguineous fluid removed from the left pleural space
-200 mL of hemopericardium removed
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia with double-lumen endotracheal intubation. Monitoring lines and devices were placed by anesthesia. The patient's right chest was then prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
Small 10 mm incision was made at the anterior axillary line, roughly the seventh intercostal space. The soft tissues were bluntly divided using hemostats and Kelly clamps and access into the right pleural space was achieved. A 24 French Silastic chest tube was then placed within the right pleural space and 500 mL of serosanguineous effusion was evacuated to an atrium. The chest tube was secured with 0 silk.
The patient was then turned and placed in the lateral recumbent position with the left chest facing up. The left chest was then prepped and draped with ChloraPrep solution. A small 5 mm incision was made at the mid axillary line, roughly the eighth intercostal space. Access into the right pleural cavity was achieved by using an Optiview technique. The 5 mm angled VATS camera was inserted into the right pleural space. Serosanguineous fluid was immediately identified. 210 mm incision was made anteriorly, one at the sixth intercostal space and the second near the cardiophrenic angle. A 10 mm incision was also made posteriorly.
600 mL of serosanguineous fluid was removed from the left pleural space. Once this was completed, it became evident that the patient had dense scarring and adhesions involving the left lower lobe to the diaphragm as well as the pericardium. Using a combination of electrocautery as well as the harmonic scalpel, the left lower lobe was completely mobilized off the diaphragm by lysing the adhesions. Portions of the adhesions along the pericardium were also released. This allowed for access to the posterior pericardium. Pericardial window was then created using the electrocautery hook. A large rush of dark blood was then evacuated from the pericardial space, estimated at 200 mL. Portions of the pleural fluid as well as the pericardial fluid were submitted for specimens as described above.
Once the pericardial effusion was evacuated, the pleural space was copiously irrigated with normal saline. Under direct visualization, a multilevel intercostal nerve block was performed using half percent Marcaine for regional anesthesia. He was also injected around the incisions for local anesthesia. A 24 French Silastic chest tube was then placed in the left pleural space. All ports were found to be hemostatic. The left lung was ventilated under direct visualization with full reexpansion. The VATS camera was removed. The incisions were closed in layers using 2-0 Vicryl for the soft tissues. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well, was extubated, then transferred to recovery.
Procedure:
1. Left VATS with pericardial window and evacuation of hemopericardium
2. Evacuation of left pleural effusion via VATS
3. Lysis of pleural adhesions
4. Open thoracostomy tube placement (24 French)
5. Left multilevel intercostal nerve block
Indication:
62-year-old male with paraplegia and recent diagnosis of severe aortic valve stenosis secondary to bicuspid aortic valve along with ascending aortic aneurysm. The patient underwent aortic valve replacement with a mechanical valve and replacement of his ascending aorta on January 26, 2021. The patient developed shortness of breath and intermittent chest pressure. Transthoracic echo as well as CT scan of the chest confirmed moderate sized bilateral pleural effusions as well as a moderate pericardial effusion without tamponade physiology. He presents today for definitive management.
Specimens:
-Left pleural fluid for cultures
-Pericardial fluid for cell count and cultures
Estimated blood loss: 5 mL
Blood replaced: None
Drains: 24 French Silastic chest tube in bilateral pleural spaces
Implants: None
Complications: None
Condition at the completion of the procedure: Stable
Intraoperative findings:
-500 mL of serosanguineous fluid removed from the right pleural space
-600 mL of serosanguineous fluid removed from the left pleural space
-200 mL of hemopericardium removed
Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite placed on the operating table where he underwent general anesthesia with double-lumen endotracheal intubation. Monitoring lines and devices were placed by anesthesia. The patient's right chest was then prepped and draped in usual sterile fashion using ChloraPrep solution. Timeout was used to confirm patient identity as well as the procedure to be performed. Antibiotics given prior to the incisions.
Small 10 mm incision was made at the anterior axillary line, roughly the seventh intercostal space. The soft tissues were bluntly divided using hemostats and Kelly clamps and access into the right pleural space was achieved. A 24 French Silastic chest tube was then placed within the right pleural space and 500 mL of serosanguineous effusion was evacuated to an atrium. The chest tube was secured with 0 silk.
The patient was then turned and placed in the lateral recumbent position with the left chest facing up. The left chest was then prepped and draped with ChloraPrep solution. A small 5 mm incision was made at the mid axillary line, roughly the eighth intercostal space. Access into the right pleural cavity was achieved by using an Optiview technique. The 5 mm angled VATS camera was inserted into the right pleural space. Serosanguineous fluid was immediately identified. 210 mm incision was made anteriorly, one at the sixth intercostal space and the second near the cardiophrenic angle. A 10 mm incision was also made posteriorly.
600 mL of serosanguineous fluid was removed from the left pleural space. Once this was completed, it became evident that the patient had dense scarring and adhesions involving the left lower lobe to the diaphragm as well as the pericardium. Using a combination of electrocautery as well as the harmonic scalpel, the left lower lobe was completely mobilized off the diaphragm by lysing the adhesions. Portions of the adhesions along the pericardium were also released. This allowed for access to the posterior pericardium. Pericardial window was then created using the electrocautery hook. A large rush of dark blood was then evacuated from the pericardial space, estimated at 200 mL. Portions of the pleural fluid as well as the pericardial fluid were submitted for specimens as described above.
Once the pericardial effusion was evacuated, the pleural space was copiously irrigated with normal saline. Under direct visualization, a multilevel intercostal nerve block was performed using half percent Marcaine for regional anesthesia. He was also injected around the incisions for local anesthesia. A 24 French Silastic chest tube was then placed in the left pleural space. All ports were found to be hemostatic. The left lung was ventilated under direct visualization with full reexpansion. The VATS camera was removed. The incisions were closed in layers using 2-0 Vicryl for the soft tissues. The skin was closed with 4-0 Monocryl in a running subcuticular manner. Dermabond was placed over the wound.
The patient tolerated the procedure well, was extubated, then transferred to recovery.