Can the 93925/93926 and 93970/93971 be billed if used for mapping of the lower extremities prior to incision of the femoral artery when doing a TAVR?
Primary Procedure:
Ultrasound mapping of bilateral groins
Bilateral femoral artery exposure and repair
Left femoral venous cannulation for temporary pacemaker wire insertion
For: Transcatheter aortic valve replacement using 23mm Edwards SAPIEN 3 valve (dictated by Dr Eltibi as separate procedure)
Findings
Small right common femoral artery with posterior calcification. (Small left femoral artery as well)
Good doppler pulse on the right (SFA and profunda) post procedure.
Specimens Removed
Specimen: none
.
Disposition
Disposition:
Post-op Destination: ICU/CCU
.
Impression and Plan
Impression and Plan
Condition
Improved.
Communication
GROSS PATHOLOGY:
Prior to prepping and draping, we used the ultrasound to map the bilateral lower extremities, marking the skin overlying the femoral arteries deep within the subcutaneous fat, and veins so as to aid our incisions.
INDICATION: Patient is a 72 year old female with history of COPD and significant shortness of breath on exertion. Noted to have severe aortic stenosis with peak gradient of 111 mm Hg. She is status post bilateral mastectomy for breast carcinoma and has had chest irradiation. Prior to TAVR, had two admissions for some dizziness and confusion. MRI head did not reveal any acute CVAs. Carotid dopplers were negative. Coronaries noted to have no significant stenosis. Patient has significant aortic calcification as well as in the ascending aorta. Her femoral and iliac arteries were diminutive on CTA. Her ammonia level was noted to be elevated preoperatively.
PROCEDURE IN DETAIL:
The patient was brought to the Operative Suite and prepped and draped in normal sterile fashion after appropriate anesthesia was given per the Anesthesia Department.
Prophylactic antibiotics were given by the Anesthesia Department.
The assistant surgeon was necessary for retraction, exposure and general assistance with the case.
We then proceeded to make longitudinal incisions over the previously marked areas in bilateral groins. These incisions were carried down through the large amount of subcutaneous fat and through the femoral sheath. Bovie electrocautery was then used to dissect down to the common, superficial and deep femoral systems on the right. The common femoral artery on the right was calcified posteriorly, diminutive in size and lying under the inguinal ligament which was partially opened with electrocautery. We did not proceed with cutting the inguinal ligament on the left as this site was planned for a 6Fr sheath. 5-0 pursestrings were placed on the left common femoral vein and left superficial femoral artery. Vessel loops were passed aroung the common femoral artery, profunda and SFA on the right side. 5-0 Prolene purse string was used on the right common femoral artery for the placement of the 14 Fr sheath. The patient was heparinized. The left femoral vein, artery and right CFA were cannulated as per Dr. operative note. Please refer to that operative report for the TAVR dictation.
We then proceeded to close the arteriotomies in the femoral arteries with 6-0 Prolene. Doppler signal in the right profunda and SFA was good. We then proceeded to close deep subcutaneous tissue over the artery with 3-0 Vicryl suture. 4-0 Vicryl subcuticular suture was used to close the skin. The prevena dressing was placed on both groins.
Primary Procedure:
Ultrasound mapping of bilateral groins
Bilateral femoral artery exposure and repair
Left femoral venous cannulation for temporary pacemaker wire insertion
For: Transcatheter aortic valve replacement using 23mm Edwards SAPIEN 3 valve (dictated by Dr Eltibi as separate procedure)
Findings
Small right common femoral artery with posterior calcification. (Small left femoral artery as well)
Good doppler pulse on the right (SFA and profunda) post procedure.
Specimens Removed
Specimen: none
.
Disposition
Disposition:
Post-op Destination: ICU/CCU
.
Impression and Plan
Impression and Plan
Condition
Improved.
Communication
GROSS PATHOLOGY:
Prior to prepping and draping, we used the ultrasound to map the bilateral lower extremities, marking the skin overlying the femoral arteries deep within the subcutaneous fat, and veins so as to aid our incisions.
INDICATION: Patient is a 72 year old female with history of COPD and significant shortness of breath on exertion. Noted to have severe aortic stenosis with peak gradient of 111 mm Hg. She is status post bilateral mastectomy for breast carcinoma and has had chest irradiation. Prior to TAVR, had two admissions for some dizziness and confusion. MRI head did not reveal any acute CVAs. Carotid dopplers were negative. Coronaries noted to have no significant stenosis. Patient has significant aortic calcification as well as in the ascending aorta. Her femoral and iliac arteries were diminutive on CTA. Her ammonia level was noted to be elevated preoperatively.
PROCEDURE IN DETAIL:
The patient was brought to the Operative Suite and prepped and draped in normal sterile fashion after appropriate anesthesia was given per the Anesthesia Department.
Prophylactic antibiotics were given by the Anesthesia Department.
The assistant surgeon was necessary for retraction, exposure and general assistance with the case.
We then proceeded to make longitudinal incisions over the previously marked areas in bilateral groins. These incisions were carried down through the large amount of subcutaneous fat and through the femoral sheath. Bovie electrocautery was then used to dissect down to the common, superficial and deep femoral systems on the right. The common femoral artery on the right was calcified posteriorly, diminutive in size and lying under the inguinal ligament which was partially opened with electrocautery. We did not proceed with cutting the inguinal ligament on the left as this site was planned for a 6Fr sheath. 5-0 pursestrings were placed on the left common femoral vein and left superficial femoral artery. Vessel loops were passed aroung the common femoral artery, profunda and SFA on the right side. 5-0 Prolene purse string was used on the right common femoral artery for the placement of the 14 Fr sheath. The patient was heparinized. The left femoral vein, artery and right CFA were cannulated as per Dr. operative note. Please refer to that operative report for the TAVR dictation.
We then proceeded to close the arteriotomies in the femoral arteries with 6-0 Prolene. Doppler signal in the right profunda and SFA was good. We then proceeded to close deep subcutaneous tissue over the artery with 3-0 Vicryl suture. 4-0 Vicryl subcuticular suture was used to close the skin. The prevena dressing was placed on both groins.