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Scenario Week of January 04, 2012:
View Current Scenario

Preoperative Diagnosis:
Mass lesion, left lower pole of thymus, with a question of a thymoma

Postoperative Diagnosis:
Enlarged and lymphatic appearing thymus gland, large, left lower pole of thymus

Procedures Performed:
Transsternal radical thymectomy
Diagnostic bronchoscopy



The patient is a 49-year-old female who obtained a chest x-ray several months ago for an unrelated reason. It was essentially negative. A CT scan was obtained and showed a 4 cm mass lesion in the left anterior mediastinum in the position of the left lobe of thymus.

Informed Consent:
The risks and benefits of the procedure were previously discussed with the patient and she elected to proceed with surgical excision at this time.

Approach and Surgical Procedure:
The patient was brought in the operating suite and placed on the operating table in a supine position. Compression boots were placed on both lower extremities and set in motion prior to induction of general anesthesia. The patient was intubated with a single lumen endotracheal tube. An epidural catheter was placed. Due to the presence of a possible anterior mediastinal tumor, the patient’s airways were explored with a diagnostic bronchoscope. The lesion was not in the airway and it was elected to proceed with an open exploration of the mass.

The chest and abdomen were prepped and draped in a sterile manner. A time-out was called and the patient’s identity was confirmed by all. Everyone agreed the patient was in the operating room for transsternal resection of mediastinal mass.

The anterior mediastinum was explored through a standard midline sternotomy. Vancomycin paste was used to control marrow bleeding. The sternum was separated using a sternal retractor and the mediastinum was explored. The thymus gland had a very “lymphatic” appearance instead of being replaced by fat. There was a significant difference in character and color between the thymus and surrounding fat. The thymus gland was enlarged. The left lower lobe of thymus was quite enlarged thus giving the appearance of a left lower lobe mass lesion.

Ligaments attaching the thymus to the pericardium were taken down. The thymic vein was identified and ligated with free ties of 2-0 silk. The innominate vein was skeletonized. The superior pole was larger of the two and was directly attached to the inferior pole of the thyroid. The thyrothymic ligament was transected and clipped. The remainder of the thymus was then removed including the enlarged left lower pole. The left upper pole was not as large and came out quite nicely.

The thymus was sent to pathology for analysis. Tissue from the junction of the innominate vein in the superior vena cava was then resected, as was tissue from the left upper mediastinum. Both were sent to pathology for analysis.

The operative site was inspected and showed no signs of bleeding. A #28 French straight Argyle chest tube was placed into the left pleural space while the mediastinum was drained with a similar tube. The sternum was reapproximated using five #5 stainless steel wire sutures in a figure-of-eight fashion. The linea alba was reapproximated with running simple stitch of 0 Vicryl. The subcutaneous tissue and fascia was closed with a running simple stitch of 2-0 Vicryl, while the skin was closed with a running subcuticular stitch of 4-0 Vicryl. Steri-Strips were applied, sterile dressing was placed, chest tubes were placed for seal suction, and the procedure was terminated. The patient tolerated the procedure well and was returned to the thoracic ICU in satisfactory condition. Instrument and sponge counts were correct at the end of the procedure. Estimated blood loss was approximately 50 mL.


ICD-9-CM Diagnoses
254.0 Persistent hyperplasia of thymus

Rationale: Based on the postoperative findings of an enlarged thymus gland, we find “Enlargement” in the ICD-9-CM index. The sub-term of “thymus” takes us to a code of 254.0, which is the appropriate code selection in this instance, after verification in the tabular section.

CPT Procedures
60521 Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection (separate procedure)
31622-58 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)

Rationale: The patient’s procedure began with a diagnostic bronchoscopy (31622) to check for a potential mediastinal tumor. As the airways were found to be clear, the surgeon proceeds with the transsternal radical thymectomy (60521). According to CCI guidelines in chapter 1, a diagnostic endoscopy followed by a more extensive open procedure is reported with modifier 58.

“An initial diagnostic bronchoscopy is separately reportable. If the diagnostic bronchoscopy is performed at the same patient encounter as the open pulmonary procedure and does not duplicate an earlier diagnostic bronchoscopy by the same or another physician, the diagnostic bronchoscopy may be reported with modifier 58 to indicate a staged procedure.”

The open procedure was removal of the thymus through an open sternotomy described in the operative report.

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