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return to OR after bedside procedure. billable?


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I would like to have other opinions on this. I believe I can only bill
33967-78 for the IABP

It sounds like the other doc did the sternal closure and the open cardiac massage was performed at bedside.
TEE done by another dr.

INDICATIONS: This is a 67-year-old gentleman who is postoperative day #1 from his minimally invasive aortic valve replacement. I saw the patient on the floor around 9:00. He was sitting in the chair doing excellent. Hemodynamically, he was stable and the plan was to diurese him and I pulled these pacing wires out. Around an hour and a half later, I got a call from the floor nurse that the patient was in rapid AFib 130s. I suggested to gave a bolus of 150 mg of amiodarone followed by a drip. Next few minutes later, I got a second call and at that time, they were courting the patient. When I arrived and a close chest CPR was performed, I opened the whole incision across the sternum and since there was no sternal saw available, I opened the sternum with the help of Mayo scissors and on the upper part of sternum where the mini sternotomy was performed, the wires were cut. It may also be noted that just before arresting (because he is a witnessed arrest), he had dumped around 600 mL of blood from his chest tubes. Once I opened the sternum, there was clot observed inside the chest, which was evacuated. The area of the right ventricular outflow tract where the patient's pacing wire had a small laceration, I had laceration, which may be the cause of his tamponade, because there was no other obvious source observed. I continued open cardiac massage and the patient was taken to the operating room and the procedure explained below.

DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and kept on his hospital bed. Immediately, an aortic versus and a venous cannula was inserted and the patient was started on cardiopulmonary bypass. Once that was done, we put pursestring sutures around cannulae . Initially, the patient was cooled down to 32 degrees. However, the patient started to fibrillate and to defibrillate the patient, he was warmed back to 35 degrees. At that time, the fibrillation stopped. In addition, a percutaneous intraaortic balloon pump was inserted from the left femoral artery and position of the tip confirmed to be in the descending thoracic aorta with the help of the TEE examination. The patient's rhythm was stabilized with the help of inotropic support and the balloon pump. The patient was kept on bypass for at least an hour. Then gradually, we started to wean the patient off from bypass. The patient was able to wean off from bypass without any difficulty. Two separate chest tubes were inserted and secured to the skin using 0 silk. These were in addition to his previous two chest tubes. The area of the laceration from the pacing wire was repaired using pledgeted 4-0 Prolene.

Protamine was given to reverse heparin. Once making sure there was adequate hemostasis maintained, we turned our attention to the sternum. As mentioned earlier in medication, we did not have a sternal saw on the floor, and the patient had a previous minimally invasive procedure with a sternotomy T off into the fourth intercostal space. Therefore to complete a sternotomy, I used Mayo scissors without a sternal saw. This had created an awkward cut into the sternum and down towards the right-sided costal cartilages. Therefore, a Robicsek procedure was not possible. I requested a consult from Dr. XXX ( orthopedics) and the plan was to insert plates. He came more graciously and inserted plates on the lower sternum from starting with the left-sided sternum down to the right ribcage. This way, the sternum was reapproximated on the lower edge. On the upper edge, we inserted standard sternal wires. It should also be noted that before closing the sternum, we thoroughly irrigated the mediastinum with a pulse irrigator with saline.
Milwaukee WI
Best answers

CV surgery is NOT my area of expertise, but ...

I would code for the thoracotomy with cardiac massage.

I would also check the Ortho doctor's documentation of the sternum repair. It almost sounds as if your surgeon assisted the Ortho surgeon in this endeavor.

Very interesting case!

F Tessa Bartels, CPC, CEMC


Best answers
What about 35820? I know the chest was re-opened bedside and I realize Medicare does not pay for bedside procedures in the global period, but this patient could not wait to get to the OR.

I would probably bill for this and the IABP, I'm pretty sure the cardiac massage will bundle into the 35820.

Lisi, CPC