Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy code selection

Latisha Coles

Charlotte, NC
Best answers
I currently support ENT providers who perform surgery. I have an op note I need help with. Our provider selected 32674, 31526, and 38510.

On review of the op note I disagree and would like some assistance. My thought is 32674 is an add on code and a primary procedure is needed to support usage. I’ve come up with 32606, 32674, and 315261. I’ve attached the op note for review.

Postoperative Information
9/23/2016 09:10:00
Preoperative Diagnosis: Squamous cell cancer of tongue (ICD10-CM C02.9, Discharge, Medical), Cervical lymphadenopathy (ICD10-CM R59.0, Discharge, Medical).
Postoperative Diagnosis: Squamous cell cancer of tongue (ICD10-CM C02.9, Discharge, Medical), Cervical lymphadenopathy (ICD10-CM R59.0, Discharge, Medical).
Procedure: Procedure History
Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary procedure) (32674).
Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope (31526).
Biopsy or excision of lymph node(s); open, deep cervical node(s) (38510)..
Indications: Miss Cronin has a history of tonsil cancer eight years ago treated with radiation therapy. A second primary was found in her base of tongue which required repeat radiation, TORS resection and bilateral neck dissections. She has had another recurrence in her tongue base which required open resection with radial forearm free flap. She now has increasing lymph nodes in her upper mediastinum as well as her right level IV in the cervical neck posterior to the carotid artery.

Type of Anesthesia: General Endotracheal (GET).
Estimated Blood Loss: 10 ml.
Drains/Packs/Other Device: None.
Findings: There were 45 enlarged lymph nodes in the upper mediastinum just anterior to the trachea which were removed and sent for frozen section which came back as reactive lymph nodes. There were 2-3 lymph nodes deep to the carotid artery on the right side which again came back as negative for carcinoma.
Specimens Removed: Upper mediastinal lymph nodes, right level IV lymph node.
Complications: None.
Post-Op Condition: Stable.
Patient Disposition: Disposition to Recovery Room.
Description of the Procedure:
After informed consent was obtained, the patient was brought back to the operating room, placed supine upon the table placed under general anesthesia. Intubation was attempted with the glide scope but this was deemed too risky for damage to the posterior pharyngeal wall so she was intubated using a fiberoptic nasal scope and endotracheal tube. Ventilation commenced through this. A timeout occurred to assure patient, site, and procedure. She was prepped in the usual fashion.

A tooth guard was applied and the Dedo laryngoscope was barely able to be passed intraorally due to the trismus. The tongue had been resected mostly on the left side of the oral tongue showed no evidence of cancer. The forearm flap and base of tongue were evaluated with 30? telescope and no cancer was identified. The epiglottis could be seen and no cancer was identified here either. The endotracheal tube was large enough that a precluded evaluation of the false cords and true vocal cords. Posterior pharyngeal wall had radiation damage as well as the palate but again no cancer was seen. The Dedo laryngoscope, tooth guard, and telescopes are removed without difficulty.

The neck was then prepped and draped in usual sterile fashion. A 4 cm incision was made from the right lower neck along her previous incision across to the left anterior belly of the SCM muscle. Subplatysmal flaps were raised superiorly and inferiorly. The strap muscles were identified separated in the midline. The trachea was identified and followed inferiorly. In the upper mediastinum several lymph nodes were encountered and these were removed together counting numbers 45. The telescope was brought in for mediastinoscopy and no other lymph nodes were identified and the innominate artery was at the bottom of the dissection.

The strap muscles were then lifted off of the left neck and the carotid artery was identified. Dissection proceeded deep to the carotid artery and the recurrent laryngeal nerve was identified as was the vagus nerve. 2-3 lymph nodes were identified in this position of the low level IV and these were circumferentially dissected and sent to pathology. There is minimal bleeding. All pathology came back as reactive lymph nodes. The neck was copiously irrigated with saline and FloSeal was placed in the wound. The neck was then closed with interrupted 3?0 Vicryls sutures and Dermabond. She was returned to anesthesia where she was extubated without difficulty and return to the PACU in stable condition..