AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 3; Ask the Editor
Decortication of Lung
A patient with recent history of pneumonia with left empyema was admitted and underwent decortication surgery with drainage of a multiloculated collection. A standard thoracotomy was made and the latissimus dorsi, as well as serratus fascia, were divided. Dense adhesions of the chest wall were taken down by blunt and sharp dissection. There was mild to moderate pleural peel, involving the lateral and posterior aspect of both lobes, which was removed. All the loculi were broken down. The left lobe had a multiloculated collection that was also drained. The lung appeared to be expanding well, and therefore, was left alone. Provider documentation indicated decortication of both left upper and lower lobes. What is the appropriate root operation for the decortication procedure? What body part value is assigned for decortication of the left upper and lower lung lobes? ...
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Article Overview
This article explains a surgical lung decortication case and focuses on how the procedure is interpreted for ICD-10-PCS assignment. It is aimed at coders and CDI or coding educators who need to understand the relevant body system terminology, operative documentation, and code-building considerations for thoracic surgery cases.
Why This Topic Matters
Lung decortication cases can be documented in ways that require careful interpretation of the operative note and anatomy involved. Understanding the coding framework for this procedure helps support accurate assignment in thoracic surgery records.
What You Will Learn
- How a lung decortication case is described in operative documentation
- How the procedure relates to ICD-10-PCS coding concepts
- How thoracic anatomy and lobe documentation affect code assignment
- What information coders look for when reviewing decortication cases
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Coding educators
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