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Thread: Opinions, wedge resection or not?

  1. #1
    Join Date
    Apr 2007

    Question Opinions, wedge resection or not?

    AAPC: Back to School
    This is from the header of the note

    PROCEDURE: Coronary artery bypass x3, left internal mammary
    artery to left anterior descending anastomosis, saphenous to PLA
    anastomosis, radial to OM1 anastomosis, left minimally invasive
    radial artery harvest, right endoscopic saphenous vein harvest,
    left upper lobe wedge lung biopsy of small pulmonary nodule,
    right lower lobe wedge biopsy of small pulmonary nodule.

    This is from the body of the op report itself

    The chest was
    entered through a midline sternotomy and the left internal
    mammary artery harvested in the usual manner. The left internal
    mammary artery was harvested from the level of the subclavian
    vein and extended down past the bifurcation of the IMA. The
    distal limb was left intact at this point and the pedicle was
    wrapped in a papaverine-soaked sponge. The left lung was
    palpated and inspected and explored for nodules that had been
    identified on prior CT scans. A small left upper lobe pulmonary
    nodule was identified. Additionally, the pleural surface had a
    mildly irregular nodular appearance and biopsy was then
    performed. A small nodule was grasped with ring forceps along
    the free margin of the lung and using two firings of an Endo-GIA
    stapler, a wedge biopsy was performed. The specimen sent to pathology for permanent section analysis. Next, an Ankeney
    retractor was placed in the chest and the mediastinum exposed.
    The thymic fat pad was incised at the level innominate vein and
    the pericardium opened just to right of midline and T'd off at
    the diaphragm and then suspended using six pericardial stay
    stitches to create a pericardial well. The right pleural space
    was entered and the right lung explored and an additional
    pulmonary nodule that had been identified on prior CT scan was
    identified and grasped with ring forceps along the free margin of
    the lung and an additional biopsy taken using 3 firings of an
    Endo-GIA stapler. Additionally, the right lung did appear to
    have a similar slightly irregular nodular appearance of the
    pleural surface. Specimen was sent to pathology for permanent
    section analysis.

    The procedure in question is 32500, is it supported or not?


    Laura, CPC, CPMA, CEMC

  2. #2

    Thumbs up

    I read the CDR description and with this op report note I would be confident in saying that the 32500 is supported.

    Christina Musser, CPC

  3. #3
    Join Date
    Apr 2007


    Thank you for your response.

    I agree completely.

    Laura, CPC, CPMA, CEMC

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