# Need help coding anesthesia for sternal debridement



## akj (Apr 27, 2016)

Can anyone advise which anesthesia CPT to use for the following?

PREOPERATIVE DIAGNOSIS:
Sternal wound infection.

POSTOPERATIVE DIAGNOSIS:
Sternal wound infection.

OPERATION PERFORMED:
1. Sternal wound debridement of 2 separate sites:.
    a.     The inferior sternal wound size was 8 cm in length x 5 cm in width
     x 2 cm in depth.
    b.     The 2nd wound site was more superior in the old sternotomy wound
     and measured 6 cm in length x 4 cm in width x 2 cm in depth.
2. Pulsavac lavage.
3. Vacuum-assisted closure sponge placement.

ANESTHESIA:
General endotracheal anesthesia.

FINDINGS:
1. Minimal amount of granulation tissue in both superior and inferior
    sternal wounds.
2. Necrotic material in the muscle and fascial layers.
3. Undermining of the skin in the superior aspect of the wound with hematoma
    formation.
4. Necrotic fragments with involucrum of the superior plate of the sternal
    bone in the inferior wound.

SPECIMENS:
Wound debris sent for microbiological examination including Gram stain,
culture, sensitivity, TB culture, fungal culture.

BRIEF CLINICAL SUMMARY:
The patient, who had coronary artery bypass graft, but subsequently developed a wound infection requiring readmission in October 2015, bedside wound debridement and VAC sponge
placement.  The patient developed persistent discharging sinuses then and had
been on multiple antibiotics and 1-2 weekly office visits until a bone scan
and CT scan of the chest suggested osteomyelitis requiring extensive wound
debridement of separate 2 sternotomy wounds including sternal bone debridement
and VAC sponge placement.  The patient had been on thrice weekly VAC sponge
changes and is back for re-exploration of the wound and for possible more
wound redebridement.  

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room and placed on the operating table
in the supine position.  Under general anesthesia with endotracheal tube in
place, the anterior aspect of the chest was prepped with chlorhexidine
solution and isolated with sterile drapes.  Next, the VAC sponges in the
superior and inferior wound were removed.  The 2 separate wounds still looked
unhealthy with a minimal amount of granulation tissue and extensive amounts of
necrotic tissue.  Both wounds were then extensively debrided by sharp
debridement of subcutaneous tissue, muscle, and fascial tissue including
sternal bony tissue in the inferior wound until there was fresh bleeding all
around.  The rest of the debridement consisted of curettage.

Next, both wounds were then irrigated with 3 L of antibiotic-enriched warm
saline solution using the Pulsavac lavage equipment.  This was followed by
further irrigation with 1 L of plain warm saline solution again employing the
Pulsavac lavage equipment.

Next, a small piece of VAC sponge was cut to size and placed in the concavity
in the sternal bone following the sternal bone debridement, and a bigger piece
of VAC sponge was then cut to size and placed over the rest of the inferior
wound.  The superior wound was similarly treated with a small piece of VAC
sponge placed in the concavity created by the undermined skin in the superior
wound.  The rest of the wound was then covered with a bigger piece of VAC
sponge.  A piece of VAC sponge was then placed on the healthy normal anterior
chest wall skin between the 2 separate wounds.  The entire assembly was then
covered with a Bioclusive dressing and connected to -125 mmHg suction.


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## CodingKing (Apr 27, 2016)

I'm thinking 00400 which is procedures on the integumentary system of the anterior trunk (and other parts connected to the upper torso), NOS


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## akj (Apr 28, 2016)

I would say 00400 also except there is bone tissue debridement, which is why I am questioning it.


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## jls4567 (Apr 28, 2016)

Take a look at ASA 00550.


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## akj (Apr 29, 2016)

Many thanks!  I wasn't thinking to look under the Intrathoracic category...


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