VATS surgery

Can someone please help? I am not sure if I should be billing for the decortication and pleurodesis. I was thinking 32608,32650 and possibly 32651 and of course 36556,76937 for CCVL w/US. But is the documentation enough to bill the decortication or is he just doing the mechanical pleurodesis?


The patient was taken to the operating room and after appropriate preop antibiotics were given and time-out was read, the patient was then located in the lateral decubitus position with the right side up and prepped and draped in the usual sterile fashion. The patients right side of the neck region was prepped and draped in a sterile fashion and anesthetized with 1% Lidocaine with epinephrine.  The internal jugular vein was entered and a wire was placed under ultrasound guidance.  A tract was dilated and triple lumen catheter was threaded over the wire and into the vein, all three ports were noted to flush and aspirate without difficulty. The line was secured with silk and a sterile dressing was applied

Using a #15 blade, right below the scapula and anterior to the dorsalis muscle, we made an incision about 1.5 cm.  Using a Kelly clamp, we went down to the pleura.  At this point, we were inserting our thoracoscopic port and the camera was inserted as well.  Then, we noted that the lung had some blebs in the lower lobe, that they were small, and there were some adhesions noted in the upper right lobe attached to the apex of the lung with some big blebs crossing over the top of the lung.  At this point, 2 more ports were placed, 1 between the 4th and 5th intercostal space anterior axillary line and another 1 below that in the posterior axillary line, those were placed under direct visualization in order not to injure the diaphragm and it was placed.  At this point, we started our dissection, suctioning all the small amount of fluid that was posterior anterior to the right upper lobe.  The right upper lobe was freed from those adhesions using the scissors and cautery.  At this point, the right upper lobe was examined and blebs were identified.  Using the Echelon stapler and green load, the blebs were wedged out using 2 loads.  At this point, appropriate hemostasis was achieved.  We started the decortication scoring the pleura with scissors and cautery.  After the pleura was scored using blunt dissection laparoscopically, we started to elevate the pleura and using the ring instruments, we started out mechanical pleurodesis in the upper part of the lung.  At this point, after both sides of the anterior posterior and lateral side of the upper lung were pleurodesed, we extracted the pleura from 1 of the ports.  Irrigation was then performed.  A local anesthesia was injected in the intercostal spaces.  Two chest tubes were inserted.  A 32-French chest tube that was posterior and was facing down and another 28-French chest tube that was anterior and facing all the way up to the apex.  The chest tubes were placed under direct visualization.  The lung was reinflated by Anesthesia and a watched to be reinflated under direct visualization with a thoracoscope.  The patient's incisions were closed with 0 Vicryl for fascia and 3-0 Vicryl for the dermal layer, and 4-0 Monocryl for the skin.  Dermabond was applied. Dressings were applied to the chest tubes.  Those 2 chest tubes were connected to the pleura suction in -20 mmHg.  The patient was awake and transported to the PACU and recovering in stable condition by Anesthesia.  We will obtain a chest x-ray stat to see how the lungs re-expanded.  The patient will be sent to the ICU for recovering.  All the counts were correct.  No complications.
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