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Thread: Need help with Op Note

  1. #1

    Default Need help with Op Note

    AAPC: Back to School
    My provider and I have chosen different codes for the procedure below. Can someone please review this op note and let me know your opinion on the codes:

    1. Resection of the right cervical rib
    2. Right middle scalenectomy.

    Procedure detail:
    The right neck was prepped and draped in usual fashion and a curvilinear incision was made along the lateral aspect of the sternocleidomastoid. The sternocleidomastoid was retracted medially and dissection carried down to the omohyoid which was dissected up and retracted inferiorly. The scalene fat pad was mobilized and a portion of it was removed and the exposure of the roots of the brachial plexus and the anterior and middle and posterior scalene muscle was accomplished as well the phrenic nerve. The phrenic nerve was identified and preserved throughout the procedure. A portion of the anterior scalene was divided using bipolar cautery and the procedure was accomplished under 3x magnification to gain further exposure, as the anterior scalene appeared somewhat enlarged. There were no particularly unusual bands in this muscle and it was nice and soft and not impinging on the plexus. Further dissection freeing up the plexus allowed mobilization of that and exposure of the middle scalene muscle and the cervical rib was exposed after taking down the proximal portion of the middle scalene. The midportion of the middle scalene contained multiple abnormal fibrous bands and these were divided and a portion of the scalene resected using bipolar cautery with particular care to avoid stretch for injury to the plexus. The rib was then resected by elevating the periosteum and dividing the fibrous bands extending from its tip and was resected using the Carrington rongeurs and retraction to protect the brachial plexus. At this point, hemostasis was achieved and application of Arista and direct pressure on the stump of the cervical rib and the plexus was then found to be nice and mobile and not impinged upon by any further identifiable bands or bony structures. The wound was then closed by closing the platysma with running 3-0 Vicryl and the skin with subcuticular 4-0 Monocryl.

    The procedure was coded as 21705; however the provider feels that codes 21615 and 21556 are better codes for the procedure.

    Thank you in advance for any help with this.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default 21705

    This is NOT my area of expertise, but I agree with 21705. I don't see any evidence to support 21556. And I'm not certain that he removed the entire 1st rib.

    Here's the lay description from Encoder Pro ...
    21705 - Division of scalenus anticus; with resection of cervical rib
    The physician performs a surgical procedure where the scalenus anticus muscle is divided, usually for the purpose of treating thoracic outlet syndrome. With the patient under anesthesia, the physician makes an incision overlying the scalene muscle. This incision is carried deep to the muscle. The muscle is exposed and identified. A discission of the muscle is performed in line of the fibers. This relieves the pressure on the neurovascular structures. The wound is irrigated and closed in layers. Report 21700 if the procedure does not include resection of the cervical rib. Report 21705 if resection of the cervical rib is performed during the procedure.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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