maine4me
Guru
Can someone please help me with this operative note? The doctor reported CPT code 32651, and I do not believe this is correct. I do not see where any agents were introduced into the lung, it reads that the loculations were broken up with a sterile glove finger. Plus the two chest tubes, can both be coded?
PREOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.
POSTOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.
OPERATION: Video assisted thoracic surgery with drainage of loculations, lysis of
adhesions and placement of large bore chest tubes.
ANESTHESIA: General by IV and double lumen endotracheal tube.
PROCEDURE AND FINDINGS: The patient was brought to the Operating Room, properly
identified. He was already intubated because of respiratory failure in the ICU. The
preoperative diagnosis, procedure and site were confirmed on time out. The patient was
already on IV antibiotics. He had sequential TEDs placed and a Foley already in place. He
had exchange of the single lumen tube for a double lumen endotracheal tube by Anesthesia
Department. He was then placed in a right lateral decubitus position with the left side
up. Beanbag was used for stabilization. Care was taken regarding his pressure points. The
left arm was out on an arm retractor. The left chest wall was then prepped with
ChloraPrep per protocol and draped applied. Incision was made at the fifth interspace at
the anterior axillary line and carried down sharply with electrocautery and the pleural
space was entered with a Kelly and then gloved finger. Adhesions and loculations were
broken up with sterile gloved finger and then the trocar was inserted. Smelly, blood
tinged, cloudy fluid was suctioned and placed into containers for cytology, fluid
analysis and cultures. Further suctioning was done until at least a liter or more of
fluid was obtained. Two additional trocars were then inserted under direct vision of the
thoracoscope. There were multiple areas of loculations and fibrinous exudate. These were
all carefully lysed until at the end there were no other pockets or loculations noted.
The entire chest cavity appeared to be communicating. There was no obvious sign of tumor
and no other biopsies were performed. The chest was then irrigated with saline and
suctioned dry and two 36 French tubes were inserted through the two more anterior trocar
sites and directed posterior and superiorly and more medially and superiorly. The
thoracoscope was then left in long enough just to see that the lung was expanding nicely.
The chest tubes were secured to the skin with two heavy silk sutures each and the other
trocar site was closed using 0 Vicryl to the intercostal muscle and to the chest wall
muscles with 3-0 Vicryl to the sub-cu and then 4-0 Monocryl and Steri-Strips to the skin.
Dressings were then applied and taped in place and the chest tubes were attached to two
separate Thora-Klex systems. He tolerated the procedure well and afterwards was changed
to a supine position and the double lumen tube was again exchanged to a single lumen by
Anesthesia Department.
He left the Operating Room in stable condition being ventilated manually to return to the
ICU to continue on the ventilator.
PREOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.
POSTOPERATIVE DIAGNOSIS: Massive multiloculated empyema left chest.
OPERATION: Video assisted thoracic surgery with drainage of loculations, lysis of
adhesions and placement of large bore chest tubes.
ANESTHESIA: General by IV and double lumen endotracheal tube.
PROCEDURE AND FINDINGS: The patient was brought to the Operating Room, properly
identified. He was already intubated because of respiratory failure in the ICU. The
preoperative diagnosis, procedure and site were confirmed on time out. The patient was
already on IV antibiotics. He had sequential TEDs placed and a Foley already in place. He
had exchange of the single lumen tube for a double lumen endotracheal tube by Anesthesia
Department. He was then placed in a right lateral decubitus position with the left side
up. Beanbag was used for stabilization. Care was taken regarding his pressure points. The
left arm was out on an arm retractor. The left chest wall was then prepped with
ChloraPrep per protocol and draped applied. Incision was made at the fifth interspace at
the anterior axillary line and carried down sharply with electrocautery and the pleural
space was entered with a Kelly and then gloved finger. Adhesions and loculations were
broken up with sterile gloved finger and then the trocar was inserted. Smelly, blood
tinged, cloudy fluid was suctioned and placed into containers for cytology, fluid
analysis and cultures. Further suctioning was done until at least a liter or more of
fluid was obtained. Two additional trocars were then inserted under direct vision of the
thoracoscope. There were multiple areas of loculations and fibrinous exudate. These were
all carefully lysed until at the end there were no other pockets or loculations noted.
The entire chest cavity appeared to be communicating. There was no obvious sign of tumor
and no other biopsies were performed. The chest was then irrigated with saline and
suctioned dry and two 36 French tubes were inserted through the two more anterior trocar
sites and directed posterior and superiorly and more medially and superiorly. The
thoracoscope was then left in long enough just to see that the lung was expanding nicely.
The chest tubes were secured to the skin with two heavy silk sutures each and the other
trocar site was closed using 0 Vicryl to the intercostal muscle and to the chest wall
muscles with 3-0 Vicryl to the sub-cu and then 4-0 Monocryl and Steri-Strips to the skin.
Dressings were then applied and taped in place and the chest tubes were attached to two
separate Thora-Klex systems. He tolerated the procedure well and afterwards was changed
to a supine position and the double lumen tube was again exchanged to a single lumen by
Anesthesia Department.
He left the Operating Room in stable condition being ventilated manually to return to the
ICU to continue on the ventilator.