I'm sure someone has experience coding this situation. A patient had a CABG three years ago and has a chronic sternal non union. the thoracic surgeon removed wires and rewired the sternum with debridement. I'm looking at 21750 and/or 21825. Thoughts?
DESCRIPTION OF PROCEDURE: His previous midline sternotomy incision was opened and inflammatory tissue in the midline divided. The sternal edges were palpable and separated. Using Bovie cautery, the soft tissue overlying both sides of the sternum was divided down to the bone. Sternal wires were removed as encountered. Once the sternal edges were clearly visible, they were carefully dissected off of the mediastinum including the right ventricle. Care was taken to avoid the graft sites including the internal mammary pedicle posterior to the left hemimanubrium. This portion of the case was done with the assistance of Dr. P. The left upper lobe was quite adherent to the posterior aspect of the left hemisternum and dissected off using Bovie cautery. Once the appropriate planes were entered, the entire posterior aspect of the sternum was cleared to the lateral aspect of the bone cephalad and caudad. Once this was accomplished, the anterior aspect was cleared sufficiently for fashioning of the plates for fixation. The sternalock system was brought onto the table and three plates contoured to fit the manubrium, midsternum, and inferior aspect. Once this was complete, a rongeur was brought onto the field and used to freshen up the medial aspects of the bone on both sides, and there was actually quite a bit of oozing indicating decent blood supply to the bone. Chest tubes were then placed, one within the right pleural space and a 28 straight chest tube within the mediastinum. Just prior to closure, ProGEL was placed on the raw surface of the left upper lobe underneath the sternum.
Attention was then turned to closure. The Synthes stainless steel cables were placed in figure-of-eight fashion including one within the manubrium and five additional cables inferiorly. Once these were in place, they were sequentially tightened as the three plates including 1 X-plate on the manubrium, an X-plate on the mid sternum, and a long ladder plate at the inferior aspect were all positioned underneath the cables as they were tightened down. The bone actually came together quite nicely and once the cables were completely tightened, screws were placed into the plates, 16 mm was the depth measured prior to closure for the manubrium. The middle plate was secured with 14 mm screws and then the inferior plate with 12 and 14 where the lip of the plate was slightly up off of the bone. Once these were all secure, the sternum was irrigated.
Once the sternum was closed, it actually felt quite solid. The remaining portion of the case will be dictated by Dr. X which includes partial mobilization of the pectoralis muscles bilaterally for coverage of the hardware and soft tissue closure.
DESCRIPTION OF PROCEDURE: His previous midline sternotomy incision was opened and inflammatory tissue in the midline divided. The sternal edges were palpable and separated. Using Bovie cautery, the soft tissue overlying both sides of the sternum was divided down to the bone. Sternal wires were removed as encountered. Once the sternal edges were clearly visible, they were carefully dissected off of the mediastinum including the right ventricle. Care was taken to avoid the graft sites including the internal mammary pedicle posterior to the left hemimanubrium. This portion of the case was done with the assistance of Dr. P. The left upper lobe was quite adherent to the posterior aspect of the left hemisternum and dissected off using Bovie cautery. Once the appropriate planes were entered, the entire posterior aspect of the sternum was cleared to the lateral aspect of the bone cephalad and caudad. Once this was accomplished, the anterior aspect was cleared sufficiently for fashioning of the plates for fixation. The sternalock system was brought onto the table and three plates contoured to fit the manubrium, midsternum, and inferior aspect. Once this was complete, a rongeur was brought onto the field and used to freshen up the medial aspects of the bone on both sides, and there was actually quite a bit of oozing indicating decent blood supply to the bone. Chest tubes were then placed, one within the right pleural space and a 28 straight chest tube within the mediastinum. Just prior to closure, ProGEL was placed on the raw surface of the left upper lobe underneath the sternum.
Attention was then turned to closure. The Synthes stainless steel cables were placed in figure-of-eight fashion including one within the manubrium and five additional cables inferiorly. Once these were in place, they were sequentially tightened as the three plates including 1 X-plate on the manubrium, an X-plate on the mid sternum, and a long ladder plate at the inferior aspect were all positioned underneath the cables as they were tightened down. The bone actually came together quite nicely and once the cables were completely tightened, screws were placed into the plates, 16 mm was the depth measured prior to closure for the manubrium. The middle plate was secured with 14 mm screws and then the inferior plate with 12 and 14 where the lip of the plate was slightly up off of the bone. Once these were all secure, the sternum was irrigated.
Once the sternum was closed, it actually felt quite solid. The remaining portion of the case will be dictated by Dr. X which includes partial mobilization of the pectoralis muscles bilaterally for coverage of the hardware and soft tissue closure.