lsilbaugh
Contributor
Im helping a fellow coder out and i have never coded cvts. how would this report be coded? Im getting stuck with the injury/anastomosis
i got cpt 32840-22,38746,32507,33320
Preoperative Diagnosis:
RUL lung cancer, s/p chemotherapy.
Postoperative Diagnosis: RUL lung cancer, s/p chemotherapy. RLL lung cancer
Procedure(s) Performed:
1. Right serratus muscle sparing mini lateral thoracotomy, extensive lysis of adhesions.
2. RUL lobectomy, Med LN dissection.
3. Cryoanalgesia spent 30 min4. intercostal nerve block.
5. Repair of injured right PA.
6. RML lobectomy.
7. RLL nodule wedge biopsy.6. chest tube placement.
Complications:
Accidental right PA injury during RUL lobectomy which was successfully repaired. Patient has been stable throughout the incident with blood loss about 150ml in the cell saver and estimated total blood loss about 200ml for the entire case.
Findings: Enlarged LN at locations described above and sent for pathology.
Due to vascular injury, we had to remove her right middle lobe which was a smaller lobe compared to right upper and right lower lobes.
Incidental finding of RLL lung nodule with finger palpation, wedge resectional biopsy showed NSCLC by frozen section
Operative Technique: right mini lateral thoracotomy with sparing of anterior serratus muscle was performed. The dense adhesions mostly from RUL to chest wall was encountered, extensive LOA was performed to free the lung off the chest wall. The cryoanalgesia was performed using AtriCure cryoprobe to freeze the intercostal nerves from 3rd through 8th intercostal space, each 2min. This spent about 30 min.
After that, I performed the intercostal nerve block using exparel and marcaine mixture from 3rd to 9th intercostal space. After that, I started dissection around the right superior PV RUL branch, and stapled and transected it using an endostapler. After that, I carefully dissected and transected the RUL PA using endostaplers. Next, I dissected, stapled and transected the RUL bronchus. Lastly, I stapled and separate the incomplete fissure between RUL and RLL, also RUL and RML.
The RUL lobe was removed in its entirety and sent for pathology to check the bronchial margin which was reported as negative for Ca. However, I found the aberrant right PA that was supposed to be RUL was actually right main PA that was transected. At this time, I asked anesthesia to give heparin 5000 units IV and ensure the ACT > 250 with additional heparin if needed. Then, I used vascular clamps to control the both end of the PA stumps (one was right main PA, another was RLL and RML PA trunk). I then removed the staples at the stump of both ends, used 6-0 prolene suture and did the anastomosis to bring right main PA with RLL PA back together with continuous running fashion, after careful de-air, the anastomosis was completed. clamps were removed, blood flow restored going into RLL. After that, protamine 25mg was given iv to reverse the heparin. However, I found RML PA was too short from the anastomosis and had to be clipped from the bleeding. So, I ended up having to remove RML in the anatomic way after further dissection. The LN dissection was performed along the way with lobectomy and after. I found and removed the LNs from station 7, 8, 10 and11 which were sent for pathology.
At this time, the right chest cavity was irrigated copiously with warm sterile water followed by ABX solution. The air leak was check from the bronchial stump and lung parenchyma which was found none. 2 chest tubes were inserted, angled one to the base, straight one to the apex which all anchored to the skin with 0 silk sutures. The thoracotomy was closed with #1 vicryl sutures in figure of 8 interrupted fashion. The wound was irrigated with antibiotic solution. The wound was closed in layers with Vicryl sutures. Then, a sterile dressing was applied. All the needles, sponges, and instruments were counted twice prior and after the procedure. The patient tolerated the procedure well, extubated and was sent back to the ICU in satisfactory condition.
i got cpt 32840-22,38746,32507,33320
Preoperative Diagnosis:
RUL lung cancer, s/p chemotherapy.
Postoperative Diagnosis: RUL lung cancer, s/p chemotherapy. RLL lung cancer
Procedure(s) Performed:
1. Right serratus muscle sparing mini lateral thoracotomy, extensive lysis of adhesions.
2. RUL lobectomy, Med LN dissection.
3. Cryoanalgesia spent 30 min4. intercostal nerve block.
5. Repair of injured right PA.
6. RML lobectomy.
7. RLL nodule wedge biopsy.6. chest tube placement.
Complications:
Accidental right PA injury during RUL lobectomy which was successfully repaired. Patient has been stable throughout the incident with blood loss about 150ml in the cell saver and estimated total blood loss about 200ml for the entire case.
Findings: Enlarged LN at locations described above and sent for pathology.
Due to vascular injury, we had to remove her right middle lobe which was a smaller lobe compared to right upper and right lower lobes.
Incidental finding of RLL lung nodule with finger palpation, wedge resectional biopsy showed NSCLC by frozen section
Operative Technique: right mini lateral thoracotomy with sparing of anterior serratus muscle was performed. The dense adhesions mostly from RUL to chest wall was encountered, extensive LOA was performed to free the lung off the chest wall. The cryoanalgesia was performed using AtriCure cryoprobe to freeze the intercostal nerves from 3rd through 8th intercostal space, each 2min. This spent about 30 min.
After that, I performed the intercostal nerve block using exparel and marcaine mixture from 3rd to 9th intercostal space. After that, I started dissection around the right superior PV RUL branch, and stapled and transected it using an endostapler. After that, I carefully dissected and transected the RUL PA using endostaplers. Next, I dissected, stapled and transected the RUL bronchus. Lastly, I stapled and separate the incomplete fissure between RUL and RLL, also RUL and RML.
The RUL lobe was removed in its entirety and sent for pathology to check the bronchial margin which was reported as negative for Ca. However, I found the aberrant right PA that was supposed to be RUL was actually right main PA that was transected. At this time, I asked anesthesia to give heparin 5000 units IV and ensure the ACT > 250 with additional heparin if needed. Then, I used vascular clamps to control the both end of the PA stumps (one was right main PA, another was RLL and RML PA trunk). I then removed the staples at the stump of both ends, used 6-0 prolene suture and did the anastomosis to bring right main PA with RLL PA back together with continuous running fashion, after careful de-air, the anastomosis was completed. clamps were removed, blood flow restored going into RLL. After that, protamine 25mg was given iv to reverse the heparin. However, I found RML PA was too short from the anastomosis and had to be clipped from the bleeding. So, I ended up having to remove RML in the anatomic way after further dissection. The LN dissection was performed along the way with lobectomy and after. I found and removed the LNs from station 7, 8, 10 and11 which were sent for pathology.
At this time, the right chest cavity was irrigated copiously with warm sterile water followed by ABX solution. The air leak was check from the bronchial stump and lung parenchyma which was found none. 2 chest tubes were inserted, angled one to the base, straight one to the apex which all anchored to the skin with 0 silk sutures. The thoracotomy was closed with #1 vicryl sutures in figure of 8 interrupted fashion. The wound was irrigated with antibiotic solution. The wound was closed in layers with Vicryl sutures. Then, a sterile dressing was applied. All the needles, sponges, and instruments were counted twice prior and after the procedure. The patient tolerated the procedure well, extubated and was sent back to the ICU in satisfactory condition.
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