VATS with exploration and Aspira catherter placement

angela.clayberg@mwhc.com

Hi - Coding Question:

Op performed:  R/L VATS w/exploration and Aspira catheter placement

Details:  Pleural space was notable for an area of loculations that were partially decorticated to free up the lung and create a common space mobilizing the fibrous cortex off the lung and liberating the lung to allow for free flowing effusion

Question is do you code the decortication or do you query MD to see if this was inherent to the procedure? 

Thanks!

morris-jeff@CooperHealth.edu

Wouldn't the decortication be the procedure and the VATS is just the approach? That's how we do our decortications and pleurodesis cases done video assisted

angela.clayberg@mwhc.com

I think the issue was that Surgeon said "partially decorticated" in the op description but didn't include it in the title of the procedure. 

morris-jeff@CooperHealth.edu

What's the preop dx? Empyema?

angela.clayberg@mwhc.com

Malignant pleural effusion plan was to place Aspira catheter but per description surgeon needed to perform partial decortication to place the catheter.