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?
In this case, extensive adhesiolysis of the pericardium and pleura was done. The appropriate body part values are “Pericardium” and “Pleura,” respectively, since the objective of the adhesiolysis in this case was to restore the pericardium and pleura by releasing the abnormal connections that the adhesions had established. The excision of pericardium should be coded as well, because the surgeon documented that the pericardium was extensively calcified, and was excised using electrocautery and scissors. Assign the following ICD-10-PCS codes: