# Please help with codes -  I am leaning toward 20680 for the removal



## pygreen (Jun 1, 2016)

I am having trouble with the below OP note.   I am leaning toward 20680 for the removal of the plates; 11043 for the debridement of the fragmented costal cartilage.  I am not sure about the stabilization of the chest wall with the mesh;  CPT 49568 implantation of mesh, cannot be billed since primary codes 11004-11006, 49560-49566 are not coded.  Any advise and/or suggestions will be deeply appreciated.  Thanks.

*Pre-post- op diagnosis*: Chronic nonunion of costal cartilage fracture, left lower rib margin.
*Procedures:*  1:  Removal of 2 rib plates from previous rib fracture stabilization
                    2: Excision of fragmented costal cartilage fracture and chronic inflammatory tissue
                   3:  Stabilization of chest wall with implantation of polypropylene mesh.

*History of Present Illness:* a 54 year old with significant chronic lung disease. Diabetic and hypertensive.  He had a previous left anterior rib fracture from MVA 4 years ago and was treated acutely with plates along the lowermost ribs.  He has a chronic mal-union of the costal cartilage with rubbing of the bone and pain.  He felt something had changed recently, his pain has been more severe.

CT scan and x-rays of the chest showed the ribs to be well healed, but examination and x-ray showed nonunion of the costal cartilage with movement f the free edge of the ribs.  He was admitted for exploration and stabilization of the chronic nonunion.

*Findings:* The plates were well healed and ribs were well healed.  To allow placement of the sutures for the mesh, the previously placed plates were removed.  

There was a chronic separation of the free edges of the lower most 2 ribs and the lower edge of the sternum.  There was some chronic fragments of cartilage and a cystic space of about 3 to 4 cm in diameter, which was debrided.

*Description of Procedure:*  The patient was brought to the operation room.  General anesthesia was induced.  The patient was placed in supine position.  Anterior chest and upper abdomen were prepped and sterile drapes were placed.
Previous incision identified a cystic space with serous fluid.  The walls of this were excised along with some fragments of a chronic non-healed cartilage.  The plates went right up to the free edge of the rib, and to allow placement of sutures, I removed the plates.  Several loose screws could not be removed because of being firmly implanted in the rib and stripped.  These were able to be extracted directly and the plates removed.  After removal of the plates, interrupted #1 Prolene sutures were passed through the bony portion of the ribs through the cartilage and the soft tissues around the edge of the defect.  A patch of Prolene mesh was cut slightly larger than the defect and the sutures were passed through the mesh and tied down securing in place under mild tension.  The edge was then over sewn with a running Prolene suture.

The wound was irrigated several times during the procedure and after the mesh was in place, irrigated its final time.  The Prolene provided some stabilization to the edges and by removal of the fragments of cartilage there did not appear to be any areas where the bone or cartilage rub against each other and it was felt this would reduce his discomfort.

The fascia and subcutaneous tissue then approximated over the rib with reasonably healthy amount of tissue.  The soft tissues were then closed in layers with absorbable Monocryl suture.  The skin was closed and the patient returned to the recovery room.

During the procedure, his oxygenation was marginal due to his chronic lung disease and ongoing smoking.  Decision was made to admit him to the hospital for pain control, observation and bronchodilator therapy as needed.  He tolerated the procedure well.  Blood loss was minimal.  No specimens were obtained.


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