# HELP PLEASE! Very complicated Coronary Artery Bypass Graft



## ksschroeder (Jan 4, 2011)

I really need help coding this note.  If you like a good challenge please take the time to read this very long note and let me know how you would code it.  I sincerely appreciate anyone who responds.   The codes I came up with are listed at the end of the op note.

INDICATIONS:
This is a 79 yo man admitted several days ago with chest discomfort.  He underwent a cardiac catheterization, which showed a significant left main and small nondominant right.  During that procedure he became hemodynamically unstable.  An intra-aortic balloon was inserted.  The angiogram also showed that he had a tight carotid stenosis.  With a balloon the patient remained stable and it was felt that the patient whould undergo carotid endarterectomy followed by coronary bypass grafting.  He underwent the carotid endarterectomy yesterday and now comes for coronary bypass grafting.  The risks of this procedure including death, stroke, MI, bleeding, infection, damage to any organ system, as well as the benefits and alternatives were explained to the patient and the family.  They had no further questions and gave informed consent.

OPERATIVE FINDINGS:
All of the vessels were approximately 1.5mm.  Flow down the mammary was good.  Flow down the grafts were good.  It should be mentioned that on completion of the operation the patient was weaned successfully from  bypass.  During the closure of the skin the patient became bradycardic and hypotensive.  The chest, therefore, was reopened.  The heart was barely moving and internal cardiac massage was begun.  Heparin was readministered and the patient was then placed back on bypass.

Once on bypass, it was noted that the heart rhythm returned and there was ST elevation in basically the inferior and the lateral leads.  After a period of time on bypass this ST elevation improved although not normal and with the heart being allowed to eject, the echocardiogram showed basically a normal wall motion.  The patient was then weaned from bypass, again, however after approximately 20 minutes the echocardiogram and the heart itself showed evidence of right ventricular dysfunction and inferior wall dysfunction.  Therefore bypass was reinstituted again.

The grafts were examined again.  It should have been mentioned that previously the clip was removed from the internal mammary artery, which showed good forward flow as well as excellent back bleeding.  The sequential graft also looked good, however because we were not sure exactly what was happening, it was decided to redo the bypasses to the posterolateral and high lateral, as well as bypass the PDA branch.

Therefore the patient was cooled.  The aorta was clamped.  A liter of blood cardioplegia was given antegrade and retrograde.  A piece of saphenous  vein was harvested again and these bypasses were then performed.  Again the clamp was removed and the patient warmed and again the patient was weaned from bypass on a small amount of adrenaline with what looked to be a relatively normal EKG in all leads and normal wall motion on the echocardiogram.  However, again after about 20 or 25 minutes, the echocardiogram and the heart itself showed evidence again of right ventricular and inferior akinesia and in spite of the intra-aortic balloon and inotropes and cardiac pacing he remained hypotensive and bradycardic with evidece of ST elevation in the inferior and lateral leads.

At this time it was decided that there was not much else that we could do.  We went out and talked with the family and told them the grave nature of this situation and that we were probably going to be unable to wean the patient from bypass, but that we would support him as best we could with inotropes, an intra-aortic balloon and pacing and send him to the intensive care unit.

OPERATIVE PROCEDURE:
Under adequate general anesthesia, the patient was prepped and draped in usual sterile manner.  A left subclavian Swan-Ganz catheter was inserted in the pulmonary artery via Seldinger technique.  The saphenous vein was excised endoscopically from the left leg via an incision that was closed at the end of bypass and hemostasis was achieved with Vicryl.

Simultaneoulsy, the median sternotomy was performed.  The left side of the sternum was elevated.  There was a fair amount of dense adhesions of the lung to the chest wall which were lysed and eventually space was made to dissect down the internal mammary artery.  The heart was then exposed.  Heparin was administered.  The aorta and right atrium were cannulated.  Bypass was institued.  The patient was cooled to 26 degrees.  The aorta was clamped.  A liter of cardioplegia was given and repeated every 20 minutes during clamping and the needle in the root vented the heart during the procedure.  The post lateral of the circumflex was exposed and end-to-side anastomosis was performed.  Then a sequential anastomosis to the high lateral performed then the LAD was exposed and end-to-side anastomosis with the mammary was performed.

Following this, the patient was warmed.  The heart was cardioverted into sinus rhythm.  A partial occlusion clamp was applied.  One 5mm punch aortotomy made and the proximal anastomosis was completed with running 6-0 Prolene suture removing the clamp to evacuate air before tying the last stitch.  When warming was complete, the patient was weaned from bypass with the intra-aortic balloon, which had been inserted preoperatively with a sinus rhythm of 80, a blood pressure of 100 and a PAD of about 18.

The patient was decannulated, protamine administered.  Hemostasis achieved.  A mediastinal and left pleural chest tube was inserted.  Temporary ventricular pacing wires were inserted.  The sternum was closed with wires.  The  fascia subcu and skin were clsoed in layers of Vicryl.  During the closure of the skin; however, the patient became bradycardic and hypertensive.

The chest was, therefore, reopened.  The heart was barely moving.  Heparin was readministered and internal cardiac massage was performed as the aorta and right atrium were cannulated again and bypass instituted again.  

Now with the heart decompressed, the EKG became more normal and showed however ST elevation in the inferior and some of the lateral leads, which improved as the patient remained on cardiopulmonary support.  All of the grafts were examined.  The internal mammary artery clip was removed and it showed excellent forward and backward bleeding and looked to be plump.  Without evidence of spasm.  The sequential graft also appeared to have forward and backward flow.  The heart, after a period on bypass, looked better and therefore the patient was ventilated and the heart allowed to fill as the patient was weaned from bypass.  During this time, the echocardiogram showed normal wall motion.  There was sinus rhythm of 70 with some ST elevation in the inferior leads.  Because of the previous episode the protamine, once he was weaned from bypass, was given very slowly and over the next 20 to 25 minutes, as we were observing the heart and the echocardiogram, again, there appeared to be evidence of RV dysfunction and inferior hypokinesia.  The heart began to distend and become bradycardic and showed again significant ST elevation in inferior and lateral leads.

Bypass was instituted again.  It was felt that this time, because the echo findings of the right ventricular and really inferior wall, that we should bypass the vessels on the back of the heart again.  A saphenous vein was then excised from the right leg.  The aorta was clamped and agian a liter of blood cardioplegia was iven antegrade and retrograde and repeated every 20 minutes during clamping and the needle and the root vented the heart during this part of the procedure.  This time the PDA, which was not bypassed veofre was bypassed and sequential side-to-side anastomosis to both the posterolateral and high lateral, which had been bypassed before were completed.

During this time, the patient was warmed, the clamp was removed.  The heart was converted to a sinus rhythm with no evidence of any ST elevation.  A partial occlusion clamp was applied.  One 5mm punch aortotomy was made.  The proximal anastomosis was then completed with running 6-0 Prolene suture, removing the clamp to evacuate air before tying down the last stitch.  Once this was done, again the patient was weaned from bypass with a sinus rhythm of 80, blood pressure of 100, PAD of 18 wiht intra-aortic balloon and a small amount of adrenaline.  again echocardiogram at this time showed normal wall motion.   Protamine was administered sowly.  Hemostasis was achieved.  After a period of time of watching the heart, again there was some evidence of RV dysfunction and inferior wall dysfunction and lateral wall dysfunction.

At this point in time, we went out to speak to the family and let them know that the patient was not doing well, that we had trouble weaning him from bypass on several occasions and had redone the grafts and that we would be weaning him from bypass and try to support him medically and they agreed with this.

Therefore, the patient was weaned from bypass with a blood pressure of 80, PAD of 20 and an AV sequentially paced rhythm at 80.  The patient was decannulated, protamine was administered.  Hemostasis achieved.  Previous inserted chest tubes were put into position.  The sternum was closed with wires.  The fascia, subcu and skin were closed in layers of Vicryl and staples.

The patient returned to the intesive care unit in critical condition.


I came up with:

33533-79  dx: 414.01 
33518-79  dx: 414.01
32124-79  dx: 511.0
33508-79  dx: 414.01
33512-79-59 dx code 997.1 

Thank you so much for taking the time to read this and let me know how you would code it.


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## ksschroeder (Jan 6, 2011)

I talked with a more experienced coder who suggested the following:

33533-22-79
33514-22-79
33508-22-79

I believe these codes make more sense that the ones I chose originally.  After a lot of discussion, we believe that both procedures were done during the same surgical session since the surgeon was closing the skin at the time the patient crashed, the patient was still in the OR and still under anesthesia, therefore the -78 modifier would not apply to this situation.  

We also believe that the lysis of adhesions was an integral part of the procedure because it needed to be done to get to the mammary artery that was used for the arterial graft and therefore is inherent to the surgery.  It was not done for a separate reason.

We will submit a letter with this claim along with the op report to explain and show all of the extenuating circumstances that were involved in this unique case that support the use of the 22 modifier.

If anyone has a different perspective, please share your thoughts.....

Thank you,

Kristi


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## Jess1125 (Jan 6, 2011)

You might want to try this one under the Cardiothoracic forum instead but it sounds like you know what to do...

Jessica CPC, CCC


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