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how to code for take-back for pack removal/bleeding after previous thoracotomy?

Lynn Posted Tue 15th of March, 2016 18:39:09 PM

Not sure how to code this.

Patient was previously taken to OR for bleeding. THoracotomy was performed and chest was packed with lap sponges.

Today's case was take back, remove packs, look for bleeding, wash Out. There was minimal bleeding so the chest was covered with a plastic dressing. Will have to go back in a few days for re-exploration and possible closure.


SuperCoder Answered Wed 16th of March, 2016 03:27:47 AM

For the first visit when thoracotomy was performed, CPT code 32100 with modifier 53 would be appropriate.
In the second visit only the dressing was done and since its a thoracotomy procedure, so we assume it to be done under anaesthesia, therefore, CPT code 15852 would be appropriate.

Lynn Posted Wed 16th of March, 2016 07:46:20 AM

what codes would be appropriate for the re-exploration and closure? Thanks for the other answers.

Lynn Posted Thu 17th of March, 2016 03:38:57 AM

actually turns out the chest closure was not done only the re-exploration--what code please

SuperCoder Answered Mon 21st of March, 2016 03:11:47 AM

CPT code 32100 would be appropriate in this scenario. If the patient is returning in the same global period then append modifier 78 with the CPT code.
Closure is inclusive of this procedure.

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