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Exploration Post Op left Open

  1. #1
    Default Exploration Post Op left Open
    Medical Coding Books
    Hello ~ Does anyone have any suggestions how to code this? Post CABG the mediastinum was left open and the next day the patient becomes unstable, so they return him to the OR (mediastinum already open) find evidence of a blood clot lavauge the mediastinum and replace new chest tubes.

    Thank you for any help,

  2. #2
    Richardson, TX
    What about 35820? Or 39010. I thought about 21627 but that is sternal debridement and this is the mediastinum.

    It would have been easy had he done this before the patient left O.R. - not billable.

    Anyone else have an idea? I'm open to suggestions or correction
    Julie Graham, BA, CPC, CCC

  3. Default
    I would bill 35820-78. If they were taking him back to just close the chest, I would have billed 21750-58. In fact, if the chest IS still open & there are planning to bring the patient back to the OR again to close it, bill 21750-58 at that time.

    Lisi, CPC

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