rpettigrewcpc
Contributor
I have a very complicated surgery that I'd love a second pair of eyes on coding. An additonal surgeon was called in to help and so I've copied both notes. There's a LOT of documentation here - again, I'd love any additional insight.
I'm coding for the initial surgeon, Dr. H ... Dr. R was called in as secondary.
1st Surgeon report OPERATIVE REPORT
PREOPERATIVE DIAGNOSES:
1. Gunshot wound to the upper mid sternum.
2. Massive bleeding from the right chest and hemorrhagic shock.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to the upper midsternum.
2. Hemorrhagic shock.
3. Laceration of the right innominate vein.
4. Perforation of the apex of the left upper lobe.
OPERATION:
1. A median sternotomy, exploration, resection of right sternoclavicular
joint and manubrium and repair of innominate vein/right subclavian vein
laceration.
2. Wedge resection of apex of the left upper lobe.
FINDINGS: The patient had a gunshot wound to the upper center of the
sternum. The bullet had however, skived slightly to the right and gotten
through the lower part of the right manubrium, through the
sternoclavicular junction and lacerated the innominate vein on the right
side, or the subclavian-innominate junction. The bullet then had gone
through the apex of the left upper lobe and lodged into the upper
posterior chest wall. There was copious amount of venous blood in the
left chest and there was massive amount of bleeding from the innominate
vein. This was very difficult to ligate by simple suturing through the
sternotomy. Dr. R assisted in extending the sternotomy incision into
the right neck, resecting the upper part of the manubrium and the
sternoclavicular junction in order to get access to the underlying vein.
The vein was repaired with simple 3-0 Prolene suture. The patient lost
several liters of blood and required multiple blood transfusions and
transfusion of clotting factors.
INDICATIONS FOR THE PROCEDURE: Mr. who
was apparently brought to the Emergency Room by his friends after a
gunshot wound to the chest. The patient collapsed in the Emergency Room
and was resuscitated and intubated. Bilateral chest tube was placed by
the surgical resident with massive amount of blood coming from the right
chest. He was then emergently taken to the Operating Room for
exploration.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room
already intubated. Multiple venous lines, and arterial line were placed
in the groin. He was then prepped from the chin to the waist and draped
in the usual sterile fashion. A standard sternotomy incision was used
and the sternum was divided with a sternal saw. There was clear evidence
of bullet entry that had skived towards the right, and shattered the
manubrium on the right side. The thymus was divided and the pericardium
was opened. There was no evidence of bleeding or any injury to the heart
or the great vessels inside the pericardium. The right pleural cavity
was then opened and there was massive amount of venous blood inside the
chest cavity. The Cell Saver unfortunately was not set up; therefore,
this was suctioned into the canister. The bullet had entered
through-and-through the chest wall and perforated the lung. Some venous
bleeding was noted from the apex of the left upper lobe through which the
bullet had penetrated. I could see the entry into the posterior chest
wall where the bullet I think was lodged at the apex. Once all the blood
was suctioned from the pleural cavity, I noticed that the blood
accumulated relatively fast. The patient continued to be hypotensive at
this point, blood pressure in the 60s. Once I elevated the right
hemisternum I noted there was blood gushing out from what had looked like
part of the innominate vein or the right subclavian vein. This was
controlled using manual finger compression. This was very difficult to
access and ligate by suture. I consulted the vascular surgeon on-call,
Dr. R, to see if this could be repaired using endovascular
covered stent. Dr. R arrived to the operating room and we decided, at
this point, because of the massive amount of blood loss, to just attempt
to surgically repair this. The incision was then extended into the right
neck by Dr. R and dissected. The portion of the right manubrium along
with the sternoclavicular junction was resected in order to get access to
the underlying vein. The bleeding vein was then, partially, was
identified and Allis clamps were placed to get hemostasis. The vein was
then suture repaired using 3-0 Prolene suture. Good hemostasis was
achieved.
Once the bleeding was controlled, then, attention was then diverted to
the lungs. The apex of the left upper lobe was grasped using Endo Duval
clamps and this portion of the lung was wedge resected using Endo
stapling devices. The chest cavity was then copiously irrigated with
warm saline solution. Once adequate hemostasis was assured, the sternum
was reapproximated using stainless steel wires in a mattress fashion.
There was significant amount of coagulopathic oozing from all the soft
tissues. The neck incision was closed by Dr.R and the sternotomy
incision was closed using 0 Vicryl for the deep layer and staples for the
skin. The patient was then emergently transferred to the Intensive Care
Unit in critical condition.
2ndary Surgeons report OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Gunshot wound to mid anterior chest with massive
bleeding from superior anterior mediastinum, and hemorrhagic shock.
POSTOPERATIVE DIAGNOSIS: Gunshot wound to mid anterior chestwith massive
mediastinal bleeding from superior anterior mediastinum with traumatic
laceration of right innominate vein.
NAME OF PROCEDURE: Extension of sternotomy incision into right neck,
resection of right sternoclavicular joint and repair of right innominate
vein.
ESTIMATED BLOOD LOSS: About 1000 mL.
BLOOD TRANSFUSION: With blood products and plasma as per anesthesia.
DRAIN: A #15 Blake drain to drain the neck and the superior
mediastinum.
SPECIMEN: Nil.
INDICATIONS FOR SURGERY: , presented with hemorrhagic
shock with bilateral hemopneumothorax wound through the upper mid sternum
with blood in bilateral pleural cavity and hypotension. The patient was
brought to the Operating Room by Dr. H and midline sternotomy was
carried out and the details of his findings will be dictated by him in a
separate note. I was called around 2:00 a.m. to help explore the
torrential bleeding from the posterior aspect of the innominate vein
behind his right sternoclavicular joint.
DESCRIPTION OF PROCEDURE: The control of the bleeding from the backside
of the right innominate vein area that could not be dissected easily and
was behind the right sternal clavicular joint was controlled with hand
pressure from within the right pleural cavity. Dr. H had already
repaired the bleeding from the right lung apex. The patient was
hypotensive into 50s and 60s at this time. Anesthesia was keeping up with
blood transfusions. While the pressure hemostasis was maintained,
carefully and slowly the area was dissected; however, the exposure was
severely limited by the upper end of the sternotomy incision as well as
the sternoclavicular joint, which had been shattered by the gunshot
wound and sharp spicules of the bones were protruding into the surgical
field. Surrounding soft tissue was deeply edematous from the bleeding.
While maintaining pressure hemostasis, the bone fragments were carefully
resected to gain more exposure. The tapes were passed around to gain
control; however, the injury site was well lateral to the control site
under the bones.
At this stage, it was decided to elongate the sternotomy incision into
the right neck along the anterior border of the sternocleidomastoid
muscle with the intent to gain control of the internal jugular vein as
well as the subclavian vein behind the clavicle. However, as more
exposure was obtained, we were still not able to locate a site of
bleeding and neck veins was still very difficult. Presence of hand
maintaining hemostasis was hanged ring dissection. However, the fragments
of the shattered sternum and the right clavicle at this stage became more
accessible and were carefully dissected and resected to achieve better
exposure of right lateral component of right innominate vein. at this
stage it became more visible that the laceration was on the medial a
SPECT of right innominate vein and the internal jugular vein in the
thoracic cavity. Margins were coapted with Allis clamps and hemostasis
was achieved. Laceration could be better appreciated now. With the 4-0
Prolene, lateral venorrhaphy with 2 rows of sutures was carried out and
control was achieved. After this, the patient's blood pressure came up
to 120.
The both pleural cavity pericardial cavity was inspected. The patient at
this stage was beginning to ooze from all over and his PTT was more than
100 with a PT of more than 12. After achieving good hemostasis of all
surgical sites, it was decided best to close and to help stabilize the
patient in surgical intensive care unit ,with correction of
coagulopathy,with option of reexploration if there is any evidence of
continued bleeding. To do so, Dr. H closed the sternotomy and I
closed the neck wound by approximating platysma only. A #15 Blake drain
was left in the neck, which was coursing downwards behind the
sternoclavicular joint at the gunshot wound site and the wound was
approximated in layers using Vicryl for deeper sutures and skin staples
for the skin. The drain was secured to the skin at the neck incision.
Occlusive dressings were applied. Still intubated, the patient was
transferred to Surgical Intensive Care Unit in fairly good condition with
a blood pressure above 120. His pulse rate is slowing down; however,
his metabolic indices revealed him to be some still acidotic, but slowly
improving. There was minimal urine output in the Foley bag.
Completion chest x-ray showed the bullet fragment to be in right neck,
which may very well be in the right back since it had penetrated the apex
of the lung and had entered the posterior chest wall as per Dr.
H. Extra quality was not great. Chest tubes were in place. No
retained surgical needles or instruments could be identified. Patient was
rotated office surgery as he was transferred to the stretcher. There was
no evidence of any injury on his back. Patient's skin and body
temperature appear to be reasonable.
We were thinking CPT 39010 for initial opening / surgery (includes sternotomy)
CPT 33320 and 35216 for the repairs to veins / vessels
and CPT 32505 for the wedge resection of the lung (unsure of this one as the chest was already open).
In addition I'm wanting to make sure the extension of the incision up the neck (done by Dr. R) is included in all this.
I know it's a lot to go over, I appreciate any thoughts.
I'm coding for the initial surgeon, Dr. H ... Dr. R was called in as secondary.
1st Surgeon report OPERATIVE REPORT
PREOPERATIVE DIAGNOSES:
1. Gunshot wound to the upper mid sternum.
2. Massive bleeding from the right chest and hemorrhagic shock.
POSTOPERATIVE DIAGNOSES:
1. Gunshot wound to the upper midsternum.
2. Hemorrhagic shock.
3. Laceration of the right innominate vein.
4. Perforation of the apex of the left upper lobe.
OPERATION:
1. A median sternotomy, exploration, resection of right sternoclavicular
joint and manubrium and repair of innominate vein/right subclavian vein
laceration.
2. Wedge resection of apex of the left upper lobe.
FINDINGS: The patient had a gunshot wound to the upper center of the
sternum. The bullet had however, skived slightly to the right and gotten
through the lower part of the right manubrium, through the
sternoclavicular junction and lacerated the innominate vein on the right
side, or the subclavian-innominate junction. The bullet then had gone
through the apex of the left upper lobe and lodged into the upper
posterior chest wall. There was copious amount of venous blood in the
left chest and there was massive amount of bleeding from the innominate
vein. This was very difficult to ligate by simple suturing through the
sternotomy. Dr. R assisted in extending the sternotomy incision into
the right neck, resecting the upper part of the manubrium and the
sternoclavicular junction in order to get access to the underlying vein.
The vein was repaired with simple 3-0 Prolene suture. The patient lost
several liters of blood and required multiple blood transfusions and
transfusion of clotting factors.
INDICATIONS FOR THE PROCEDURE: Mr. who
was apparently brought to the Emergency Room by his friends after a
gunshot wound to the chest. The patient collapsed in the Emergency Room
and was resuscitated and intubated. Bilateral chest tube was placed by
the surgical resident with massive amount of blood coming from the right
chest. He was then emergently taken to the Operating Room for
exploration.
DESCRIPTION OF PROCEDURE: The patient was brought to the Operating Room
already intubated. Multiple venous lines, and arterial line were placed
in the groin. He was then prepped from the chin to the waist and draped
in the usual sterile fashion. A standard sternotomy incision was used
and the sternum was divided with a sternal saw. There was clear evidence
of bullet entry that had skived towards the right, and shattered the
manubrium on the right side. The thymus was divided and the pericardium
was opened. There was no evidence of bleeding or any injury to the heart
or the great vessels inside the pericardium. The right pleural cavity
was then opened and there was massive amount of venous blood inside the
chest cavity. The Cell Saver unfortunately was not set up; therefore,
this was suctioned into the canister. The bullet had entered
through-and-through the chest wall and perforated the lung. Some venous
bleeding was noted from the apex of the left upper lobe through which the
bullet had penetrated. I could see the entry into the posterior chest
wall where the bullet I think was lodged at the apex. Once all the blood
was suctioned from the pleural cavity, I noticed that the blood
accumulated relatively fast. The patient continued to be hypotensive at
this point, blood pressure in the 60s. Once I elevated the right
hemisternum I noted there was blood gushing out from what had looked like
part of the innominate vein or the right subclavian vein. This was
controlled using manual finger compression. This was very difficult to
access and ligate by suture. I consulted the vascular surgeon on-call,
Dr. R, to see if this could be repaired using endovascular
covered stent. Dr. R arrived to the operating room and we decided, at
this point, because of the massive amount of blood loss, to just attempt
to surgically repair this. The incision was then extended into the right
neck by Dr. R and dissected. The portion of the right manubrium along
with the sternoclavicular junction was resected in order to get access to
the underlying vein. The bleeding vein was then, partially, was
identified and Allis clamps were placed to get hemostasis. The vein was
then suture repaired using 3-0 Prolene suture. Good hemostasis was
achieved.
Once the bleeding was controlled, then, attention was then diverted to
the lungs. The apex of the left upper lobe was grasped using Endo Duval
clamps and this portion of the lung was wedge resected using Endo
stapling devices. The chest cavity was then copiously irrigated with
warm saline solution. Once adequate hemostasis was assured, the sternum
was reapproximated using stainless steel wires in a mattress fashion.
There was significant amount of coagulopathic oozing from all the soft
tissues. The neck incision was closed by Dr.R and the sternotomy
incision was closed using 0 Vicryl for the deep layer and staples for the
skin. The patient was then emergently transferred to the Intensive Care
Unit in critical condition.
2ndary Surgeons report OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Gunshot wound to mid anterior chest with massive
bleeding from superior anterior mediastinum, and hemorrhagic shock.
POSTOPERATIVE DIAGNOSIS: Gunshot wound to mid anterior chestwith massive
mediastinal bleeding from superior anterior mediastinum with traumatic
laceration of right innominate vein.
NAME OF PROCEDURE: Extension of sternotomy incision into right neck,
resection of right sternoclavicular joint and repair of right innominate
vein.
ESTIMATED BLOOD LOSS: About 1000 mL.
BLOOD TRANSFUSION: With blood products and plasma as per anesthesia.
DRAIN: A #15 Blake drain to drain the neck and the superior
mediastinum.
SPECIMEN: Nil.
INDICATIONS FOR SURGERY: , presented with hemorrhagic
shock with bilateral hemopneumothorax wound through the upper mid sternum
with blood in bilateral pleural cavity and hypotension. The patient was
brought to the Operating Room by Dr. H and midline sternotomy was
carried out and the details of his findings will be dictated by him in a
separate note. I was called around 2:00 a.m. to help explore the
torrential bleeding from the posterior aspect of the innominate vein
behind his right sternoclavicular joint.
DESCRIPTION OF PROCEDURE: The control of the bleeding from the backside
of the right innominate vein area that could not be dissected easily and
was behind the right sternal clavicular joint was controlled with hand
pressure from within the right pleural cavity. Dr. H had already
repaired the bleeding from the right lung apex. The patient was
hypotensive into 50s and 60s at this time. Anesthesia was keeping up with
blood transfusions. While the pressure hemostasis was maintained,
carefully and slowly the area was dissected; however, the exposure was
severely limited by the upper end of the sternotomy incision as well as
the sternoclavicular joint, which had been shattered by the gunshot
wound and sharp spicules of the bones were protruding into the surgical
field. Surrounding soft tissue was deeply edematous from the bleeding.
While maintaining pressure hemostasis, the bone fragments were carefully
resected to gain more exposure. The tapes were passed around to gain
control; however, the injury site was well lateral to the control site
under the bones.
At this stage, it was decided to elongate the sternotomy incision into
the right neck along the anterior border of the sternocleidomastoid
muscle with the intent to gain control of the internal jugular vein as
well as the subclavian vein behind the clavicle. However, as more
exposure was obtained, we were still not able to locate a site of
bleeding and neck veins was still very difficult. Presence of hand
maintaining hemostasis was hanged ring dissection. However, the fragments
of the shattered sternum and the right clavicle at this stage became more
accessible and were carefully dissected and resected to achieve better
exposure of right lateral component of right innominate vein. at this
stage it became more visible that the laceration was on the medial a
SPECT of right innominate vein and the internal jugular vein in the
thoracic cavity. Margins were coapted with Allis clamps and hemostasis
was achieved. Laceration could be better appreciated now. With the 4-0
Prolene, lateral venorrhaphy with 2 rows of sutures was carried out and
control was achieved. After this, the patient's blood pressure came up
to 120.
The both pleural cavity pericardial cavity was inspected. The patient at
this stage was beginning to ooze from all over and his PTT was more than
100 with a PT of more than 12. After achieving good hemostasis of all
surgical sites, it was decided best to close and to help stabilize the
patient in surgical intensive care unit ,with correction of
coagulopathy,with option of reexploration if there is any evidence of
continued bleeding. To do so, Dr. H closed the sternotomy and I
closed the neck wound by approximating platysma only. A #15 Blake drain
was left in the neck, which was coursing downwards behind the
sternoclavicular joint at the gunshot wound site and the wound was
approximated in layers using Vicryl for deeper sutures and skin staples
for the skin. The drain was secured to the skin at the neck incision.
Occlusive dressings were applied. Still intubated, the patient was
transferred to Surgical Intensive Care Unit in fairly good condition with
a blood pressure above 120. His pulse rate is slowing down; however,
his metabolic indices revealed him to be some still acidotic, but slowly
improving. There was minimal urine output in the Foley bag.
Completion chest x-ray showed the bullet fragment to be in right neck,
which may very well be in the right back since it had penetrated the apex
of the lung and had entered the posterior chest wall as per Dr.
H. Extra quality was not great. Chest tubes were in place. No
retained surgical needles or instruments could be identified. Patient was
rotated office surgery as he was transferred to the stretcher. There was
no evidence of any injury on his back. Patient's skin and body
temperature appear to be reasonable.
We were thinking CPT 39010 for initial opening / surgery (includes sternotomy)
CPT 33320 and 35216 for the repairs to veins / vessels
and CPT 32505 for the wedge resection of the lung (unsure of this one as the chest was already open).
In addition I'm wanting to make sure the extension of the incision up the neck (done by Dr. R) is included in all this.
I know it's a lot to go over, I appreciate any thoughts.