1. Right lateral thoracotomy.
2. Wedge resection of the right lower lobe.
3. Incisional biopsy, right mediastinal mass.
Description Of Procedure: After general endotracheal anesthesia was performed, she was prepped and draped in usal sterile fashion. A lateral thoracotomy incision was made and carried down to the fifth interspace where abouve findings were noted. The mass was not well circumcised and appeared to be somewhat infiltrative, extending across the midline, but not involving her heart. It did involve her diaphragm. Frozen section revealed adenocarcinoma. The diaphragm was closed with double layer of #1 Prolene running sutures. There was a small 4-mm granuloma-type mass in her right lower lobe, which was biopsied and sent for permanent section. With 2 separate stab incisions, 32-French chest tubes were in place and secured with 0 silk suture. The ribs were reapproximated with #2 figure-of-eight Vicryl suture, muscle layers with #1 Vicryl, deep subcutaneous tissue with 0 Vicryl, and skin with running 4-0 Monocry. Sponge count and needle count were correct.
I have coded this as 32500 is this the only procedure code I can bill?
I appreciate all the help.
I don't think the note is the greatest. The surgeon wrote that, "There was a small 4-mm granuloma-type mass in her right lower lobe, which was biopsied and sent for permanent section." but he/she didn't write how that biopsy was done - in other words, it doesn't say a "wedge resection" was performed. If its definitely a wedge, yes I would code 32500.
As far as the mass extending into the diaphragm, again, I'm not clear on how far it went into the diaphragm and how much of the diaphragm was excised/resected. I would think you could probably bill 39220 though.
I haven't checked these in CCI but I don't think they bundle.