Sternotomy Only

Matt Cooper

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Stuck on How to Code this. Can only see the Sternotomy and the peritoneal sutures. How do i code the sternotomy or can I just code for the closure? Op Note follow:

An incision was made from the suprasternal notch to the xiphoid process. The subcutaneous tissues were divided with electrocautery. The sternum was divided with a sternal saw. An Ankeney retractor
was inserted and placed. The pericardium was transected from the innominate vein down to the diaphragm. Upon entering the pericardial space there was no evidence of any hematoma or hemopericardium.

Examination of all the chambers of the heart revealed the absence of any injuries. The ascending aorta was also devoid of any injuries. The right and the left pleural spaces were entered. There was no evidence of any hemopericardium. There was a significant amount of edema within the parenchyma of the lung along with some atelectasis. There was no evidence of any hilar injuries or any significant parenchymal injuries.

Examination of the peritoneum revealed some protrusion of the peritoneal layer. This was entered during the process of dissection and a moderate amount of succus entericus mixed with blood emanated from the peritoneal cavity. The rent in the peritoneum was closed with Prolene. The mediastinum and the bilateral pleural spaces were irrigated with approximately five liters of warm saline. #24 French Blake drains were positioned within the mediastinum, one behind the heart and one anterior to the heart and #32 French straight thoracostomy tubes were placed into the right and left pleural spaces respectively. The sternum was reapproximated with stainless steel wires. The fascia was closed with a running #1 Vicryl. The subcutaneous tissues were closed in layers and the skin was closed with Biosyn stitch.

Thanks For any Advise

Matt Cooper


Oakpark, Illinois
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What was the reason for this exploration? If it was for post-op hemorrhage, thrombosis, or infection, you could use code 35820 (and/or 35840).

If not, you could look at codes 33310 or maybe 49000??

I wouldn't bill for the peritoneal sutures, it sounds as if the surgeon knicked this while dissecting the area. He had to repair what he "broke."

Sorry, that's all the advice I've got :)

Lisi, CPC