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Thread: OPERATION: Video assisted thoracic surgery with drainage of loculations, lysis of

  1. #1

    Default OPERATION: Video assisted thoracic surgery with drainage of loculations, lysis of

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    Can someone please help me with this operative note? The doctor reported CPT code 32651, and I do not believe this is correct. I do not see where any agents were introduced into the lung, it reads that the loculations were broken up with a sterile glove finger. Plus the two chest tubes, can both be coded?

    PREOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.

    POSTOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.

    OPERATION: Video assisted thoracic surgery with drainage of loculations, lysis of
    adhesions and placement of large bore chest tubes.

    ANESTHESIA: General by IV and double lumen endotracheal tube.

    PROCEDURE AND FINDINGS: The patient was brought to the Operating Room, properly
    identified. He was already intubated because of respiratory failure in the ICU. The
    preoperative diagnosis, procedure and site were confirmed on time out. The patient was
    already on IV antibiotics. He had sequential TEDs placed and a Foley already in place. He
    had exchange of the single lumen tube for a double lumen endotracheal tube by Anesthesia
    Department. He was then placed in a right lateral decubitus position with the left side
    up. Beanbag was used for stabilization. Care was taken regarding his pressure points. The
    left arm was out on an arm retractor. The left chest wall was then prepped with
    ChloraPrep per protocol and draped applied. Incision was made at the fifth interspace at
    the anterior axillary line and carried down sharply with electrocautery and the pleural
    space was entered with a Kelly and then gloved finger. Adhesions and loculations were
    broken up with sterile gloved finger and then the trocar was inserted. Smelly, blood
    tinged, cloudy fluid was suctioned and placed into containers for cytology, fluid
    analysis and cultures. Further suctioning was done until at least a liter or more of
    fluid was obtained. Two additional trocars were then inserted under direct vision of the
    thoracoscope. There were multiple areas of loculations and fibrinous exudate. These were
    all carefully lysed until at the end there were no other pockets or loculations noted.
    The entire chest cavity appeared to be communicating. There was no obvious sign of tumor
    and no other biopsies were performed. The chest was then irrigated with saline and
    suctioned dry and two 36 French tubes were inserted through the two more anterior trocar
    sites and directed posterior and superiorly and more medially and superiorly. The
    thoracoscope was then left in long enough just to see that the lung was expanding nicely.
    The chest tubes were secured to the skin with two heavy silk sutures each and the other
    trocar site was closed using 0 Vicryl to the intercostal muscle and to the chest wall
    muscles with 3-0 Vicryl to the sub-cu and then 4-0 Monocryl and Steri-Strips to the skin.
    Dressings were then applied and taped in place and the chest tubes were attached to two
    separate Thora-Klex systems. He tolerated the procedure well and afterwards was changed
    to a supine position and the double lumen tube was again exchanged to a single lumen by
    Anesthesia Department.

    He left the Operating Room in stable condition being ventilated manually to return to the
    ICU to continue on the ventilator.

  2. #2



    Well, decortications are performed for empyema but the surgeon's documentation does not make it clear that that is what he did. He didn't describe actually removing a "peel" off of the lung (and, for that matter, how much of the lung - partial vs total). It sounds more like he cleaned out the pleural space.

    Based on this documentation, I would bill CPT 32653. You cannot bill separately for the chest tubes (these are placed at the end of all thoracic procedures).

    Lisi, CPC

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