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Removal of a chest tube

Pediatric Posted Thu 25th of August, 2016 12:33:51 PM
The patient has an indwelling chest tube from a thoracotomy procedure a few days prior. The chest tube could not be removed without the patient crying out in pain; therefore it was decided to take the patient to the operating room under anesthesia. Is there a code for this? Thank you for your response. PREOPERATIVE DIAGNOSIS:    1. Chest tube dysfunction. 2. Osteosarcoma.   PROCEDURE:  Chest tube removal.   POSTOPERATIVE DIAGNOSIS:    1. Chest tube dysfunction. 2. Osteosarcoma. female who has a history of osteosarcoma and pulmonary metastatic disease who underwent resection of pulmonary nodules about 4 days ago.  She had a chest tube placed routinely during the operation and was supposed to have her chest tube removed  today, but significant resistance was met, making it unable to be removed on the floor due to discomfort, as well as concerns that the chest tube was  going to fracture.  She is brought to the operating room.   TECHNIQUE:  The patient was brought to the operating room and general anesthesia was administered through an IV and mask airway.  The chest tube dressing was removed.  A Kelly clamp was placed at the skin level proximal to the sentinel hole to prevent air from re-entering the chest.  A significant amount of traction was placed, but initially the chest tube would not dislodge.  I attempted to try and rotate the tube 360 degrees but was unable  to, as though the tube was tethered somewhere on the inside of the chest. At this point, I opted to apply more pressure and traction, and eventually a popping sensation was felt and the chest tube dislodged completely but intact.The tube itself did not show any signs of fracture.  There was no rush of air to suggest a pneumothorax nor was there any bleeding from the site.  A 2 x 2 and Tegaderm dressing were applied.  She was transferred to  the PACU in stable condition, where a chest x-ray will be obtained.
SuperCoder Answered Fri 26th of August, 2016 07:13:19 AM

Hi,

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 customerservice@supercoder.com for more information.

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