Coding Surgical Procedures


Vol. 13 •Issue 24 • Page 9
Coding Corner

Coding Surgical Procedures

Case Study 1: Hemic and Lymphatic System

Preoperative Diagnosis: Left posterior cervical lymphadenopathy

Postoperative Diagnosis: Left posterior cervical lymphadenopathy

Procedure Performed: Excision of left cervical lymph node, 1.5 cm

Anesthesia: Local with intravenous (IV) sedation

Operative Technique: The patient was taken to the operating room and was placed in the supine position on the operating table. IV sedation was induced without complication.

After adequate sedation had been obtained, the left neck was prepped and draped with Betadine scrub, and the patient was draped in the usual sterile surgical fashion. Under local anesthesia with 1 percent Xylocaine, a transverse incision was made in the left posterior cervical triangle, carried down through subcutaneous tissue and platysma, identifying the posterior border of the posterior cervical triangle.

Dissecting anterior to this, a 1.5 cm lymph node was dissected out. Its neurovascular bundle was doubly clipped with hemoclips and divided. The specimen was then passed off for pathologic examination. Hemostasis was secured.

The wound was closed in layers with interrupted #3-0 Vicryl for the deep layers and running subcuticular #4-0 undyed Vicryl for skin. Steri-Strips were applied. A sterile dressing was applied.

The patient tolerated the procedure well and was taken to the postanesthetic recovery room in stable and satisfactory condition.

Coding Rationale and Assignments

As stated above, the surgeon first made an incision to remove a lymph node. Normally, a physician will remove superficial nodes, which means that the incision does not extend past subcutaneous tissue.

However, in the above case, the lymph node removed was a deep cervical lymph one. As a result, the incision extended through muscle tissue.

You would first look in the index under the term Excision, then Lymph Nodes. The following codes are listed: 38500, 38510-38530. After checking the descriptions in the manual, you will see that the following is the correct code to assign for both the facility and professional components. Your choice is determined by the fact that this procedure involved a “deep” node.

38510 Biopsy or excision of lymph node(s); open, deep cervical node(s)

The following would be assigned as both the preoperative and postoperative ICD-9-CM code.

785.6 Enlargement of lymph nodes

Case Study 2: Mediastinum and Diaphragm

Preoperative Diagnosis: Mediastinal lymphoma

Postoperative Diagnosis: Small cell carcinoma of the lung with mediastinal invasion

Procedure Performed: Bronchoscopy and mediastinotomy, right anterior approach

Anesthesia: General

Operative Indications: The patient is a middle-aged male with early superior vena cava syndrome and evidence of a large mid and anterior mediastinal mass. Biopsy was advised to establish diagnosis and consider further treatment.

Operative Procedure: Under general anesthesia, a bronchoscopy was performed that did not disclose any intrinsic lesions of the airway. There was external compression noted on the right stem bronchus.

The patient was then prepared for anterior mediastinotomy on the right side.

A transverse incision was made, and we entered the anterior mediastinum by resecting the anterior one-third of the second rib. All bleeding points were controlled including interruption of the internal mammary artery and vein. A large, anterior mediastinal mass was palpable. A biopsy was taken and was positive for probable small cell carcinoma. Hemostasis was completed. The wound was closed in layered fashion. Sterile dressings were applied. The patient was moved to the recovery room in stable condition. An X-ray was taken in the operating room to exclude pneumothorax.

Pathological Findings: Mediastinal mass is positive for small cell carcinoma.

Coding Rationale and Assignments

As stated, the physician performed the bronchoscopy to determine whether the mediastinal lymphoma had spread to the bronchi or lungs. A biopsy was taken via a mediastinotomy.

In the CPT index, you would first check the term Bronchoscopy and under that the term Exploration. You will see that code 31622 is listed.

For the biopsy, you would check in the index under the term Mediastinum, then the term Exploration. The code range 39000-39010 is listed. Checking those codes will lead you to correct code 39010, which describes a biopsy of mediastinal tumor.

The following codes would be assigned for both the facility and professional components. Note that for the professional component you also must assign modifier 51 (multiple procedures) to code 31622.

39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy;

transthoracic approach, including either transthoracic or median sternotomy

31622 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure)

The patient’s preoperative diagnosis is listed as a mediastinal lymphoma. ICD-9-CM code 202.82 would be assigned for this condition. The postoperative diagnosis is small cell carcinoma of the lung with mediastinal invasion for which codes 162.9 and 197.1 would be assigned.

Preoperative: 202.82 Other lymphomas of intrathoracic lymph nodes

Postoperative:162.9 Malignant neoplasm of bronchus and lung, unspecified

197.1 Secondary malignant neoplasm of mediastinum:

Kathleen A. Mundy is manager of consulting services, physician division, with Medical Learning (MedLearn®), St. Paul, MN.

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