AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 3; Ask the Editor

Aortic Cross-Clamping and Exploratory Thoracotomy

A patient was admitted with a gunshot wound and active chest hemorrhage. An emergency left anterior thoracotomy was performed. The aorta was isolated and clamped with an aortic cross-clamp. The right side of the chest was opened with the same technique. The chest was explored and a large amount of active bleeding was encountered despite aortic cross clamping. Concurrent active resuscitation was performed, and multiple units of packed red cells were administered. Exploratory laparotomy revealed a large rent in the liver from posterior hepatic or inferior vena cava injury. Bleeding was determined uncontrollable, and resuscitative efforts ceased. Would it be appropriate to assign an ICD-10-PCS code for the aortic cross clamping - or is the clamping inherent to the exploratory thoracotomy? If reported, what is the correct body part value? ...

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