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Boerhaave's w/intrapleural contamination

  1. Default Boerhaave's w/intrapleural contamination
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    I don't see this everyday and need some help with the CPT coding. Here is the procedure discription from the doc's op note:

    DESCRIPTION OF PROCEDURE(S): The patient was taken emergently to the operating room and induced via general endotracheal anesthesia. Prepped and draped in sterile fashion. She was placed in the lateral decubitus position with the left side up after a double lumen endotracheal tube was placed. A generous posterolateral 7th interspace incision was made. Before a retractor was placed I prepared the intercostal muscle bundle preserving the neurovascular bundle. The above findings were noted. It took quite a while to get all the debris out of the chest cavity, but we irrigated with 5-7 L of saline subsequent to that and encountered food particles as described above.

    We followed the mediastinal tear down to the esophageal tear noting that it was about 4.5 cm in length, 3 cm proximal to the gastroesophageal junction. All the gastric contents were removed. As we tried to close the tear repeated boluses of gastric content were brought out into the operative field. The ____ port used to suck the stomach out along with a nasogastric tube, but the nasogastric tube had a difficult time getting it sucked out because it was very particulate. After the stomach was empty and again the field was completely removed of debris, 3-0 Vicryl was used in a running fashion to close the mucosal layer over the NG tube being careful not to pull the mucosal layer up too tight to narrow it. A 4-0 Prolene running suture was then used to close the muscle layer. The intercostal muscle was generous length. It was taken almost completely posteriorly to where it laid nicely against the posterior chest wall draped up over the aorta and cut to the appropriate length to just lie directly over the repair. This was sutured with 4-0 Prolene circumferentially. The pleura was then closed over this so as not to compromise the vascular supply. When I did cut the end of the muscle bundle
    there was bright red arterial bleeding coming from the muscle itself.

    Subsequent to all of this the pleural space in the operative area was irrigated with copious amounts of saline once again, as was the subcutaneous tissue. Two large 34 chest tubes were placed, 1 angled in the gutter and 1 straight slightly more superiorly. Multiple #2 pericostal sutures were placed to reapproximate the ribs. Using a neurovascular sparring technique the muscle, subcutaneous and skin layers were closed in routine fashion. At the end of the procedure the sponge, needle, and instrument counts reported as correct.

    Please help.

  2. #2
    Fayetteville, NC
    Have you looked at 43310, 43312, 43313, or 43314?
    I see some of the elements of this surgery in those codes but 43313-43314 is for repair of a congenital defect so you would need to know how the tears came about. Were they the result of an accident during another procedure or did they just tear without outside cause.
    Of course I could be way off....This is one is difficult
    A. McCormick, CPC, CGSC
    Walters Surgical Associates

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