Connor.clarissa
New
Help??? I am new to cardio-thoracic coding....
I have an OP report that basically my doc went in to provide hemi-sternotomy with exposure for another MD that is performing a thyroidectomy. My doc only performs the opening and then leaves the OR. Once they thyroidectomy is completed he returns to perform sternal closure. I get the CPT for closure 21750 but i am unsure of the opening please help.....below is the OP report
PREOPERATIVE DIAGNOSIS: Thyroid goiter, which was substernal in location.
POSTOPERATIVE DIAGNOSIS: Thyroid goiter, which was substernal in location.
OPERATION: Hemi-sternotomy approach with exposure and then sternal closure
for Dr. Alric Simmonds.
OPERATIVE INDICATIONS: The patient is a 53-year-old female with the
above-mentioned pathology. She has had a substernal goiter and I was
asked by Dr. Simmonds to provide exposure with a hemi-sternotomy. I
discussed this with the patient in the office. She states she understood
and consented to proceed as planned.
OPERATIVE PROCEDURE IN DETAIL: The patient was brought to the operating
room and placed in supine position. After general endotracheal
anesthesia, she was prepped and draped in usual fashion. A small
hemi-sternotomy was made just through the third intercostal space. This
was teed off and opened and dissection was done. At that point, we left
and let Dr. Simmonds proceed with thyroidectomy.
Once this was completed, we returned to close the hemi-sternotomy in
routine fashion. The patient tolerated the procedure well and was taken
to the recovery room in stable condition.
I have an OP report that basically my doc went in to provide hemi-sternotomy with exposure for another MD that is performing a thyroidectomy. My doc only performs the opening and then leaves the OR. Once they thyroidectomy is completed he returns to perform sternal closure. I get the CPT for closure 21750 but i am unsure of the opening please help.....below is the OP report
PREOPERATIVE DIAGNOSIS: Thyroid goiter, which was substernal in location.
POSTOPERATIVE DIAGNOSIS: Thyroid goiter, which was substernal in location.
OPERATION: Hemi-sternotomy approach with exposure and then sternal closure
for Dr. Alric Simmonds.
OPERATIVE INDICATIONS: The patient is a 53-year-old female with the
above-mentioned pathology. She has had a substernal goiter and I was
asked by Dr. Simmonds to provide exposure with a hemi-sternotomy. I
discussed this with the patient in the office. She states she understood
and consented to proceed as planned.
OPERATIVE PROCEDURE IN DETAIL: The patient was brought to the operating
room and placed in supine position. After general endotracheal
anesthesia, she was prepped and draped in usual fashion. A small
hemi-sternotomy was made just through the third intercostal space. This
was teed off and opened and dissection was done. At that point, we left
and let Dr. Simmonds proceed with thyroidectomy.
Once this was completed, we returned to close the hemi-sternotomy in
routine fashion. The patient tolerated the procedure well and was taken
to the recovery room in stable condition.