# Need help with Op Note



## akmorgan (Jan 18, 2012)

My provider and I have chosen different codes for the procedure below.  Can someone please review this op note and let me know your opinion on the codes:

Procedure:
1.  Resection of the right cervical rib
2.  Right middle scalenectomy.

Procedure detail:
The right neck was prepped and draped in usual fashion and a curvilinear incision was made along the lateral aspect of the sternocleidomastoid.  The sternocleidomastoid was retracted medially and dissection carried down to the omohyoid which was dissected up and retracted inferiorly.  The scalene fat pad was mobilized and a portion of it was removed and the exposure of the roots of the brachial plexus and the anterior and middle and posterior scalene muscle was accomplished as well the phrenic nerve.  The phrenic nerve was identified and preserved throughout the procedure.  A portion of the anterior scalene was divided using bipolar cautery and the procedure was accomplished under 3x magnification to gain further exposure, as the anterior scalene appeared somewhat enlarged.  There were no particularly unusual bands in this muscle and it was nice and soft and not impinging on the plexus.  Further dissection freeing up the plexus allowed mobilization of that and exposure of the middle scalene muscle and the cervical rib was exposed after taking down the proximal portion of the middle scalene.  The midportion of the middle scalene contained multiple abnormal fibrous bands and these were divided and a portion of the scalene resected using bipolar cautery with particular care to avoid stretch for injury to the plexus.  The rib was then resected by elevating the periosteum and dividing the fibrous bands extending from its tip and was resected using the Carrington rongeurs and retraction to protect the brachial plexus.  At this point, hemostasis was achieved and application of Arista and direct pressure on the stump of the cervical rib and the plexus was then found to be nice and mobile and not impinged upon by any further identifiable bands or bony structures.  The wound was then closed by closing the platysma with running 3-0 Vicryl and the skin with subcuticular 4-0 Monocryl.  


The procedure was coded as 21705; however the provider feels that codes 21615 and 21556 are better codes for the procedure. 

Thank you in advance for any help with this.


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## codedog (Jan 18, 2012)

This is what I found surfing the web , not sure if its 100 % correct, but I seen this figure it might help. Trent

Q: When coding for a scalentectomy w/first rib resection, what the difference between CPT code 21615 and 21705. Would you bill both CPT codes for this procedure?



A: I am going to first address your question of what is the difference between 21615 and 21705. The codes 21615-21616 are reported for surgery where an incision is made just above the clavicle down to the rib. The rib and attached soft tissues are dissected and excised, the rib is removed. 21616 is used if the sympathetic nerve pathway is also cut he procedure.

For codes 21700-21705 the incision is made over the scalene muscle deep to the muscle. The muscle is dissected. If the cervical rib is removed code 21705 is reported.

Now, for a scalentectomy w/first rib resection, I would recommend using the 21700 to report the scalentectomy and the 21615 to report the resection of the first rib. There are no bundling issues according to CCI for the use of these two codes together. If this were a scalentectomy with cervical rib resection then 21705 would be the appropriate code and would be used alone.- was some article on internet , not sure where


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