Wiki Thoracotomy - need help

[ksrkelly7]

Hi there,

Any help I can get on this OP report would be greatly appreciated. I'm thinking 32098 but not sure there should be an additional code.

Thanks so much!

Kelly - CPC


Indication for Surgery
ESOPHAGEAL PERFORATION

Preoperative Diagnosis
ESOPHAGEAL PERFORATION

Postoperative Diagnosis
ESOPHAGEAL PERFORATION

Operation
RIGHT THORACOTOMY, DRAINAGE OD ESOPHAGEAL PERFORATION, POSTERIOR MEDIASTINUM

Estimated Blood Loss
50CC

Findings
50CC SEROUS PLEURAL FLUID
NORMAL APPEARING LUNG WITH COMPLETE FISSURES
SEROSANGINOUS FLUID IN PARAESOPHAGEAL TISSUES

Specimen(s)
AEROBIC AND ANAEROBIC CULTURES OF PARAESOPHAGEAL FLUID

Complications
NONE

Technique
PATIENT TAKEN TO THE OPERATING ROOM AND INTUBATED WITH SINGLE LUMEN ENDOTRACHEAL TUBE DUE TO INABILITY TO PLACE DOUBLE LUMEN TUBE.
PATIENT PLACED IN LEFT LATERAL DECUBITUS POSITION. RIGHT CHEST PREPPED AND DRAPED IN USUAL STERILE FASHION.
PROPHYLACTIC ANTIBIOTICS ADMINISTERED.
RIGHT AXILLARY THORACOTOMY PERFORMED IN THE 4TH INTERCOSTAL SPACE.
50CC SEROUS FLUID EVACUATED FROM RIGHT PLEURAL SPACE. RIGHT LUNG RETRACTED ANTERIORLY TO PROVIDE EXPOSURE TO THE POSTERIOR MEDIASTINUM. THE PARIETAL PLEURA OVER THE ESOPHAGUS WAS INCISED SUPERIOR TO THE AZYGOS VEIN.
ESOPHAGUS IDENTIFIED AND EXAMINED , NO OBVIOUS PERFORATION VISUALIZED. SEROSANGINOUS FLUID IN PARAESOPHAGEAL TISSUES, CULTURES
LIMITED MOBILIZATION OF THE ESOPHAGUS PERFORMED.
PARIETAL PLEURA OVER THE ESOPHAGUS INFERIOR TO THE AZYGOS VEIN WIDELY INCISED. 28FR. CHANNEL DRAIN TUNNELED FROM INFERIOR PLEURAL SPACE AND PLACED ADJACENT TO THE ESOPHAGUS. THE PARIETAL PLEURA WAS LOOSELY APPROXIMATED OVER THE TUBE TO HOLD IT IN PLACE.
A 32FR. STRAIGHT PLEURAL TUBE WAS TUNNELED AND PLACED POSTERIORLY IN PLEURAL SPACE. THE TUBE WAS SEWN IN PLACE.
ADEQUATE HEMOSTASIS WAS OBTAINED USING ELECTROCAUTERY.
#1 VICRYL PERICOSTAL SUTURES WERE USED TO REAPPROXIMATED THE RIBS.
THE INCISION WAS CLOSED IN LAYERS AND SKIN CLOSED WITH RUNNING SUBCUTICULAR STITCH WITH 3-0 MONOCRYL
THE TUBES WERE CONNECTED TO 15CM OF H2O SUCTION.
STERILE DRESSING APPLIED
PATIENT TRANSFERRED TO ICU IN STABLE CONDITION
SPONGE AND NEEDLE COUNTS CORRECT AT COMPLETION OF PROCEDURE
NO COMPLICATIONS


Surgical Sweep Complete (Yes/No/Not Applicable)

 

[dvance4210]

Hi Kelly, I think your on the right track but I didn't read where he actually took a sample of the lung/pleural tissue. Yes, he did drain pleural fluid but I not actually sample the pleura. I would look at 32100 since it looks like was looking for an esophageal tear/bleed somewhere.

Hope this helps!

Dorinda V., CPC, CCVTC

 

[ksrkelly7]

Hi Kelly, I think your on the right track but I didn't read where he actually took a sample of the lung/pleural tissue. Yes, he did drain pleural fluid but I not actually sample the pleura. I would look at 32100 since it looks like was looking for an esophageal tear/bleed somewhere.

Hope this helps!

Dorinda V., CPC, CCVTC

Thanks for your response Dorinda! I also was now questioning CPT 39010. The mediastinum was incised and drained. What are your thoughts? Really appreciate your expertise!

Kelly C, CPC

 

[mmholly1231]

I would agree with Dorinda, the 32100 seems most appropriate. I would not select the 39010 because that's not what the doctor did. His approach was a thoracotomy not through the mediastinum..

-Melissa Holly, CPC, CCVTC