Wiki Thoracotomy with decortication and drainage pleural space

drhoads

Guru
Messages
112
Location
Annville, PA
Best answers
0
Please help in coding op report.

Procedure Performed:

Left thoracotomy with decortication and drainage of left pleural space and placement of chest tubes.

Description of Procedure:

A small posterolateral thoracotomy incision was performed just below the tip of the scapula. The was carried down to the level of the ribs with bovie electrocautery and the thorax was enter in the six inner space on top of the seventh rib. The thorax was significantly full of a jell-like and clear substance. Multiple cultures were sent of the material. The thoracic space was than decorticated of the vast majority of this material. As much peel as could be extracted for the surface of the lung was done. Expansion fo the lung at this point revealed that it filled pretty much the entire thoracic space on the left side without complication. There were no significant air leaks. Two chest tubes were then placed in the anterior and diaphragmatic positions. The ribs were then reapproximated with heavy Vicryl sutures and the chest was closed in layers with 0 Vicryl for the musculofascial layer, 2-0 Vicryl for the subcutaneous fiscial layer and 4-0 Monocryl stitches for the skin.
 
The note isn't the best because it is not clear if the surgeon decorticated the entire lung or just a portion of it. If it was my physician, I would have him clarify this in the note. I suspect this was a full decortication so the code would be 32220. Neither the drainage nor placement of chest tubes are separately billable.

Lisi, CPC
eharkler@nmh.org
 
Top