Sandra Posted Mon 02nd of March, 2015 16:01:12 PM
How to code the following:
The patient presented with Pancoast tumor, resulting in left arm weakness, especially involving the hand and severe pain. Known lung cancer; large mass documented in apex of left ling and apex of left thoracic cage. Combined procedure was with cardiothoracic surgeon who would remove intrathoracic portion of tumor.
After intrathoracic portion of the tumor was removed, neurosurgery assumed care. The T3 pedicle was identified. The foraminal extension of the tumor was followed into the spinal sac with removal of the pedicle of T3 along with removal of the superior and inferior articular processes of T3. A portion of the superior articular process of T4 was also trimmed away to gain adequate access. Then lateral dissection in the spinal canal was extended superiorly and inferiorly until the entire extent of the tumor was exposed. The tumor was found totally in the epidural space and did not infiltrate the dura nor did it extend into the intradural space. The tumor was carefully separated from the underlying dura and removed gross totally. The T3 nerve root was divided and the nerve root sleeve was occluded with hemoclips. The the clusore was carried out by cardiovascular surgeon.
SuperCoder Answered Wed 04th of March, 2015 06:15:22 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.