AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 2; Ask the Editor
Pericardiectomy for Constrictive Pericarditis
The patient is a 72-year-old who was admitted with heart failure secondary to constrictive pericarditis, and underwent pericardiectomy involving excision of the pericardium and lysis of adhesions. At surgery, calcified portions of the pericardium were excised anterior to the phrenic nerve. The apex and diaphragmatic borders of the heart were additionally lysed of adhesions. Extensive calcifications of the diaphragmatic pericardium were excised, and dissection was carried out posteriorly to the level of the left atrium, where pericardium was excised. On the right side of the heart, pericardium was dissected off the surfaces of the right ventricle, right atrium, superior vena cava (SVC) and aorta. Extensive adhesions and scarring of the right pleura were lysed. Pericardium was excised from the anterior surface of the SVC. The heart was freed from adhesions to the pericardium using sharp dissection. Although the pericardium was excised, it appears that the surgical objective is adhesiolysis to free the heart from the pericardium. However, there is no body part value for heart on the Release table 02N. What is the appropriate procedure code for this surgery? ...
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Article Overview
This article covers an operative case involving constrictive pericarditis and surgical removal of pericardium with extensive lysis of adhesions. It is relevant to coders and CDI professionals working with cardiothoracic surgery documentation, operative reporting, and procedure identification. The discussion centers on how the documented surgical work is characterized for coding purposes in a complex heart and pericardium case.
Why This Topic Matters
Accurate interpretation of complex cardiothoracic operative notes affects procedure selection, compliance, and correct representation of the surgical work performed.
What You Will Learn
- How a constrictive pericarditis operative note is described in coding-focused language.
- What documentation elements in a pericardial surgery case are emphasized for procedural interpretation.
- How complex adhesions and pericardial dissection are presented in a cardiothoracic operative record.
- Questions that arise when determining the principal procedural focus in a pericardial surgery case.
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Cardiothoracic surgery billers
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