# Repair of esophogeal perforation and foreign body removal



## mhanson1 (Jul 1, 2011)

Forgive me if this is in the wrong section- my specialty is usually vascular surgery with a sprinkle of cardio-thoracic!  =)

I am looking at 2 codes 43415 and 43045 for the following:

"Pre-op diagnosis:  esophageal perforation
Post-op diagnosis:  a 9-cm linear esophageal perforation in the middle to distal esophagus.

Operation performed:
1.  Right lateral thoracotomy
2.  Esophageal debridement and repair of 9-cm right middle thoracic esophageal perforation.

Description of operation/procedure:

.........A right lateral thoracotomy was then created.  We divided the latissimus dorsi with electrocautery.  We spared the serratus anterior.  Prior to entering the pleural space, the right lung was isolated.  We entered the pleural space and there was a moderate amount of purulent tan-gray fluid.  We divided the 8th rib posteriorly.  We then placed the rib retractors to facilitate exposure.  At this point, there was a significant amount of purulent fluid and fibrinous exudate in the pleural space.  Several specimens were sent to microbiology for evaluation.  We identified the esophagus and the pleura overlying the esophagus was dark gray.  At this point, we mobilized the inferior pulmonary ligament.  We then entered the pleura overlying the esophagus.  It was at this point that we noted a large, light brown, plastic/rubber, tubular structure protruding from the lumen of the esophagus along with tan-white pasty material. This was collected and sent to pathology for evaluation.  We mobilized the pleura overlying the entire mid to distal esophagus and we identified a 9-cm linear tear extending from the distal mid esophagus down to approximately 4cm above the diaphragm.  We had anesthesiology pass a nasogastric tube and we and we were able to indentify the tube within the lumen of the esophagus.  We passed it distally down into the stomach.  We secured the NG tube into place at the nose.  At this point, we were able to identify our proximal and distal ends of the laceration.  The mucosa was light pink, viable,and bled when manipulated.  We utilized 14 interrupted 4-0 Vicryl sutures to approximate the mucosa of the esophagus over the nasogastric tube.  Upon completion, we mobilized a segment of intercostal muscle and tacked it over the repair site....."

We are having a discussion in our office on this one.  Initially, I coded the repair code 43415.  Then it was suggested that foreign body removal would be more appropriate 43045.  I disagreed, because that was subsequent findings once the doctor went in to close the tear.  Then, as we dissected the op note, it seems that perhaps both are billable.  What are your thoughts?  Thanks in advance for looking!
Michelle


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