# Help!! Aortic stent graft coding....



## sslater (Jul 29, 2011)

here is another OP note i was given to help with.. i am not familiar with these procedures.  Would be greatly appreciative if someone could lead me in the right direction.. thanks!!!

PREOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.

POSTOPERATIVE DIAGNOSIS:
Distal aortic suture line pseudoaneurysm and two right iliac
aneurysms.

OPERATIVE PROCEDURE:
  1.  Abdominal aortic stent graft.
  2.  Embolization of right internal iliac artery.

HISTORY:  The patient is a 70-year-old gentleman eight years out
from a tube graft repair of an abdominal aortic aneurysm.  Six
days ago he began having back pain, which was relatively severe
over three days.  It subsided and he saw Dr. Hoke on the day
before surgery and a CT scan was done.  The CT scan showed
periaortic fluid collection consistent with an acute bleed
process versus an enlarging pseudoaneurysm.  The patient had been
totally stable and the pain decreased so he was worked up and
brought to the operating room at this point in time for hope for
endovascular repair of distal aortic suture line pseudoaneurysm
versus a leaking expanding right iliac aneurysm.

PROCEDURE:  The patient was brought in the operating room and
placed in the supine position and underwent induction of general
endotracheal anesthesia.  He was then positioned, prepped, and
draped in the usual sterile fashion.

Initial step was to place an 8-French sheath in the left groin,
which was done percutaneously.  Once this was in place transverse
incision was made over the right groin and the common femoral
artery exposed for adequate length.
Initial step here was to embolize the right internal iliac
artery.  Initially we tried this by placing a 6-French sheath in
the right femoral artery and accessing the internal iliac with
various sorts of hook-type guiding catheters.  We were

unsuccessful in this after an extended period of time.  Next we
went to the left groin, crossed the iliac bifurcation using a
contra catheter and glidewires.  We were able to get a guidewire
into the internal iliac and extend the guiding cath in but were
never able to extend the sheath into that area.  After an
extended period of time doing this, Dr. White graciously came in
and helped us address this problem.  He was able to get a guiding
catheter over to the 8-French x 55 sheath at the left groin over
the bifurcation and once this was in place then cannulate the
internal iliac with an 0.014 coronary wire over which we were
able to eventually advance the sheath and get good purchase into
the internal iliac artery.

Once we had done this two Amplatz occluder devices, first an 8 mm
and then once this was deployed per routine a second 6-mm Amplatz
occluder device was deployed.  Once this was done initial
angiogram showed continued flow into the internal iliac artery
but good position of the Amplatz devices.

Once we had gotten this done, which actually took a number of
hours, we proceeded on with the aneurysm repair.  The short 8-
French sheath was replaced in the left groin.  A 12-French strip-
away sheath was placed in the right groin.  Once these were in
place a Meier wire was advanced up the right iliac into the
thoracic aorta.  The Endologix device was then advanced up over
the wire into the thoracic aorta loaded with a 28 x 16 __________
bifurcator device.  Just prior to placing this, the SurePass
guidewire to the contra lateral limb was advanced up the sheath
grabbed with a snare and brought out the left 8-French sheath.
Once we had done this we were able to strip away the strip-away
sheath in the right groin advancing the entire device up into the
thoracic aorta as noted above.  Once this was in position the
wires were in the sheath and the device was appropriately
oriented and wires under nice control, we were able to retract
the stent graft integrating sheath below the iliac bifurcation.
Once we had done this we were able to pull the entire system down

to the aortic bifurcation seating it nicely by the aortic
bifurcation.  An 0.014 Endologix wire was then advanced up the
SurePass contra limb precannulating gate before deployed.  Once
we had done this we deployed the main body of the graft by
pulling the device control cord.  Having done this we were able
to retract the integrated sheath deploy the ipsilateral limb.

Having successfully deployed both limbs a pigtail catheter was
advanced up the 0.014 left groin 0.014 wire and aortogram
performed.  Note the location of the renal arteries were noted at
this point in time.  Having done this we placed the infrarenal 34-
34-100 aortic extension using the pin and pull technique and
placed it just at the top of the previously placed graft
specifically below the area of about 50% narrowing in the main
aorta.  Once this was successfully deployed the main body overlap
and proximal areas were dilated with a Reliant balloon and the
right limb of the graft dilated as well.

At this point in time we advanced an 0.014 guidewire back up the
pigtail catheter, pulled it back to the aortic bifurcation then
carefully advancing it up using a little twirl as went.  We

advanced the pigtail back up to the aorta just above the upper
limits of the graft.  Having done this we were able to go ahead
over the right limb guidewire advance a 20 x 13 x 70 right limb
extension.  We positioned this and successfully deployed this.
Having done this, Coda balloon was used to dilate this as well.

Following this a completion arteriogram was shot.  We showed no
evidence of any endoleak.  The proximal location was perfect.  By
this time the right internal iliac was totally occluded as per
our plans with good flow into the right iliac artery.  We felt at
this point we did not need to dilate the left limb as there was
good apposition and good flow.

Having done all this we were able to go ahead and remove all the
devices from the right femoral artery.  Clamps were applied and
the artery carefully reapproximated using 6-0 Prolene.  This was
a heavily diseased artery and actually we noted we did have
virtually no back flow.  However once we got the artery repaired,
released the clamp to good pulse and good Doppler pulse from the
left ankle and so we felt we were okay.

Having done this ACT was done and was found to be adequate.  The
right groin was closed using running 3-0 Vicryl deep and running
subcuticular 4-0 Vicryl on the skin.  The left 8-French sheath
was removed and we used a Mynx closure device for this procedure.
This worked well and successfully.

At this point the patient was allowed to wake up, was extubated,
and was taken to the recovery room having tolerated the procedure
well.  Sponge and needle count correct x2.


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## jewlz0879 (Aug 16, 2011)

34804 for the graft deployment; 75952-26

34812 - 50 for bilateral femoral artery exposure 

36200 - 50 introduction of cath into aorta rt/lt

For extentions or 'cuffs' bill 34825/34826; 75953-26

You can also bill for IVUS 37250/75945-26 if performed.


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## diadem (Sep 29, 2011)

*Julie could you help me please with this OP note*

POSTOPERATIVE DIAGNOSES:

1.  Aortoiliac occlusive disease with focal moderately severe mid-infrarenal 

abdominal aortic stenosis.

2.  Disabling bilateral lower extremities intermittent claudication (Rutherford 

III).

3.  Left lower extremity atheroembolic events (probably related to aortic 

stenosis).

4.  Diabetes mellitus.

5.  Chronic obstructive pulmonary disease.

6.  Chronic tobacco abuse.

7.  Morbid obesity.



PROCEDURES PERFORMED:

1.  Aortogram.

2.  Aortic catheterization.

3.  Primary stenting of infrarenal aorta with iCast 9 mm x 58 mm stents dilated 

to a final diameter of 12 mm.


ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

FINDINGS:

1.  Moderately severe calcific and ulcerative mid infrarenal aortic stenosis 

associated with moderate bilateral ostial common iliac artery occlusive 

disease.

2.  No significant resting transaortic pressure gradient following stent 

implantation.

3.  Palpable pedal pulses at case conclusion.



COMPLICATIONS: None.



COUNTS: Correct.



DRAINS: None.



SPECIMENS: None.



DISPOSITION: To recovery unit in stable condition.



STATEMENT OF MEDICAL NECESSITY: Mrs. Blank is a 50-year-old Caucasian 

female with diabetes mellitus and a history of extensive tobacco use who 

recently presented with an episode of ischemic sigmoid colitis coincident with 

left lower extremity atheroembolism.  She further described disabling bilateral 

and symmetrical lower extremity exertional discomfort consistent with 

intermittent claudication.  Lower extremity arterial duplex identified a severe 

distal infrarenal aortic stenosis and a CT arteriogram revealed a complex and 

partially calcified moderately severe distal infrarenal aortic stenosis 

associated with iliac occlusive disease.  She desired treatment.  I recommended 

endovascular aortic treatment on the basis of the focality and location of the 

stenosis (in the aorta) and her moderate surgical risk profile.  The risks, 

benefits, and alternatives to treatment were described to the patient in detail.

She expressed understanding of these, provided informed consent, and wished to 

proceed.



DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed

in the supine position.  General anesthesia was induced.  The left arm was 

tucked and padded.  The right arm was extended on an arm board and padded.  A 

right internal jugular central venous catheter and radial arterial line were 

placed by the anesthesia service.  A Foley catheter was sterilely inserted.  

Preoperative antibiotics were administered.  The abdomen and groins were then 

prepared and draped sterilely.  An Ioban drape was applied.



The right common femoral artery was percutaneously cannulated under fluoroscopic

and ultrasonographic guidance with a standard Seldinger technique.  A 5-French 

sheath was inserted in a retrograde fashion.  The left common femoral artery was

similarly percutaneously cannulated under fluoroscopic and ultrasonographic 

guidance with a micropuncture needle.  A 5-French sheath was inserted in a 

retrograde fashion.



A 0.035-inch magic torque guidewire was advanced through the left iliac system 

and positioned in the thoracic aorta.  An 8-French x 35 cm Brite Tip sheath was 

advanced through the left iliac system and positioned in the caudad aspect of 

the infrarenal aorta.  A 0.035 inch floppy Glidewire was advanced through the 

right iliac system in conjunction with a marker pigtail catheter and positioned 

in the proximal infrarenal aorta proximal to the proximal location of the known 

mid aortic stenosis.  A standard aortogram was then performed utilizing dilute 

Visipaque contrast and digital subtraction arteriography under magnification.  

The aortogram again demonstrated a moderately severe ulcerative and calcified 

mid aortic stenosis.  The ostia of the common iliac arteries possessed moderate 

calcific occlusive disease.  The common iliac artery stenoses, however, 

possessed no significant velocity acceleration according to recent duplex 

interrogation.  I elected to proceed with primary aortic stenting on the basis 

of these arteriographic results.  The indication for primary aortic stenting was

to exclude the mid aortic stenosis because of its probable involvement with the 

prior lower extremity atheroembolic events and to relieve her intermittent 

claudication symptoms.



A systemic anticoagulation was induced by the administration of 5000 units of 

heparin intravenously.  An iCast 9 mm x 58 mm stent was advanced through the 

left iliac system and centered over the aortic stenosis.  The stent was deployed

to a nominal pressure.  The stent was then dilated proximally and distally 

sequentially with 10 mm x 20 mm and 12 mm x 20 mm semi-compliant balloons.  The 

central portion of the stent at the stenosis site was then gently dilated with a

12-mm balloon.  A subsequent aortogram demonstrated a satisfactory result with 

exclusion of the stenosis and no significant residual stenosis.  A minor amount 

of contrast was noted to track around the stent edge proximally and supplied a 

patent lumbar artery.  No evidence of extravasation nor dissection was noted.  I

elected to conclude the procedure on the basis of these arteriographic results. 

The diagnostic catheter was removed under direct visualization.  The 8-French 

sheath was withdrawn and replaced with a short 8-French sheath.  She tolerated 

the operation well, was extubated, and was transported to the recovery unit in 

stable condition.  The sheaths were removed per protocol.  She possessed 

palpable pedal pulses at the conclusion of the procedure.

 I have never requesting coding help. Not sure if this is the correct protocal.
I was very confused on this one?
DX 440.21 + 444.22
36200-50 + 34812-50 75625-26 ???
Thank you
Dianne


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## lisammy (Sep 29, 2011)

37205 for aortic stent
36200-50 for cath placement in aorta
75630-26 for S&I of aorta with runoff
75960-26,59 for S&I stent placement
no cutdown was performed so 34812 would not be correct.
for dx I would use 440.0 for aortci stenosis, 440.21 for claudication, 444.22 for lower ext emboli.


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## sslater (Nov 14, 2011)

*Aortic Stent Graft for AAA*

These still have me so confused.  Could you look at this one too and tell me what you think?  I have these codes but i'm second guessing myself.  I'm just still not comfortable with these.. Thanks again!!!!

34804
75952 26
34812/50
36200/50
and then i get lost...?????


*OPERATIVE PROCEDURE:
Aortic stent graft for treatment of aortic aneurysm*
An 8-French sheath was placed in the right femoral artery
percutaneously for access.  The left groin cutdown was made using
a transverse suprainguinal crease incision.  Common femoral
artery was dissected out and looped for vascular control.  A
guidewire was passed up the right femoral artery into the aortic
arch area.  An 18-gauge needle was used to access the exposed
left femoral artery and a guidewire likewise positioned up the
thoracic aorta.

Next a snare was placed up the right femoral sheath.  Following
this the 17-French AFX sheath was placed up the left femoral
artery replacing it for the previously placed 6-French sheath.
This was done and the contralateral limb wire was passed up the
17-French sheath, snared with a snare, and brought out the right

femoral sheath.  Once we had these under control.  The AFX
bifurcated device was transferred to the AFX sheath and advanced
under fluoroscopy to the distal end to well above the aortic
bifurcation releasing the limb to the graft.  We then pulled the

entire system down the aortic bifurcation.  At that point we then
advanced the 0.014 Endologix guidewire up the contralateral limb
wire hypotube.  Once this was done the main body of the graft was
deployed by pulling the control cord handle.

At this point retracted the AFX sheet deploying the ipsilateral
limb.  We then removed the inner core assembly and advanced the
dilator into the AFX sheet.  We then advanced the dilator and
sheath assembly to just above the level of the lowest renal
artery.

At this point we released the contralateral limb by retracting
the SurePass wire and pulling the limb cover from the limb.  We
then passed up a pigtail catheter up over the 0.014 wire and
placed at just above the renal arteries.

At this point arteriogram was done to visualize the areas of the
renals.  These were marked and a C-arm fixed.

Once this was done we advanced the infra- and suprarenal aortic
cuff above the renal arteries.  We then removed the safety clip
and began deployment deploying two segments.  We then pulled the
whole assembly back to place the highest point of the aortic cuff
graft just at the lower edge of the left renal artery, which was
about a centimeter distal from the right renal artery.  Once we
had this in place deployment was completed.  We then pulled back
the pigtail catheter and advanced up the center of the graft
through the aortic cuff.  Arteriogram was done at this point
showing no visible endoleaks and good placement of the graft.
Because the deployment was made complete the decision was made to
forego any balloon dilatation.

Once we had accomplished this the device was removed from the
left femoral artery and clamps applied.  The artery was repaired
using interrupted 6-0 Prolene sutures.  Clamps released and good
pulse felt beyond repair.  The right 8-French sheath was removed

using a Mynx closure device.  This worked well without any
problems.


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