Question:
Vickie Hyde Bodden:
Hi my name is Vickie Hyde Bodden, I'm Cardiothoracic Coder for the last two years it's very challenging.
That's why I'm in need of some help for this Opt Report......
PREOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve replacement. Postoperative course complicated with respiratory insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
POSTOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve replacement. Postoperative course complicated with respiratory insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
PROCEDURE PERFORMED:
Sternal rewiring using Robicsek technique, insertion of irrigation system catheters with mediastinal and right pleural chest tube, bilateral myocutaneous pectoralis muscle flap advancements, and
insertion of a new right subclavian vein Quinton catheter for
hemodialysis.
SURGEON:
ASSISTANT:
ANESTHESIA: General endotracheal.
INDICATIONS:
The patient is a 66-year-old gentleman who is status post coronary artery bypass grafting and aortic valve replacement about a couple of weeks back. His postoperative course was complicated with respiratory insufficiency and renal insufficiency requiring CVVH and hemodialysis.
The patient developed complete sternal dehiscence and was subsequently scheduled for sternal rewiring.
DESCRIPTION OF PROCEDURE:
He was taken to the operating room on 03/13/2013. General anesthesia was induced, intubated, and the area of the chest was prepped and draped per routine fashion. The sternal incision was reopened. There was a lot of fluid which was sent for culture and sensitivity. After drainage of all fluid, the sternum was felt to be complete dehisced with wires on both sides of the sternum and completely torn to either side of the sternum.
There was about a 2 to 3 cm separation from both sternal edges. All wires were removed.
Dissection was carried out initially on the inferior plate of the sternum on both sides in order to get a plane in order to be able to place new wires in a Robicsek fashion. So, dissection was carried on both sides of the posterior edges of the sternum. The right side pleura was violated, and subsequently a right pleural chest tube was placed.
The left side was not violated. Once good dissection was carried out to separate the mediastinum and pericardium from the posterior sternal sides on both sides. Attention was then drawn to the myocutaneous pectoralis area. Advancement flaps were performed on both sides in order to be able to reapproximate the muscle and fascia, and the skin without any tension. Good hemostasis was felt to be noted in both flaps. Once exposure was felt to be appropriate on the top and bottom of the sternum, the closure was undertaken in a Robicsek fashion after copious irrigation og the mediastinum was undertaken with warm antibiotic solution.
Sternal wires were
placed in a vertical manner on both sides of the sternum, and subsequently a total of eight stainless steel horizontal wires were placed horizontally to reapproximate the sternum. A couple of them were closed in a figure-of-eight. Prior to doing that, copious irrigation of the whole mediastinum was undertaken. Some tissues were also sent from debridement of the bones of the sternum. Two mediastinal chest tubes were placed, as well as a red rubber catheter for irrigation was also placed in the mediastinum. Subsequently, the two edges of the sternum were reapproximated with the help of the horizontal wires.
Subsequently, confirmation again of the myocutaneous flaps was undertaken for good hemostasis. Two JP drains were placed one under each muscle flap. Subsequently, using interrupted 0 Vicryl in a figure-of-eight manner, the myocutaneous flaps were reapproximated.
After that, a single layer of 0 Vicryl fascial layer closure was undertaken, and the skin was closed with staples. Also, using the right subclavian approach, a Quinton catheter with two lumens for hemodialysis was placed. Using an introducer needle, the right subclavian vein was localized, through which a guide wire was passed. The needle was taken off. Over the guide wire, dilators were passed to make a tract using A seldinger_______ maneuver and subsequently, the dilators were removed, and over the guidewire the Quinton catheter was passed into the subclavian all the way to the right atrial- SVC junction. Good blood return was noted. Chest x-ray was Then ordered to rule out pneumothorax and confirm positioning of the catheter. Subsequently, the catheter was sutured into place. Irrigation was also initiated through the red rubber catheter with bacitracin at 50 mL an hour, and the patient was transferred back to the intensive care unit intubated, on some minor inotropic support in a stable condition.
Can someone please help me with the Operative Report I'm confused with this one, thanks in advance for any help.......
Answer:
Ruth Sheets:
During the June Q&A Webinar, Alicia tackled this op report and showed how to pull key terms out to determine how to code it.
ICD terms:
Vickie Hyde Bodden:
Hi my name is Vickie Hyde Bodden, I'm Cardiothoracic Coder for the last two years it's very challenging.
That's why I'm in need of some help for this Opt Report......
PREOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve replacement. Postoperative course complicated with respiratory insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
POSTOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve replacement. Postoperative course complicated with respiratory insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
PROCEDURE PERFORMED:
Sternal rewiring using Robicsek technique, insertion of irrigation system catheters with mediastinal and right pleural chest tube, bilateral myocutaneous pectoralis muscle flap advancements, and
insertion of a new right subclavian vein Quinton catheter for
hemodialysis.
SURGEON:
ASSISTANT:
ANESTHESIA: General endotracheal.
INDICATIONS:
The patient is a 66-year-old gentleman who is status post coronary artery bypass grafting and aortic valve replacement about a couple of weeks back. His postoperative course was complicated with respiratory insufficiency and renal insufficiency requiring CVVH and hemodialysis.
The patient developed complete sternal dehiscence and was subsequently scheduled for sternal rewiring.
DESCRIPTION OF PROCEDURE:
He was taken to the operating room on 03/13/2013. General anesthesia was induced, intubated, and the area of the chest was prepped and draped per routine fashion. The sternal incision was reopened. There was a lot of fluid which was sent for culture and sensitivity. After drainage of all fluid, the sternum was felt to be complete dehisced with wires on both sides of the sternum and completely torn to either side of the sternum.
There was about a 2 to 3 cm separation from both sternal edges. All wires were removed.
Dissection was carried out initially on the inferior plate of the sternum on both sides in order to get a plane in order to be able to place new wires in a Robicsek fashion. So, dissection was carried on both sides of the posterior edges of the sternum. The right side pleura was violated, and subsequently a right pleural chest tube was placed.
The left side was not violated. Once good dissection was carried out to separate the mediastinum and pericardium from the posterior sternal sides on both sides. Attention was then drawn to the myocutaneous pectoralis area. Advancement flaps were performed on both sides in order to be able to reapproximate the muscle and fascia, and the skin without any tension. Good hemostasis was felt to be noted in both flaps. Once exposure was felt to be appropriate on the top and bottom of the sternum, the closure was undertaken in a Robicsek fashion after copious irrigation og the mediastinum was undertaken with warm antibiotic solution.
Sternal wires were
placed in a vertical manner on both sides of the sternum, and subsequently a total of eight stainless steel horizontal wires were placed horizontally to reapproximate the sternum. A couple of them were closed in a figure-of-eight. Prior to doing that, copious irrigation of the whole mediastinum was undertaken. Some tissues were also sent from debridement of the bones of the sternum. Two mediastinal chest tubes were placed, as well as a red rubber catheter for irrigation was also placed in the mediastinum. Subsequently, the two edges of the sternum were reapproximated with the help of the horizontal wires.
Subsequently, confirmation again of the myocutaneous flaps was undertaken for good hemostasis. Two JP drains were placed one under each muscle flap. Subsequently, using interrupted 0 Vicryl in a figure-of-eight manner, the myocutaneous flaps were reapproximated.
After that, a single layer of 0 Vicryl fascial layer closure was undertaken, and the skin was closed with staples. Also, using the right subclavian approach, a Quinton catheter with two lumens for hemodialysis was placed. Using an introducer needle, the right subclavian vein was localized, through which a guide wire was passed. The needle was taken off. Over the guide wire, dilators were passed to make a tract using A seldinger_______ maneuver and subsequently, the dilators were removed, and over the guidewire the Quinton catheter was passed into the subclavian all the way to the right atrial- SVC junction. Good blood return was noted. Chest x-ray was Then ordered to rule out pneumothorax and confirm positioning of the catheter. Subsequently, the catheter was sutured into place. Irrigation was also initiated through the red rubber catheter with bacitracin at 50 mL an hour, and the patient was transferred back to the intensive care unit intubated, on some minor inotropic support in a stable condition.
Can someone please help me with the Operative Report I'm confused with this one, thanks in advance for any help.......
Answer:
Ruth Sheets:
During the June Q&A Webinar, Alicia tackled this op report and showed how to pull key terms out to determine how to code it.
ICD terms:
- Post CABG
- Post Valve Replacement
- Complication Respiratory Insufficiency
- Chronic Renal Insufficiency
- Dialysis Status (Has to have started Dialysis)
- Sternal Dehiscence
- 15732 - Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
- Tube Insertion
- Hemodialysis Catheter