How Would You Code This?

Greetings! How would you code the following op note? Please note, we are using a team approach with surgeons from urology, vascular, and cardiothoracic depending on the level of the tumor thrombus. I do not believe CPT code 50230 is intended for an extensive thrombectomy and this is where I am running into trouble with the codes and the "other" coders. Any advice and/or feedback is greatly appreciated! Thank you!

DATE OF SURGERY: 01/19/2017

Cardiac surgeon was present for oversight of the perfusionist for Cell
Saver and possible venovenous bypass and was on standby to perform
sternotomy to assist with suprahepatic control in case needed.


PREOPERATIVE DIAGNOSIS
Right renal mass with IVC tumor thrombus (level 3).

POSTOPERATIVE DIAGNOSIS
Right renal mass with IVC tumor thrombus (level 3).

TITLE OF PROCEDURE
1. Right radical nephrectomy.
2. IVC tumor thrombectomy.
3. Retroperitoneal lymph node dissection.
4. Total hepatic mobilization

TYPE OF ANESTHESIA
General anesthesia.

OPERATIVE FINDINGS
1. Large right renal mass with level 3 tumor thrombus.
2. Complete rem oval of tumor thrombus.
3. Very high BMI, more than 51, which increased the complexity of surgery
modifier 22.

OPERATIVE SPECIMENS
Right radical nephrectomy specimen with IVC tumor thrombus, IVC final
margin.

ESTIMATED BLOOD LOSS
2.5 liters.

TRANSFUSIONS
8 units of RBCs, 8 units FFP,cryoprecipitate, 1 platelet.

OPERATIVE INDICATIONS
The patient is a 51-year-old gentleman with a large complex right renal
mass with IVC tumor thrombus. He has been severely symptomatic with
increasing lower extremity swelling, progressive jaundice, fatigue, anemia
requiring blood transfusions, and dizziness. His thrombus has progressed
based on review of outside scans. Therefore, the above-mentioned procedure
is indicated. The patient was seen in clinic this past week and to
expedite his care was admitted to the urology service and we performed an
expedited workup and scheduled him for this procedure. The informed
consent, risks and complications have been extensively discussed and
documented in my clinic note and progress note from this morning.

DRAINS
Foley catheter.

NARRATIVE OF PROCEDURE
The patient was brought to the operating room and placed in supine
position. After the smooth induction of anesthesia, all his pressure
points were adequately padded. Cardiac anesthesiologist
was available and performed a transesophageal echocardiogram. This was
performed throughout the case in a real-time fashion. A Foley catheter was
placed after central line and arterial line were placed. The patient was
secured in supine position, prepped and draped in a standard surgical
fashion.

Chevron incision was made extending from the left to the right side.
External oblique, internal oblique, transversus abdominis and rectus
muscles were incised to enter into the abdomen. Complete inspection of the
peritoneum was performed. No evidence of gross metastasis was seen. The
disease appeared to be locally advanced as indicated by extensive
involvement of the right retroperitoneum and large tumor thrombus with
extensive collateral vessels which were very friable. Also note that the
patient had elevated INR of 1.8 on induction for which he received
cryoprecipitate and fresh frozen plasma. We then mobilized the right colon
medially at the white line of Toldt as well as the retroperitoneal space.
The duodenum was kocherized and the inferior vena cava was identified and
cleaned off of fibrofatty tissue.

The right renal artery was identified and lateral to the cava dissected off
and then taken down with the Endo-GIA stapler. There was an accessory
renal artery, which was taken down at the inferior pole using the Endo-GIA
stapler. We then performed mobilization of the liver and retracted
cranially to expose the IVC underneath, cleaning off the caudate lobe.
This portion required tedious dissection as the caudate lobe was wrapped
around the IVC. We tied off some of the accessory hepatics and short
hepatics. We sequentially tied off the accessory hepatic veins draining
into the IVC from the caudate lobe. We then mobilized the liver
completely. Intraoperative ultrasound was performed to locate the tumor
thrombus level. We were able to gently pull the thrombus below the hepatic
veins and were able to get a Rumel below the hepatic vein. Once we had
control of the IVC above the tumor thrombus but below the hepatic vein, we
obtained sequential control of the left renal vein and inferior vena cava
below the renal vein. We tied off all the lumbars which drained this
segment of the inferior vena cava.

Once this was done, we performed a test clamp to insure that the patient
would tolerate clamping of the inferior vena cava, which he did. At this
point we cinched the Rumel tourniquet sequentially above the tumor
thrombus, the supra tumor thrombus Rumel followed by left renal vein and
IVC Rumel. We then made tennis racquet incision circumferentially around
the renal vein and extended the midline into the IVC. We were able to
extract the tumor thrombus from the IVC along with the kidney. The IVC was
then carefully inspected. No residual tumor thrombus was seen. We then
closed the IVC defect with 4-0 Prolene. We did send a final margin from
the IVC around the renal vein area. Once we were completely certain that
there was no residual tumor confirmed by intraoperative transesophageal
echocardiogram, we elected to close the IVC in a continuous fashion with
4-0 Prolene. This was a primary closure. As we neared the end of closure,
we unclamped the inferior vena cava to allow the cava to fill up and
exclude any air. At the same time, we checked with the transesophageal
echocardiogram to make sure there was no air emboli in the atrium or
ventricle.

Once that was done, we secured hemostasis in the retroperitoneum and around
the liver. We then performed the retroperitoneal lymph node dissection and
cleaned off all the nodes in the interaortocaval and paracaval regions.
Next, we turned attention to closure. We examined the small bowel and
colon. No evidence of any enteric injury was seen. There were adhesions
of terminal ileum to the peritoneum, which were released. We then closed
the abdominal fascia in two layers, an inner layer of internal oblique and
outer layer of external oblique. This was closed with #1 looped PDS in
running fashion, starting at each corner and tying in between. The skin
was closed with staples.

The patient was taken to the intensive care unit intubated.


Respectfully,
Kendra

Kendra Songer, CPC, CUC
Medical Records Coder

Department of Urology
UT Health San Antonio
7703 Floyd Curl Drive, Mail Code 7845
San Antonio, Texas 78229
210.567.1235 (W)
210.567.5977 (F)
songer@uthscsa.edu
uthscsa.edu

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