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Pericardial & pleural effusion drainage via VATS

  1. Default Pericardial & pleural effusion drainage via VATS
    Medical Coding Books
    Overview of op report.
    Two stab incisions, entered pleural space and easily drained 500 cc of fluid, sent for culture. Using other insicion, retraction of lung was done, we had difficulty with double-lumen tube which made thoracoscopic exam very difficult. Third incision made anteriorly and direct visula identification of pericardium. Once pleural effusion completely drained, pleural space inspected. No biopsy. Evidentally able to dissect some pericardial fat away, identify lateral pericardium beneath phrenic nerve. I grasped the pericardium and mad an incision into it and drained fluid. Once drained, a 19 Blake drain was inserted thru separate stab incision. A 28 chest tube was brought through separate incision into posterior lateral pleural cavity.
    All incisions closed with deep suture of Vicryl and skin with subcuticular stitch.

    I cannot find a code for pleural and pericardial effusion drainage via VATS. I believe everything else will be inclusive.
    Thanks for any help.

  2. #2
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    Default
    Quote Originally Posted by Licorice5 View Post
    Overview of op report.
    Two stab incisions, entered pleural space and easily drained 500 cc of fluid, sent for culture. Using other insicion, retraction of lung was done, we had difficulty with double-lumen tube which made thoracoscopic exam very difficult. Third incision made anteriorly and direct visula identification of pericardium. Once pleural effusion completely drained, pleural space inspected. No biopsy. Evidentally able to dissect some pericardial fat away, identify lateral pericardium beneath phrenic nerve. I grasped the pericardium and mad an incision into it and drained fluid. Once drained, a 19 Blake drain was inserted thru separate stab incision. A 28 chest tube was brought through separate incision into posterior lateral pleural cavity.
    All incisions closed with deep suture of Vicryl and skin with subcuticular stitch.

    I cannot find a code for pleural and pericardial effusion drainage via VATS. I believe everything else will be inclusive.
    Thanks for any help.
    What about 32601? That's a diagnostic code and no biopsy performed.
    Julie Graham, BA, CPC, CCC

  3. Default
    32601 description doesn't say anything about pleural or pericardial drainage which is the only reason I believe there should be a better code. The chest tube for this code is the standard chest tube inserted for all VATS procedures.

    32659 is the code I believe should be used for the pericardial drainage but I am now wondering if I should add -22 for increased service or if there is another VATS code I should use for the pleural drainage. Separate stab incisions were made for these procedures.
    Last edited by Licorice5; 02-13-2012 at 02:07 PM.

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