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A little rusty, looking for a study teacher to help me pass the 1st time around test

I live in the Amherst, OH area and I am looking for someone to help me study with before signing up for the CPC coding exam. I want to pass it the first time around. I completed my online course with Penn Foster 3-4 months ago and I am a tad rusty. I did purchase the test questions through AAPC, but I am willing to pay if someone that has been in my shoes and is now a coder can help me out and be my study partner to help me pass the first time around would be awesome.
Thanks in advance

Medical Billing and Coding Forum

Rusty and need help…please!

Hi there

Three years away from CT surgery and I am rusty! It’s coming back but I feel ‘off’ on this report. I’m not sure about the 19271 and I feel 32507 is wrong because doc states chest wall tumor and resection. I would really appreciate some help and feedback on this.

19271
32220
32480
32507? or 32505
39401

Right LL cancer – C34.31

Patient has Medicare so I did not bill for thoracoscopy since doc converted to thoracotomy and if I remember correctly, MC won’t pay for that; they will pay for the open procedure only.

Mediastinoscopy with multiple mediastinal biopsies.
2. Right thoracoscopy with lysis of adhesion.
3. Right thoracotomy with complete decortication of right lung.
4. Right lower lobectomy.
5. Wedge resection, right middle lobe.
6. Resection of chest wall tumor with neurovascular identification and preservation and reconstruction of chest wall.

BRIEF OPERATIVE REPORT:
Following delivery into the operating room and placement in a supine position on the operating table and successful induction
of general anesthesia with placement of an endotracheal tube by the anesthesiologist, the appropriate monitoring devices were
established and the patient was positioned in the mediastinoscopy osition and his neck and anterior chest were prepped and draped in the usual sterile manner. The skin incision was made 2 fingerbreadths above the sternal notch using a #10 scalpel to cut down through the skin, and subcutaneous tissues were divided using electrocautery in a coagulating mode until the anterior mediastinum was entered. The anterior mediastinum was entered using blunt finger dissection and the mediastinoscope was inserted. The mediastinal nodes were removed and sampled and sent to Pathology from level 7, level 4R, level 4 L, and level 2L lymph node stations. All frozen sections from the biopsies of the mediastinal nodes were negative. Hemostasis was demonstrated and the wound was closed with 2 layers of 2-0 Vicryl followed by a running 4-0 Monocryl skin closure followed by Steri-Strips and clean sterile dressings. The patient was then repositioned in the lateral thoracotomy position with the right chest up. The patient’s chest was reprepped and draped in the usual sterile manner and a skin incision was made in the 8th interspace using a #10 scalpel to cut down through the skin, and subcutaneous tissues were divided using electrocautery in a coagulating mode until the pleural cavity was reached and entered. The thoracoscope was inserted. There were some adhesions of the lung to the chest wall, which were able to be lysed thoracoscopically; however, the tumor itself was large and adherent to the chest wall and it was felt that a thoracotomy incision was warranted. Thus, a thoracotomy incision was made using a #10 scalpel to cut down through the skin, and subcutaneous tissues were divided using electrocautery in a coagulating mode until the pleural cavity was reached and entered. A chest retractor was placed. The tumor was able to be removed away from the chest wall chest wall, and the chest wall where it was attached to was resected under direct vision after the neurovascular bundle was identified and preserved. The specimen of the chest wall was sent to Pathology. The resected site of the chest wall was repaired using silk sutures.

Then, attention was directed towards doing a right lower lobectomy and control of the vasculature on the bronchial stumps
was obtained using multiple firings the Power-Echelon stapling device. The lower lobectomy was performed. The tumor itself was also adherent very closely to the middle lobe. It did not appear to be grossly involving the middle lobe; however, it was very close to it. The staple line was at that junction and thus it was decided to do a wedge resection of the middle lobe at this area as well. This was performed without difficulty and hemostasis was demonstrated. The lung was inspected where the
decortication had been performed. The decortication was performed when we first entered. Complete decortication of the
entire right lung had been performed because there was a reactive peel encasing and involving the lung. This was very filmy in nature and a small piece of it was able to be obtained and sent to Pathology. The remainder was able to be disrupted without difficulty, but great care was taken to avoid injury to the underlying lung parenchyma. Hemostasis was again demonstrated upon completion of the case and air leak was checked for and none was visible. A #36 straight chest tube was inserted under direct vision and secured using a pursestring and stay suture. The ribs were approximated with multiple #1 Ethibonds in a figure-of-eight fashion. The fascial and muscle layers were approximated with multiple layers of 0 Vicryl followed by 2-0 Vicryl followed by a running 4-0 Monocryl skin closure followed by Steri-Strips and clean sterile dressings. Needle, sponge, and instrument counts were correct for all aspects of the operation. The patient tolerated the procedure and was to be delivered to the Postanesthesia Care Unit on the way to the Intensive Care Unit in stable condition. The estimated blood loss was less than 10 mL, and there was no blood or blood products required for transfusion Intraoperatively.

Medical Billing and Coding Forum

Rusty on CT surgery

OPERATIONS:
1. Mediastinoscopy.
2. Left thoracotomy.
3. Left lower lobectomy.
4. Resection of chest wall mass.

DESCRIPTION OF PROCEDURE: While in supine position, the neck was extended. The anterior neck was
prepared with ChloraPrep solution and draped in a sterile manner with sterile linens and towels.
A small transverse neck incision was made and taken down through the soft tissues utilizing electrocautery
for hemostasis. Pretracheal fascia was encountered and a blunt passageway was directed into the
superior mediastinum.

Afterwards, the mediastinoscope was inserted and continued dissection to remove lymph nodes. These
were resected and sent to pathology. Frozen section analysis revealed benign nodes. In the process of
the blunt dissection, a pericardial cyst was ruptured draining clear watery fluid. Once good hemostasis
and dryness was noted within the mediastinal space, the scope was removed and the neck tissues were
closed with interrupted sutures of 3‐0 Vicryl. The skin margin was approximated with a running
subcuticular stitch of 4‐0 Vicryl.

Patient was turned to the right lateral decubitus position. The anterior left chest was prepared with
ChloraPrep solution and draped in a sterile manner with sterile linens and towels. A small curvilinear
lateral thoracotomy incision was made and taken down through the soft tissues utilizing electrocautery
for hemostasis and as a muscle sparing incision. Dissection revealed a soft tissue mass directly beneath
and adjacent to the scapula. The mass was white in color with cystic pockets. The mass was excised and
frozen section analysis revealed benign fibro‐elastoma. The sixth intercostal space was entered with
severance of the posterior to prevent rib fractures and stretching of the intercostal nerves.
Examination of the left pleural space revealed a very large hiatal hernia with an intact hernia sac
compressing the lower lobe. The patient was placed in Trendelenburg position to assist in reducing the
effect of the hiatal hernia. No attempt to repair the hiatal hernia.

Hilar blunt dissection was undertaken to release the pleura. The inferior pulmonary ligament was taken
down to expose the inferior pulmonary vein. Several nodes were submitted to pathology and found
negative for tumor, including the carinal node. The major fissure was entered and bluntly dissected to
expose the pulmonary artery. Branches to the upper lobe were identified isolating them from those of
the lower lobe. Utilizing vascular stapling devices, the pulmonary structures to the lower lobe were
stapled and divided. Afterwards, the inferior pulmonary vein was divided with a TA vascular stapler. The
bronchus was mobilized to sweep the lymph nodes to the specimen. The TA stapling device was placed
across the lower lobe bronchus. Compression was applied and the lung was inflated. Only the upper lobe
inflated signifying correct application of the bronchial stapler. The bronchial stapler was deployed and
the bronchus was sharply severed with removal of the specimen from the wound. Bronchial margins
reported as clear of tumor.

The left pleural space was irrigated with warm saline solution while the bronchial stump was under water.
Anesthesia applied 40 cm of sustained pressure to the lung and no air leak was demonstrated. Good
expansion of the left upper lobe was identified.

Two 28‐French chest tubes were placed into the chest and brought through separate stab incisions. These
chest tubes were secured with 0 silk sutures. The seventh rib was reapproximated and fixed with a
titanium plate. Afterwards, intercostal space was approximated with several interrupted sutures of #2
Vicryl. The soft tissues were approximated with running sutures of 0 and 2‐0 Vicryl. The skin margin was
approximated with a running subcuticular stitch of 4 0 Monocryl.

The patient tolerated the procedure well. He was extubated and taken to the PACU in stable
hemodynamics and breathing well.

Am I on the right track here?

CPT 32480-LT; 39402 ( or should I use 38746 I don’t see at least 4nodes removed); 19260-52 (no ribs removed-can or should I use the modifier 52?) or 21555 (no documentation of size i.e. 3cm). STS states that when no ribs are removed to use either 21555-21557.

Medical Billing and Coding Forum