thorascopy converted to open procedure


Cleveland, OH
Best answers
Help! CPT code for thoracotomy for control of bleed? 32110 or 32120? Anything? 32560 or 32650 for talc pleurodesis? Thanks!:)

Procedure: Right VATS, pleural biopsies, converted to open thoracotomy for
control of bleed, talc pleurodesis, flexible bronchoscopy

Pre-op diagnosis: Right effusion, multiple pleural-based and lung nodules

Post-op diagnosis: same, frozen section probable malignancy

Findings: diffuse studding of the parietal and visceral pleurae, multiple small
pulmonary nodules

Operative report:
After satisfactory double-lumen endotracheal anesthesia, the patient was
bronchoscoped; no endobronchial pathology found. The patient was then placed in
the left lateral decubitus position and prepped and draped as per routine.
Through a port placed in the right mid-axillary line, 5th interspace, the pleura
was enterd and felt to be diffusely studded. The camera port was then placed in
the 8th interspace. 350 cc serous fluid was encountered and sent for cytology
and culture.There was diffuse studding of the visceral and parietal pleura and
several 1-3 cm nodules over the esophagus,although the esophagus did not appear
to be involved. Using the endoscissors, one of the pleural nodules was excised
and sent for frozen section. The pathologist could not make a diagnosis of
malignancy, but felt that it was very suspicious, so further samples were taken
and sent fresh for various tumor markers. During biopsy of one of the nodules, a
chest wall vein was torn, requiring 5th interspace thoracotomy for suture control
Multiple other nodules were noted and biopsies taken, a sample of a
middle lobe nodule was also taken using the endogia stapler, all were sent
fresh. Talc was then insufflated over the visceral pleura, a #36 chest tube
placed through the camera port and 1 liter of warm saline instilled and the lung
re-expanded. The thoracotomy incision was closed with four #2 vicryl pericostal
sutures, 10 cc of 0.5% marcaine injected into the 4th, fifth and sixth
interspaces posterior to the incision, muscle closed with 0 vicryl, 2-0 and 4-0
vicryl for subq and skin. Sponge, needle and instrument counts were reported as
correct, and the patient was taken to PACU after dressings were applied and the
patient was extubated. The findings were reported and discussed with the family.
I would not use 32120 because the tear happend during the biopsy so that would not meet 'postoperative complications.' I would use CPT 32110.

The correct code for the pleurodesis the way it was done is 32560 (since the procedure had already been converted to open) but you can't bill 32110 and 32560 together per CCI. You can bill 32110 and 32650. Not sure I would bill the 32650 here since, again, the procedure had already been converted to open.

Per CPT assistant: when a thorascopic procedure is aborted due to problems and conversion to an open thoracotomy is necessary, the open procedure is reported on the first and then the thorascopic with a -52 as the second procedure. This applies to Private Payors only...Medicare you can only bill the open.
I talked this over with my fellow surgery coders. Think all procedures likely done endoscopically with exception of thoractomy for control of bleed. I queried physician concerning this, no response. 32110 seems too extensive for what was done per coder's desk reference. Also, don't feel quite fits the intended meaning of traumatic. Perhaps CPT code like 35216 more appropriate. However, decided intraoperative control of bleed not separately reportable. I went with 32650 for surgical thorascopy with pleurodesis along with 31622 for the bronchoscopy. The biopsies bundled. I added diagnosis code 998.2 for the tear. Thanks for the input.