talitha82
Guest
I am really struggling with the correct code to choose on this one, and implore anyone with Thoracoscopy experience to enlighten me. I am leaning towards 32658 with a 52 modifier??
Here is the procedure note:
Preoperative Diagnosis: Hemothorax left multiple rib fractures
Postoperative Diagnosis: hemothorax left multiple rib fractures
Procedure: Procedure(s):
ATTEMPTED VIDEO ASSISTED THORACOSCOPY, left hemothorax evacuation, placement of tube thoracostomy 36 fr., placement of multiple rib block
Operative Findings: Hemothorax left side, multiple rib fractures
Operation: After informed consent was obtained, the patient was taken to the operating room and induced under general endotracheal anesthesia. His correct side was marked preoperatively by me corresponding to physical findings and available radiographs. The patient had SCD hose activated prior to induction. He was placed in the Right lateral decubitus position and bony prominences were padded. He was prepped with Chloraprep and draped appropriately. Aseptic technique was used. Time out was performed.
Incision was made at approximately between the seventh and eight rib interspace as an open abrasion was located at the fifth-sixth rib interspace. This was made in the anterior axillary line. Patient was noted to have extensive ecchymosis along the left lateral chest was. There was subcutaneous emphysema. His fat layer was approximately five cm deep. Upon reaching rib, interspace was selected and chest was entered bluntly with great care using Pean clamp. A rush of blood was encountered. The incision was digitally explored assuring chest cavity was entered and noting palpation of lung. A 24 french Foley catheter was introduced and 800 ml of blood was evacuated from the left chest cavity. Anesthesia commented that ventilation improved once hemothorax was evacuated. Saline was introduced via catheter and then suctioned. There were no clots retrieved. Attempt was made to place the thoracoscope via the incision into the left hemithorax. Visualization was poor and efforts were abandoned.
A 36 fr. Chest tube was introduced and placed posteriorly. This was secured with #2 Ethibond. A U-stitch was placed around the chest tube.
4-0 Prolene was used to suture additional opening with simple running stitch.
Multiple ribs were blocked with 0.25% Marcaine with epinephrine. A spinal needle was used to locate rib edges and infuse local taking great care to avoid collateral injury. There was no evidence of collateral injury. 30 ml of local anesthetic was used.
Chest tube was placed to H20 seal. Sterile dressings were applied.
Patient was place supine and transported to the PACU in stable condition.
There were no complications evident.
Thanks so much for any help provided!!
Here is the procedure note:
Preoperative Diagnosis: Hemothorax left multiple rib fractures
Postoperative Diagnosis: hemothorax left multiple rib fractures
Procedure: Procedure(s):
ATTEMPTED VIDEO ASSISTED THORACOSCOPY, left hemothorax evacuation, placement of tube thoracostomy 36 fr., placement of multiple rib block
Operative Findings: Hemothorax left side, multiple rib fractures
Operation: After informed consent was obtained, the patient was taken to the operating room and induced under general endotracheal anesthesia. His correct side was marked preoperatively by me corresponding to physical findings and available radiographs. The patient had SCD hose activated prior to induction. He was placed in the Right lateral decubitus position and bony prominences were padded. He was prepped with Chloraprep and draped appropriately. Aseptic technique was used. Time out was performed.
Incision was made at approximately between the seventh and eight rib interspace as an open abrasion was located at the fifth-sixth rib interspace. This was made in the anterior axillary line. Patient was noted to have extensive ecchymosis along the left lateral chest was. There was subcutaneous emphysema. His fat layer was approximately five cm deep. Upon reaching rib, interspace was selected and chest was entered bluntly with great care using Pean clamp. A rush of blood was encountered. The incision was digitally explored assuring chest cavity was entered and noting palpation of lung. A 24 french Foley catheter was introduced and 800 ml of blood was evacuated from the left chest cavity. Anesthesia commented that ventilation improved once hemothorax was evacuated. Saline was introduced via catheter and then suctioned. There were no clots retrieved. Attempt was made to place the thoracoscope via the incision into the left hemithorax. Visualization was poor and efforts were abandoned.
A 36 fr. Chest tube was introduced and placed posteriorly. This was secured with #2 Ethibond. A U-stitch was placed around the chest tube.
4-0 Prolene was used to suture additional opening with simple running stitch.
Multiple ribs were blocked with 0.25% Marcaine with epinephrine. A spinal needle was used to locate rib edges and infuse local taking great care to avoid collateral injury. There was no evidence of collateral injury. 30 ml of local anesthetic was used.
Chest tube was placed to H20 seal. Sterile dressings were applied.
Patient was place supine and transported to the PACU in stable condition.
There were no complications evident.
Thanks so much for any help provided!!