The patient had a post-operative complication (cardiac tamponade) following a previous CABG surgery, requiring a return to the operating room for exploration and evacuation of a blood clot. This is coded using CPT code 32658 (Exploration, mediastinum, with or without drainage; for postoperative hemorrhage, drainage of abscess, or to locate foreign body). Modifier 78 is appended to indicate an unplanned return to the operating room by the same physician following the initial procedure for a related procedure during the postoperative period.
References:
* CPT Code 32658: Exploration, mediastinum, with or without drainage; for postoperative hemorrhage, drainage of abscess, or to locate foreign body
* Modifier 78: Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period
* AAPC Coder's Desk Reference: This resource provides detailed information on coding guidelines and procedures.