wfisher67
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I am desperate for HELP!!! Can someone please help me code this? I am going a little crazy trying to find codes.:
DATE OF OPERATION: 05/15/2013
PREOPERATIVE DIAGNOSES:
1. Chest pain.
2. Large anterior mediastinal mass.
3. High blood pressure.
POSTOPERATIVE DIAGNOSES:
1. As above.
2. Metastatic poorly differentiated thymoma with invasion to left innominate vein and right diaphragmatic implants x2, and invasion to anterior pericardium.
OPERATION PERFORMED:
1. Mini sternotomy with thymectomy.
2. Resection of left innominate vein with bovine pericardium reconstruction.
3. Resection of anterior pericardium with bovine pericardial repair.
4. Resection of right diaphragmatic implant site x2.
5. On-Q pain pump implant.
6. Infiltration of the periosteum with 0.5% Marcaine.
SURGEON: xxxxx
ASSISTANT: xxxxxx
INDICATION: This is a 69-year-old male, seen recently with severe pain involving anterior chest wall. This has been going on for several months. He has been unable to sleep due to the pain. He has tried multiple pain medications without success. He was evaluated, and there was no myocardial ischemia. A CT scan obtained revealed a large anterior mediastinal mass. The beta-hCG and alpha-fetoprotein were all negative. He is now admitted for resection of the mass.
DESCRIPTION OF PROCEDURE: Consent was obtained. He was identified. He was placed under general anesthesia. He was prepped and draped in the usual way. A timeout was held according to SCIP protocol. Ancef 1 g was given about half an hour prior to the incision.
An 8 cm incision was made over the manubrium to midway the body of the sternum. Dissection was used to divide the subcutaneous tissue. The external fascia was divided. The sternum was split into two halves. Findings, a hard mass in the anterior mediastinum. Using the left internal mammary artery retractor, the mass was carefully dissected off on the left pleural cavity. The left pleural cavity was intact with visualized position of the phrenic nerve. This was repeated on the right side. The mass was very firm and hard. Sharp and blunt dissections were used to divide the thyrothymic ligament. The superior poles of the thymus were reflected down. The dissection was continued on the left side taking care not to divide the phrenic nerve. This was also done on the right side. It was quite clear that the mass was almost removable. The pericardium was then incised close to the diaphragm. The pericardium was carefully dissected out. Exploration within the pericardial cavity revealed that there was no invasion of the aorta or its branches. Further dissection was used to isolate the superior vena cava, the left innominate vein entrance to the superior vena cava. It was quite clear that the mass was growing into the left innominate vein. The 7500 units of heparin was given. The innominate vein was clamped proximal and distal to the area of the mass. The innominate vein was then resected leaving a portion of the vein on the mass. Following this, the mass was divided. The pericardium attachment posteriorly was also divided at the takeoff of the head and neck vessels. A piece of the bovine pericardium was then prepared. This was anastomosed in a curve linear manner with 5-0 Prolene suture to the oval shape defect in the innominate vein. At the end, the clamps were removed. There was minimal bleeding, which was repaired with 6-0 Prolene suture. Attention was then turned to the right diaphragmatic implant. The right pleura was opened widely. Care was used to dissect out the pericardial fat pad by the costophrenic angle. Further inspection revealed 2 areas were hard implants on the pericardium. These were carefully dissected out taking care not to cause any defect in the pericardium. It was then reflected and submitted to the lab. Frozen section revealed poorly differentiated thymoma. A #28 [*] chest tube was left in the pericardial cavity. The defect in the pericardium was repaired using a bovine pericardial patch and 4-0 Prolene suture and that #28 chest tube was then placed to the right pleural cavity. An On-Q pump tubing was then placed. Marcaine 0.5% was infiltrated in the periosteum. The sternum was reapproximated with a #5 cables and cramp. The presternal fascia was closed with 0 Vicryl. The subcutaneous tissue was closed with 2-0 Vicryl and the skin was closed with 4-0 subcuticular Vicryl. Patient tolerated procedure well and was sent to recovery room.
Please note that modifier 22 will be applied for based on the extensive tumor resected involving the innominate vein, resection of the pericardium repair, and resection of the tumor implants on the right diaphragm. These procedures added at least 1-1/2 hours to 2 hours to the operation.
DATE OF OPERATION: 05/15/2013
PREOPERATIVE DIAGNOSES:
1. Chest pain.
2. Large anterior mediastinal mass.
3. High blood pressure.
POSTOPERATIVE DIAGNOSES:
1. As above.
2. Metastatic poorly differentiated thymoma with invasion to left innominate vein and right diaphragmatic implants x2, and invasion to anterior pericardium.
OPERATION PERFORMED:
1. Mini sternotomy with thymectomy.
2. Resection of left innominate vein with bovine pericardium reconstruction.
3. Resection of anterior pericardium with bovine pericardial repair.
4. Resection of right diaphragmatic implant site x2.
5. On-Q pain pump implant.
6. Infiltration of the periosteum with 0.5% Marcaine.
SURGEON: xxxxx
ASSISTANT: xxxxxx
INDICATION: This is a 69-year-old male, seen recently with severe pain involving anterior chest wall. This has been going on for several months. He has been unable to sleep due to the pain. He has tried multiple pain medications without success. He was evaluated, and there was no myocardial ischemia. A CT scan obtained revealed a large anterior mediastinal mass. The beta-hCG and alpha-fetoprotein were all negative. He is now admitted for resection of the mass.
DESCRIPTION OF PROCEDURE: Consent was obtained. He was identified. He was placed under general anesthesia. He was prepped and draped in the usual way. A timeout was held according to SCIP protocol. Ancef 1 g was given about half an hour prior to the incision.
An 8 cm incision was made over the manubrium to midway the body of the sternum. Dissection was used to divide the subcutaneous tissue. The external fascia was divided. The sternum was split into two halves. Findings, a hard mass in the anterior mediastinum. Using the left internal mammary artery retractor, the mass was carefully dissected off on the left pleural cavity. The left pleural cavity was intact with visualized position of the phrenic nerve. This was repeated on the right side. The mass was very firm and hard. Sharp and blunt dissections were used to divide the thyrothymic ligament. The superior poles of the thymus were reflected down. The dissection was continued on the left side taking care not to divide the phrenic nerve. This was also done on the right side. It was quite clear that the mass was almost removable. The pericardium was then incised close to the diaphragm. The pericardium was carefully dissected out. Exploration within the pericardial cavity revealed that there was no invasion of the aorta or its branches. Further dissection was used to isolate the superior vena cava, the left innominate vein entrance to the superior vena cava. It was quite clear that the mass was growing into the left innominate vein. The 7500 units of heparin was given. The innominate vein was clamped proximal and distal to the area of the mass. The innominate vein was then resected leaving a portion of the vein on the mass. Following this, the mass was divided. The pericardium attachment posteriorly was also divided at the takeoff of the head and neck vessels. A piece of the bovine pericardium was then prepared. This was anastomosed in a curve linear manner with 5-0 Prolene suture to the oval shape defect in the innominate vein. At the end, the clamps were removed. There was minimal bleeding, which was repaired with 6-0 Prolene suture. Attention was then turned to the right diaphragmatic implant. The right pleura was opened widely. Care was used to dissect out the pericardial fat pad by the costophrenic angle. Further inspection revealed 2 areas were hard implants on the pericardium. These were carefully dissected out taking care not to cause any defect in the pericardium. It was then reflected and submitted to the lab. Frozen section revealed poorly differentiated thymoma. A #28 [*] chest tube was left in the pericardial cavity. The defect in the pericardium was repaired using a bovine pericardial patch and 4-0 Prolene suture and that #28 chest tube was then placed to the right pleural cavity. An On-Q pump tubing was then placed. Marcaine 0.5% was infiltrated in the periosteum. The sternum was reapproximated with a #5 cables and cramp. The presternal fascia was closed with 0 Vicryl. The subcutaneous tissue was closed with 2-0 Vicryl and the skin was closed with 4-0 subcuticular Vicryl. Patient tolerated procedure well and was sent to recovery room.
Please note that modifier 22 will be applied for based on the extensive tumor resected involving the innominate vein, resection of the pericardium repair, and resection of the tumor implants on the right diaphragm. These procedures added at least 1-1/2 hours to 2 hours to the operation.
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