hcg
Guru
Can anyone please help & check my code:
Dx code: 511.9
CPT code: 31624, 32098, 32320
Below is the procedure report. Any input will be greatly appreciated. Thank you so much.
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Preoperative diagnosis: Multiloculated right pleural effusion with total consolidation right lung.
Postoperative diagnosis: Same.
Operative procedure: Flexible bronchoscopy, therapeutic/diagnostic bronchial lavage, right thoracoscopy/thoracotomy, multiple pleural biopsies for culture and histology, extensive parietal and visceral pleurectomy with complete pulmonary decortication and placement of chest tubes x3 within apex, inferior sulcus and laterally.
Indications for surgery: Patient is a 42-year-old with a protracted history of right middle lobe infiltrate, effusions, previous Mycobacterium Avium cultured from bronchial secretions and treated, now with increased aspiratory symptoms prompting referral to Hospital A for further evaluation which included a multitude of studies ultimately suggesting lymphoma. He underwent right thoracentesis for a large hemorrhagic pleural effusion in Hospital A prior to his return. He has over the ensuing weeks developed increasingly severe respiratory symptoms with development of recurrent right pleural effusion. Thoracic surgical consultation was requested. Examination showed a 52-year-old patient in obvious respiratory distress with absent breath sounds on the right. CT of the chest showed complete opacification of the right lung along with multiloculated effusions throughout the pleural space and major fissure area. Right thoracotomy and surgical decortication was recommended. Risks/benefits with and without surgery were discussed at length with the patient and family including risks of bleeding, infection, blood clots, pulmonary emboli, other heart and lung complications, possible need for postoperative ventilatory support as opposed to the risks of observation which were felt by the patient, family and other attending physicians to be untenable. It was patient's wish to proceed as soon as possible with surgery.
Description of procedure and findings: Patient was brought to the operating suite and identified as to name and procedure following which double-lumen endotracheal anesthesia was induced. Bronchoscopy demonstrated extensive thick purulent secretions completely obliterating the right bronchial tree. These were aspirated, bronchial lavage carried out and the material sent for appropriate cultures. Following placement of appropriate monitoring lines the patient was placed in left lateral decubitus position carefully padding all pressure points and prepped and draped as to expose the right chest. Following final time out for patient and site identification a sixth intercostal anterolateral incision was made approximately 10 cm in length. The intercostal muscles and pleura were incised demonstrating a large amount of purulent appearing fluid which was aspirated and sent for cytology and culture. The 10 mm 30° thoracoscope was introduced confirming extensive loculated fluid pockets within the pleural space and marked inflammatory pleural reaction.
The incision was extended incising the lateral margin of the pectoralis major muscle, retracting serratus muscles posteriorly and incising the intercostal muscles throughout their length to afford exposure and digital examination of the lung. The lung was dissected from the chest wall using sharp and blunt dissection exposing and evacuating multiple loculations of murky, purulent appearing fluid from the entire pleural space and major fissure area. Extensive visceral and parietal pleurectomy was carried out ultimately accomplishing complete decortication of the upper, middle and lower lobes allowing expansion of the entire lung on reinflation. On dissecting the visceral pleura from the middle lobe area it was found to be quite thickened suggesting possible malignancy. A portion of this was sent for frozen section which showed cellularity suspicious for lymphoma.
The lung was reinflated under saline solution and with an endobronchial pressure of 30 mmHg no unacceptable air leak was demonstrated from the denuded surface of the lung. Two 36 French angled tubes were placed under direct vision one within the apex the other within the inferior sulcus, along with a third 30 French chest tube anterolaterally. These were brought out through separate incisions securely sutured and connected to dry suction at -40 mmHg.
Following a correct sponge and instrument count the incision was closed in the usual fashion using #2 Vicryl figure-of-eight pericostal sutures followed by running 0 Vicryl to the muscle layer and 2-0 Prolene subcuticular suture to close the skin. A light dressing was applied, the patient repositioned supine, reintubated with a single-lumen endotracheal tube and return to the intensive care unit in stable condition for continued ventilatory support.
Blood loss: 300 cc.
Blood replaced: None.
Surgeon: Dr. A
Dx code: 511.9
CPT code: 31624, 32098, 32320
Below is the procedure report. Any input will be greatly appreciated. Thank you so much.
****************************************************************
Preoperative diagnosis: Multiloculated right pleural effusion with total consolidation right lung.
Postoperative diagnosis: Same.
Operative procedure: Flexible bronchoscopy, therapeutic/diagnostic bronchial lavage, right thoracoscopy/thoracotomy, multiple pleural biopsies for culture and histology, extensive parietal and visceral pleurectomy with complete pulmonary decortication and placement of chest tubes x3 within apex, inferior sulcus and laterally.
Indications for surgery: Patient is a 42-year-old with a protracted history of right middle lobe infiltrate, effusions, previous Mycobacterium Avium cultured from bronchial secretions and treated, now with increased aspiratory symptoms prompting referral to Hospital A for further evaluation which included a multitude of studies ultimately suggesting lymphoma. He underwent right thoracentesis for a large hemorrhagic pleural effusion in Hospital A prior to his return. He has over the ensuing weeks developed increasingly severe respiratory symptoms with development of recurrent right pleural effusion. Thoracic surgical consultation was requested. Examination showed a 52-year-old patient in obvious respiratory distress with absent breath sounds on the right. CT of the chest showed complete opacification of the right lung along with multiloculated effusions throughout the pleural space and major fissure area. Right thoracotomy and surgical decortication was recommended. Risks/benefits with and without surgery were discussed at length with the patient and family including risks of bleeding, infection, blood clots, pulmonary emboli, other heart and lung complications, possible need for postoperative ventilatory support as opposed to the risks of observation which were felt by the patient, family and other attending physicians to be untenable. It was patient's wish to proceed as soon as possible with surgery.
Description of procedure and findings: Patient was brought to the operating suite and identified as to name and procedure following which double-lumen endotracheal anesthesia was induced. Bronchoscopy demonstrated extensive thick purulent secretions completely obliterating the right bronchial tree. These were aspirated, bronchial lavage carried out and the material sent for appropriate cultures. Following placement of appropriate monitoring lines the patient was placed in left lateral decubitus position carefully padding all pressure points and prepped and draped as to expose the right chest. Following final time out for patient and site identification a sixth intercostal anterolateral incision was made approximately 10 cm in length. The intercostal muscles and pleura were incised demonstrating a large amount of purulent appearing fluid which was aspirated and sent for cytology and culture. The 10 mm 30° thoracoscope was introduced confirming extensive loculated fluid pockets within the pleural space and marked inflammatory pleural reaction.
The incision was extended incising the lateral margin of the pectoralis major muscle, retracting serratus muscles posteriorly and incising the intercostal muscles throughout their length to afford exposure and digital examination of the lung. The lung was dissected from the chest wall using sharp and blunt dissection exposing and evacuating multiple loculations of murky, purulent appearing fluid from the entire pleural space and major fissure area. Extensive visceral and parietal pleurectomy was carried out ultimately accomplishing complete decortication of the upper, middle and lower lobes allowing expansion of the entire lung on reinflation. On dissecting the visceral pleura from the middle lobe area it was found to be quite thickened suggesting possible malignancy. A portion of this was sent for frozen section which showed cellularity suspicious for lymphoma.
The lung was reinflated under saline solution and with an endobronchial pressure of 30 mmHg no unacceptable air leak was demonstrated from the denuded surface of the lung. Two 36 French angled tubes were placed under direct vision one within the apex the other within the inferior sulcus, along with a third 30 French chest tube anterolaterally. These were brought out through separate incisions securely sutured and connected to dry suction at -40 mmHg.
Following a correct sponge and instrument count the incision was closed in the usual fashion using #2 Vicryl figure-of-eight pericostal sutures followed by running 0 Vicryl to the muscle layer and 2-0 Prolene subcuticular suture to close the skin. A light dressing was applied, the patient repositioned supine, reintubated with a single-lumen endotracheal tube and return to the intensive care unit in stable condition for continued ventilatory support.
Blood loss: 300 cc.
Blood replaced: None.
Surgeon: Dr. A
