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Tag Archives: thoracotomy

mini thoracotomy

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Procedure:
1. Video thoracoscopy with mini-thoracotomy, Left
2. Left lung biopsy
3. Left pleural biopsy
4. Mediastinal lymph node dissection, Left

32609
32674
vs
32097
38746
vats are my weakness

Indications:
Mr. patient is a 75 y/o gentleman w/ a hx/o CAD s/p CABG and remote hx/o tobacco abuse. He was referred following the discovery of a PET-Avid left upper lobe lung mass on imaging. Staging mediastinoscopy was performed which was negative. He was subsequently consented and brought to the operating room for biopsy and attempted resection.
*
Anesthesia:
General
*
Estimated Blood Loss:
25*mL
*
Wound Classification:
Clean
*
Findings:
A large hilar mass extending from the hilum and into the pericardium was present along the anterior/lateral border of the pulmonary artery. The patient’s pericardium was fused directly to the surface of the heart. The tumor was deemed non-resectable. Biopsy returned positive for NSCLC on frozen section.
*
Specimens:
1. 1 Level 5 lymph node
2. 1 Level 11 L lymph node
3. Pleural biopsy, left
4. Hilar mass, left
5. Left upper lobe lung mass
*
Procedure Details:*
The patient had their history and physical updated prior to the procedure. They were then transferred to the operating suite and placed on the operating table where general anesthesia with endotracheal intubation was affected. Monitoring lines were placed by anesthesia. *Next, the patient was intubated with a dual-lumen endotracheal tube by the anesthesia team. The patient was then repositioned in the right lateral decubitus position with their left side up. The left chest was then prepped and draped in the usual sterile fashion. A surgical time-out was then performed to confirm patient identity, laterality, as well as the surgery to be performed.
*
Next, an approximately 1cm skin incision was made overlying the 5th interspace anterior to the midaxillary line. Dissection was carried down through subcutaneous tissues with electrocautery. Lung isolation was verified with anesthesia. The pleural cavity was then entered. A utility incision was made overlying the 3rd interspace in the anterior axillary line and a wound protector inserted.
*
Next, the lung was reflected inferiorly and posteriorly to expose the mediastinal pleural and apex. The mediastinal pleura was incised cephalad to the pulmonary artery in the aorto-pulmonary window. A level 5 lymph node was encountered here and, dissected free with electrocautery and passed off the field for frozen section. The utility incision was extended slightly into a mini-thoracotomy and a retractor inserted. Careful blunt dissection proceeded anteriorly towards the hilum. The left upper lobe border was freed from pericardial fat pads in this area. A lung based nodule was present here, as well as an anterior parietal pleural plaque. The were biopsied directly with biopsy forceps and passed off the field for specimen. A bulky mass was encountered along the anterior medial surface of the pulmonary artery, extending into the pericardium. The pericardium was fused to the heart here. This mass was biopsied with biopsy forceps and passed off the field as specimen. This returned positive on frozen section for NSCLC. The fissure was interrogated bluntly and a level 11 lymph node was encountered, dissected free and passed off the field as specimen. Given the extent of invasion into the mediastinum, the tumor was deemed non-resectable.
*
A thorough mediastinal lymph node dissection proceeded with specimens as stated above. Hemostasis was verified. A single 32Fr chest tube was placed through an anterior-inferior incision and directed towards the apex. The left lung was reexpanded under direct vision. All skin incisions were closed in layers with No. 2 Vicryl para-costal sutures used to close the interspace of the utility incision and 0 and 2-0 Vicryl to close the subq tissues. 4-0 Monocryl in a running subcuticular manner was used to close the skin. Dermabond was placed over the wounds. At this stage, the procedure was discontinued. The patient was delivered from anesthesia, extubated, and transferred to the postanesthesia recovery unit in stable condition having tolerated the procedure well.

Medical Billing and Coding Forum

0484T- Transapical transcatheter valve in mitral ring via left thoracotomy

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Hi,

Is this the appropriate CPT code for this procedure.

0484T – Transapical transcatheter valve in mitral ring via left thoracotomy.

Also require clincial trail number for "29 mm Edwards Sapien 3 transcatheter valve"

Medical Billing and Coding Forum

Transapical transcatheter valve in mitral ring via left thoracotomy

Posted on by
Hi,

Require CPT codes and Clinical Trail for mentioned below procedure.

I though the appropriate CPT code 0484T

PROCEDURE PERFORMED:
1. Transapical transcatheter valve in mitral ring via left thoracotomy.
2. Temporary transvenous pacemaker insertion.
3. Transesophageal echocardiography.

OPERATIVE REASON FOR PROCEDURE: Intermediate risk for surgical mitral valve replacement,
4% to 8% risk of 30-day mortality.

IMPLANTATION: 29 mm Edwards Sapien 3 transcatheter valve in mitral ring via left
thoracotomy transapical approach.

CLINICAL INDICATIONS:

The patient is an 85-year-old male, who recently presented with
progressive symptoms of shortness of breath and fatigue, and was found to have severe
mitral stenosis. He does have a prior history of mitral valve repair with placement of a
mitral annuloplasty ring in 1998. He also has multiple other comorbidities including
nonischemic cardiomyopathy, ejection fraction of 30% to 40%, status post prior AICD
implantation, chronic atrial fibrillation, on long-term oral anticoagulation with
Coumadin, history of atrial fibrillation ablation twice. Due to his severe symptoms of
shortness of breath and fatigue, and underlying mitral valve stenosis, he was evaluated
initially by Cardiovascular Surgery, Dr. Accola, for an open heart surgery. However,
considering his advanced age, multiple comorbidities, diminished left ventricular ejection
fraction, he was felt to be at high risk for postoperative complications. Thus, the
decision was made to proceed with placement of a transcatheter mitral valve in his mitral
ring through a transapical approach. The rationale of the procedure, other options, all
the risks and benefits were extensively discussed with the patient and his family, and
consent was signed to proceed as planned. His case was also discussed extensively in our
structural heart meeting

DETAILS OF PROCEDURE:

Intraoperative transesophageal echocardiography was performed and
showed significant pannus within the prior mitral ring with presence of severe mitral
valve stenosis. There was no significant mitral regurgitation present. The patient was
brought to the hybrid operating room and placed in the supine position. He was prepped
and draped in the usual fashion. The patient was placed under general anesthesia.
Transesophageal echocardiography probe was placed and used throughout the procedure to
evaluate the mitral valve and position of our catheters. A 5-French bipolar pacing
catheter was placed in the apex of the right ventricle through right femoral venous
access. We also obtained access in the right femoral artery and placed a 5-French sheath,
just in case we needed to place an intra-aortic balloon pump for hemodynamic support
during the case. Subsequently, the left chest was opened via anterior thoracotomy, and we
found the anterior apical portion which would be appropriate for placement of the valve.
Two pledgetted sutures were placed around the LV apex. The left apex was cannulated with
a needle, and a soft wire was placed into the left atrium. Using a JR4 catheter, we
placed the wire into the right superior pulmonary vein. Then, we exchanged out the wire
for a stiff Amplatz wire. At that point, the patient had already been anticoagulated with
heparin to keep an ACT greater than 250 seconds. At that point, we placed an Ascendra
transcatheter valve introducer into the left ventricular apex, and subsequently we
prepared a 29 mm Edwards Sapien 3 transcatheter valve. Since this was a 31 mm ring, we
decided to go with a 29 mm regular prep of Sapien valve. We also had measured the ring
area on echocardiography. The transcatheter valve was deployed with rapid ventricular
pacing, and the valve was very carefully deployed under fluoroscopy guidance. The valve
deployed in excellent position. The delivery device was subsequently removed. We did
postdilate the valve by adding 1 mL of contrast due to presence of mild paravalvular leak.
After the postdilatation, there was only trivial paravalvular leak noted. There was no
central mitral regurgitation. The mitral valve seemed to be well seated inside the prior
mitral ring. This concluded the operation. The patient tolerated the surgery well, and
there were no complications. The postprocedure mitral valve area was 2.66 sq cm, the mean
gradient across the valve was 3 mmHg. There was presence of trivial paravalvular mitral
insufficiency after valve deployment. The patient was transferred to the cardiovascular
recovery area in a stable condition.

Medical Billing and Coding Forum

Thoracotomy with Bronch to follow

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One of my physicians performed a thoracotomy with a bronch to follow for "clean-up". This is something that he does regularly, and I want to ensure that he is getting full credit for the procedures that are performed. If the bronch does not preface the open procedure, how would it be coded? Should it be coded with an added modifier, such as 51?

Medical Billing and Coding Forum

thoracotomy coding

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I am new to cardiovascular Thoracic and trying very hard to get a handle on it. Any help would be so appreciated. I have a physician that performed the following:

A posterolateral thoracotomy incision was made and the fifth intercostal space was entered. One rib was shingled. we spent some time getting the adhesions down, which was kind of surprising seeing that the did have a pneumo, however, we did free up the lung and found what appears to be a weaker part of the lung, almost looks like it was abrased. This was biopsied and sent to pathology. Doxy was used as a chemical pleurodesis. A bovie pad was used to aggressively scratch the inside surface of the chest as a mechanical pleurodesis. once chest tubes were placed in the apex of the thorax, vicryl sutures were used to close the remaining layers. After the incision was completely closed we then directed our attention to the pretty large wound where the chest tube had been inserted. This chest tube had been taken out previously. we used a curet to truly clean this out. Asmall incision was about at least 4 inches wide and 4-5 inches deep. We did clean this out and curetted down to good bleeding tissue. There were no signs of pus. a wound vac was placed without complications.

I show the open thoracotomy with biopsy codes are 32096 – 32098. The Pleurodesis code is 32650 showing mechanical or chemical. I am not sure at all where to go with the wound from the chest tube I was looking in the 11000 codes and I show the wound vac placement as 97605. I may be way off base on all of these codes but I was doing my best before asking for help. This is the first time I used this, I hope I did it correctly.

Thank you

Medical Billing and Coding Forum

Left lateral thoracotomy with anterior

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Can someone help me code this I am new to this kind of coding and just want to get an understanding of how to code for these procedures

PREOPERATIVE DIAGNOSIS: T11-T12 compression fracture.

POSTOPERATIVE DIAGNOSIS: T11-T12 compression fracture.

PROCEDURE PERFORMED: Left lateral thoracotomy with anterior exposure of T11 and T12, with T11-12 corpectomy with cage placement and a left eleventh partial rib resection.

DISPOSITION: The patient remained intubated in stable condition for posterior portion of the procedure. The left 28-French chest tube was to low continuous suction.

HISTORY: A 73-year-old female who has been seen by Dr. for ongoing worsening back pain due to a T11-12 compression, likely due to infection. The patient is now brought to the operating room for T12-T11 corpectomy to alleviate the compression on the spinal cord. The patient was worked up by Dr.preoperatively. The patient was also seen by me preoperatively to describe the approach through the left chest wall. Risks and benefits, alternatives were discussed to her. She agreed to proceed.

REPORT OF OPERATION: After consent was obtained, the patient was brought back to the operating room. An epidural catheter was placed. The patient was then endotracheally intubated with a double-lumen ET tube and then placed in a left lateral decubitus position, secured with a beanbag. There was an axillary roll placed and the extremities were padded and secured appropriately. The C-arm was brought in and the left chest was marked. The area of the compression was noted. The
incision was planned over top of the eleventh rib, starting anterolaterally and extending around posteriorly. After this, the left chest was prepped and draped in normal sterile fashion. Prior to incision, a timeout was performed. Dr. was present as well. All team members agreed with the procedure. After placing Ioban, the thorax was incised on the left side over top of the eleventh rib with a #10 blade, deepened down through the skin and subcutaneous tissue using cautery. Overlying musculature was divided over top of the 11th rib using cautery. I then dissected into the intercostals slightly with cautery. The lung was deflated. Using a curved 6 hemostat, the intercostals were taken down, preserving the parietal pleura. A space was dissected between the pleura and the diaphragm on the left side, dissecting down
posteriorly. The lateral aspect of the vertebral bodies could be identified. In order to assist with more visualization, it was attempted to dissect the pleura off of the spine; however, there was intense inflammation in this area and the pleura was stuck. Therefore, entry was gained into the pleura with the
lung decompressed. A Finochietto rib retractor was placed to open up the space. The dissection was completed through the intercostals. Next, a periosteal elevator was used to dissect free the posterior aspect of the 11th rib. Approximately a 1-1/2 inch segment of rib was taken with rib cutters preserving the neurovascular bundle. The Finochietto rib retractor was placed again and better exposure was taken. A moistened laparotomy sponge was used to retract the lung
cephalad. We were then able to palpate the area of concern, which was inflamed. The mid portion of the T11-T12 area was incised. There was intense inflammation in this area, which was dissected, identifying the anterior aspect of the vertebral body. I then dissected through the middle of the vertebral body. There was intense cicatrix of scar tissue. Anatomy was difficult to discern. The T12 spinal artery was identified and ligated with 3-0 Prolene stick ties divided. I then dissected up to T12 and down to L1. The L1 spinal artery was preserved and dissected so that its course could be delineated. Dr. was present and it was determined that he needed more exposure cephalad. Therefore, I dissected past T11, all the way up to the inferior aspect of T10. The T11 spinal artery was also dissected and ligated using clip
applier and 3-0 Prolene stick ties. Once the anterior aspect of all the vertebral bodies were cleared off, I did use a periosteal elevator to further clear off connective tissue along the lateral aspect of the vertebral bodies. Hemostasis was ensured. At this point, Dr. was present for his portion of the procedure. Once Dr. portion was
completed and the cage with extension was inserted and confirmed to be in correct position, I was then present to close the chest wall. Hemostasis was ensured. First, a stab incision was made over top of the 10th rib and with the lung deflated and under direct visualization, a 28-French chest tube was inserted over top of the 10th rib and placed within the apex of the posterolateral chest. Next, #2 Polysorb sutures were used to close the thoracotomy, which was between the 10th and 11th ribs. Prior to closing the defect by tying down the sutures, the lung was reinflated and the chest tube was placed more posteriorly for good drainage. Once the ribs
were closed, the muscle wall was closed with a running 0 Polysorb suture. The deep dermis was closed with running 2-0 Polysorb suture, and the skin was closed with staples. The chest tube was secured using a 0 silk suture and this was hooked to 20 cm of continuous wall suction. An Op-Site dressing was placed over top of the incision and the chest tube was secured with a banding gun and gauze and tape. There were no complications. The patient remained intubated in
satisfactory condition in the operating room for the posterior aspect of Dr. procedure. Sponge counts were correct at the end of the case. Instruments were not counted; however, there were multiple fluoroscopic views of the entire thoracic cavity, which revealed no foreign bodies.

Medical Billing and Coding Forum

right thoracotomy

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Hello, I am new to some of these thoracotomy codes , can someome point me in the right direction for this one ?

DX- Long gap esophageal atresia

Procedure -Right thoracotomy and esophagoesophagostomy

After anesthesia, patient was placed in lateral decubitus position with an axillary roll in place . The previous placed traction sutures were cut at skin level and blosters were removed . The chest tube was removed and the right chest was prepped and draped. The old skin incision and the chest wall closure sutures were removed and the pleural space entered . There were a small amount of reactive fluid and exudate . The 2 pouches were dissected bluntly and there was length for anastomosis . The distal pouch was open and lumen identified. The proximal pouch was open and posterior wall of the anastomosis was reapproximated with sutures and a 10-french Replogle nasogastric tube was advanced through the anastomosis into the stomach . The anterior wall was of the anastomosis was completed with sutures .A 7-mm Jackson drain was placed into the pleural space alomgside the esophagus and exited through the old chest tube exit site and secured with sutures. The ribs were reapproximated with sutures. The chest wall muscles and skin were closed with sutures

any ideas of the code ?

Medical Billing and Coding Forum

Hemothorax drainage via thoracotomy

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skin incision was performed fascia and subcutaneous tissue were entered with electrocautery obtaining hemostasis simultaneously. the pleural cavity was entered, and clots were removed as well as blood. Once clots were removed, the cavity was irrigated. Approximately a total of 1.5-2L of blood and blood clots were removed. Two chest tubes were placed in the pleural cavity. Total hemostasis was ascertained. Packing was left behind, and the patient was actively resuscitated throughout the operation. Help with CPT I was looking at 32120 however this code says it’s for control of traumatic hemorrhage this was noted as tension hemothorax..32120-52?? any help would be much appreciated.

Medical Billing and Coding