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Vats/thoracoscopy help

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Procedure:
1. Diagnostic video thoracoscopy, Left
2. Thoracotomy, Left
3. Left lower lobe lung biopsy
4. Left pleural biopsy



Indications:
Mrs. who presented to this week with ongoing fatigue and shortness of breath. Chest imaging was concerning for complex pleural effusion versus left empyema. For these reasons, she was consented and brought to the operating room for the aforementioned procedures.

Anesthesia:
General

Estimated Blood Loss:
25 mL

Wound Classification:
Clean

Findings:
Contained bloody pleural effusion in the inferio-medial left hemithorax. No pus or sign of active infection. The was fused to the chest wall with distinct nodularity at the lung and chest wall border. The lung was not expanding well. A wedge biopsy of the left lower lobe proceeded, as did a biopsy one of the pleural based nodules.

Specimens:
1. Left lower lobe, lung, biopsy
2. Left pleural fluid for culture
3. Left pleural fluid for cytology
4. Left pleural biopsy

Procedure Details:
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.

Next, an approximately 1cm skin incision was made overlying the 8th interspace in the anterior axillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. A large walled-off fluid collection was entered. This fluid was bloody. There was no gross appearance of infection. The fluid was suctioned clear; some of which was passed off the field for culture and some for cytology. The lower lobe of the lung in several areas was adhesed to the chest wall with distinct nodularity. At this point, the decision was made to convert to a mini-thoracotomy.

The 8th interspace incision was extended and dissection carried down to the chest wall with bovie electrocautery. The interspace was developed and the hemithorax inspected. An area of the basilar segment of the lower lobe was fused to the Diaphragm and chest wall. This was resected with a 60mm endo-GIA linear cutting stapler purple tri-stapler load. Additional nodularity of the chest wall was appreciated in this area. A nodule was biopsied with a biopsy forceps and passed of the field as well. Given the fused nature of remaining portion of the lung, the decision was made end the procedure. A 32 Fr curved chest tube and 24 Fr Blake drain were placed within the pleural cavity and the lung re-expanded. The lower lobe failed to fully inflate. Hemostasis was verified.

The interspace was re-approximated with No. 2 Vicryl. All skin incisions were closed in layers with 0 and 2-0 Vicryl. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. At this stage, the procedure was discontinued. The patient was delivered from anesthesia, but remained intubated and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.
 

dvance4210

Networker
Messages
90
Location
Columbus, Ohio
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Hi TWilliam2019,

Just saw this post. These are always a little tricky.

TIP: First he started as a VATS, then converted to thoracotomy. Add your Z53.32 to your diagnosis, this way if you have combination CPT codes of VATS and thoracotomy that you bill out it explains why you used different approach codes.

There isn't a real code for drainage of the pleural fluid as the VATS other than your 32601 code. So I would use the wedge resection of the nodule(s) done as a thoracotomy which would be 32097 (can only be used once per lung). There is no mention of attention to margins, which would qualify for the 32505-per STS coding workshop should only be used when a wedge is done and they have clear margins. Physicians always want to use the 32505 b/c RVU are higher

On 32097 there are no global days attached to this, so you can bill subsequent hospital days along with post op visit in the office.

So in a nutshell.... J90, R91.1 or R91.8, Z53.32 with 32097

HTH,
DVance, CPC, CCVTC
 
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