Please note this question was answered in 2019. The coding advice may or may not be outdated.
39010 or 21750
Question:
A patient was scheduled for an open aortic valve replacement, but once surgeon did sternotomy, opening the sternum and pericardium, it was decided not to proceed after evaluation of the ascending aorta. The physician made the decision the patient would need to return at a later date for a percutaneous procedure and the patient was closed up. I am wondering if the physician evaluating the aorta would be considered "exploratory" in order to code the 39010? If not, would the better option be code 21750, even though it only states closure of sternum? One coder suggested to code the planned procedure (33405) with modifier -53, but I don't feel the physician attempted enough to code that, but of course please let me know what you think.
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