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Mediastinal exploration and drainage of pleural effusion

Sonnia Posted Thu 19th of May, 2016 11:11:46 AM
Is it correct to use 39010 for mediastinal exploration if yellow fluid was suctioned clear. What is the code for drainage of pleural effusion?
SuperCoder Answered Fri 20th of May, 2016 02:16:06 AM
Please see codes 32556/32557 for pleural drainage, depending upon the details of your case. As long as code 39010 is concerned, please send more details of the case so that we can help you with a specific answer. Thank you.
Sonnia Posted Mon 23rd of May, 2016 13:03:25 PM
The previous median sternotomy incision was opened down to the bone where the old wires were removed. The bone was opened very carefully with the oscillating saw. The underlying soft tissues were separated from the bone with cautery technique. On the right side, we entered the strange yellow fluid filled cavity and cultured this, then suctioned it clear. There was a little bleeding from the innominate vein as we came across this area and it was controlled with pressure and then with two pledgeted sutures of 4-0 Prolene. The retractor was placed and spread gently. The right pleural space was opened widely and the effusion drained. The lung was expanded with recruitment maneuvers and came up very nicely. There was no “peel” on the lung to restrict it. Then it was consulted and decided with other cardiothoracic surgeons to place a Pleurex catheter. A pleurex catheter was tunneled, placed, and positioned in the sulcus at the bottom of the right chest.
SuperCoder Answered Tue 24th of May, 2016 03:45:13 AM
Yes code 39010 seems appropriate for the given scenario, however as per CCI edits there is a conflict when reporting this code with either codes 32556 or 32557, which can be unbundled using a modifier.

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