Thoracic curgery **doozie**

ndriley10

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i definitely need some input on this one. I'm thinking of 32650 and 39545 even though 39545 is open and was performed thorocoscopically. I'm guessing the pleura biopsies and wedge resection are bundled with 32650 unfortunately.

POSTOPERATIVE DIAGNOSIS: Right catamenial pneumothorax.

PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Right video-assisted thoracoscopic surgery.
3. Right upper lobe wedge resection.
4. Multiple pleural biopsies.
5. Plication of the diaphragm.
6. Talc pleurodesis.
7. Multilevel intercostal nerve blocks.

INTRAOPERATIVE FINDINGS:
1. Evidence of possible pleural endometriosis.
2. Open channels visible in the diaphragm.
3. Successful diaphragmatic plication.
4. Right upper lobe area of possible fibrosis/scar/endometrial implant. Wedge resection performed.

DESCRIPTION OF PROCEDURE: A series of Thoracoport incisions were made, two anterior to the scapula tip and two posterior to the scapula tip for access to the pleural space. Examination of the pleural surfaces was performed after the right lung was deflated and the left lung was preferentially ventilated. The patient was noted to have multiple areas of pleura that had evidence of hemosiderin deposition that were strange in appearance. Pleural biopsies were sent. Examination of the diaphragm revealed multiple thinned out areas that looked to be the channels one associates with endometriosis into the pleural space. This diaphragmatic pleura was also sent for biopsy. The lung was examined No bulla or blebs were identified. The right apical apex of the lung was felt to be fibrotic and scarred. This was wedge resected utilizing a green load Echelon stapling device. It was sent for pathology as well. The working diagnosis at this point during the case was catamenial pneumothorax. As such, a plication of the diaphragm was performed as is appropriate for these cases in order to close the trans diaphragmatic channels. The specific images were taken. Image number 6 imported into the system shows the evidence of channels in the diaphragm. Image number 7 shows the post-plicated diaphragm. The diaphragmatic plication was performed endothoracically using multiple no knife staples. The image number 5 shows the scarring at the apex of the right lung. Once this had been completed, a complete talc pleurodesis was performed using aerosolized talc within the right pleural space. Image number 8 shows the post-talc pleura. A series of multilevel intercostal nerve blocks was then performed along the posterior rib edges using 0.25% Marcaine. A 24 French HydroGlide chest tube was then advanced in the pleural space, brought out through a separate inferior stab incision and secured appropriately. The lung was then reinflated under direct vision and found to fill the space without difficulty. The camera was removed. The incisions were then closed in layers using 2-0 Vicryl, 3-0 Vicryl and 4-0 Monocryl. Dermabond and sterile dressings were applied. The patient was awoken from anesthesia and transferred to the recovery room in stable condition.

My thoracic surgeons are doing more plications thoracoscopically but with no code to bill for this. Anyone else have the same experience or a good solution??
 

jewlz0879

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i definitely need some input on this one. I'm thinking of 32650 and 39545 even though 39545 is open and was performed thorocoscopically. I'm guessing the pleura biopsies and wedge resection are bundled with 32650 unfortunately.

POSTOPERATIVE DIAGNOSIS: Right catamenial pneumothorax.

PROCEDURES PERFORMED:
1. Flexible bronchoscopy.
2. Right video-assisted thoracoscopic surgery.
3. Right upper lobe wedge resection.
4. Multiple pleural biopsies.
5. Plication of the diaphragm.
6. Talc pleurodesis.
7. Multilevel intercostal nerve blocks.

INTRAOPERATIVE FINDINGS:
1. Evidence of possible pleural endometriosis.
2. Open channels visible in the diaphragm.
3. Successful diaphragmatic plication.
4. Right upper lobe area of possible fibrosis/scar/endometrial implant. Wedge resection performed.

DESCRIPTION OF PROCEDURE: A series of Thoracoport incisions were made, two anterior to the scapula tip and two posterior to the scapula tip for access to the pleural space. Examination of the pleural surfaces was performed after the right lung was deflated and the left lung was preferentially ventilated. The patient was noted to have multiple areas of pleura that had evidence of hemosiderin deposition that were strange in appearance. Pleural biopsies were sent. Examination of the diaphragm revealed multiple thinned out areas that looked to be the channels one associates with endometriosis into the pleural space. This diaphragmatic pleura was also sent for biopsy. The lung was examined No bulla or blebs were identified. The right apical apex of the lung was felt to be fibrotic and scarred. This was wedge resected utilizing a green load Echelon stapling device. It was sent for pathology as well. The working diagnosis at this point during the case was catamenial pneumothorax. As such, a plication of the diaphragm was performed as is appropriate for these cases in order to close the trans diaphragmatic channels. The specific images were taken. Image number 6 imported into the system shows the evidence of channels in the diaphragm. Image number 7 shows the post-plicated diaphragm. The diaphragmatic plication was performed endothoracically using multiple no knife staples. The image number 5 shows the scarring at the apex of the right lung. Once this had been completed, a complete talc pleurodesis was performed using aerosolized talc within the right pleural space. Image number 8 shows the post-talc pleura. A series of multilevel intercostal nerve blocks was then performed along the posterior rib edges using 0.25% Marcaine. A 24 French HydroGlide chest tube was then advanced in the pleural space, brought out through a separate inferior stab incision and secured appropriately. The lung was then reinflated under direct vision and found to fill the space without difficulty. The camera was removed. The incisions were then closed in layers using 2-0 Vicryl, 3-0 Vicryl and 4-0 Monocryl. Dermabond and sterile dressings were applied. The patient was awoken from anesthesia and transferred to the recovery room in stable condition.

My thoracic surgeons are doing more plications thoracoscopically but with no code to bill for this. Anyone else have the same experience or a good solution??
Aside from the plication (my physicians have never done that) you can bill 32666 and 32650-59. Unlike diagnositc thoracoscopies, multiple surgical thoracoscopies can be billed as long as they are done in different areas with -59 on the lesser code. Neither 32650/32666 bundle to 39545.
 

adkinsal

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question

New to thoracic surgery and i have a surgeon who is going to do thoracoscopic plication of the diaphragm. I don't see a thoracoscopic code for this procedure. I just see and open procedure 39545. Have you billed with an unlisted coded 39599 and stated is it related to 39545 and also 32605. Needing some help with this one. There is not much billing information out there for this one. Thank you.
 
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