Wiki Small Left thoracotomy with complete slit decortication of lung.

[bailsb]

Any help by month end is greatly appreciated. I am looking at 32220 and 32650-51, but the surgeon is asking about the pleurodesis codes and the biopsy codes. The whole "seperate procedure" on 32220 is throwing me off.

Procedure:
1. Left Thorascopy with drainage of effusion
2. Small Left thoracotomy with complete slit decortication of lung.
3. Chest wall biopsy.
4. Mechanical and talc pleurodesis.

Placed supine on op table. Skin incision then made in the anterior chest wall, approx 3 fingerbredths below the nipple level using a #10 scalpel blade. The electrocautery was used in a coagulating mode to dissect down through the subcutaneous tissues until the pleural cavity was reached. The pleural cavity was entered with a clamp and immediately there was a large amount of straw-colored effusion which was encountered and drained off and sent to cytology. Approx 2300 cc of fluid was encountered and drained off and sent for cytology. Following drainage of the fluid and the thoracoscope was inserted. There was clear tumor involvement in the encasement of the entire lung, as well as seeding of tumor along the entire surface of the chest wall. The lung itself had a film fibrotic peel of tumor encasing and entrapping it. This was preventing the lung from fully expanding. A complete slit decortication of the lung was undertaken in the meticulous fashion. Some small specimens of the peural peel were sent to pathology. The pleurodesis was then performed in mechanical fashion using the Bovie Scratch pad. Some of the tumor seeding in the chest wall which was encountered was biopsied and sent off to pathology as well. Mechanical pleurodesis was then performed using a bovie scratch pad. Air leak was checked for and none wsa visible. The aerosolized talc pleurodesis was then performed and hemostasis was demonstracted. A single 36 straight chest tube was inserted through the thorascopy incision site, which had been extended to a small thoracotomy for exposure to do the decortication. This was functioning as the chest tube insertion site now. The chest tube was secured into position using 2-0 silk stay sutures and a purestring suture. Clean sterile dressing were applied. Patient taken to ICU for recovery.

Thank you,
Brendan Bailey, CPC

 

[kvangoor]

I agree with the use of 32650. You would not use 32220 unless it was performed on a seperate area or seperate incision was made. That is the case with all seperate procedures and CCI edits. It is considered part of the 32650. Pleurodesis and biopsys are included in this procedure (32650) as well. The descrition of the code 32650 in the CPT book states that "pleurodesis, mechanical or chemical" is included. You would not use a seperate code. Here is the lay description of 32650. As you can see, there is alot included in this one code. Hope this helps!

The physician biopsies a lung nodule or mass through a rigid or flexible fiberoptic endoscope. This procedure can be done under local or general anesthesia. The surgeon makes a small incision between two ribs and by blunt dissection and the use of a trocar enters the thoracic cavity. The endoscope is passed through the trocar and into the chest cavity. One lung is usually partially collapsed by instilling air into the chest through the trocar or, if general anesthesia is used, the lung may be collapsed through a double lumen endotracheal tube inserted through the mouth into the trachea. The contents of the chest cavity are examined by direct visualization and/or the use of a video camera. Still photographs may be taken as part of the procedure. The lung nodule(s) or mass(es) selected for biopsy is identified and the biopsy is taken using a device inserted through the endoscope. At the conclusion of the procedure, the endoscope and the trocar are removed. A chest tube for drainage and re-expansion of the lung is usually inserted through the wound used for the thoracoscopy

 

[bailsb]

Thank you kvangoor for quick reply, but what about the slit decortication?

Thank you Kvangoor for your quick reply. Would't this then also warrant a decortication code such as 32320? The surgeon clearly documents that he meticulously performed a slit decorication. Maybe I'm not following your advice correctly, but the decortication seems to be the most complex part of this procedure? I did not state it before, but this patient has pleural effusions with a past history of Mesothelioma. Once again, your help is appreciated.

 

[kvangoor]

I reviewed the note once again and I did miss the decortication. I would go with 32651. That includes all of the above and the decortication. Can anyone else add to/confirm this?

 

[bailsb]

I'll take a look at your recommendation. Thank you again for your help.