Wiki AAA Repair

[nlbarnes]

I've got:

34803
34825
34826
37236
37236
75710, 75658, &/or 75952

POSTOPERATIVE DIAGNOSES:
1. Abdominal aortic aneurysm status post fenestrated endograft.
2. Superior mesenteric artery stenosis/shuttering.

PROCEDURE:
1. Mesenteric angiogram via left brachial artery approach.
2. Placement of 7 x 22 iCAST covered balloon expandable stent graft
in the orifice of the superior mesenteric artery.

DESCRIPTION OF PROCEDURE:
We cut down onto the left brachial artery by making an incision in the mid
upper arm. This was taken down through the subcutaneous tissue and
through the brachial sheath to expose the brachial artery. Brachial
artery was dissected free for length to place clamps. At that time,
the patient was anticoagulated to an ACT of greater than 250. We
accessed the left brachial artery with micropuncture needle.
Micropuncture wire was advanced into the axillary artery and exchanged
for a 0.035 guidewire. A 6-French sheath was then placed. We then
used an angled Glidewire and a Kumpe catheter to navigate the aortic
arch to place our SOS OmniFlush catheter into the distal thoracic
aorta. At that point, we performed multiple oblique views of the
aorta and the visceral vessels. It appeared that there was both a
stenosis in the celiac artery approximately 1 to 2 cm distal to
takeoff consistent with median arcuate compression. In addition,
there was what appeared to be shuttering of the superior mesenteric
artery by the scallop of the fenestrated stent graft.

At that time, a Kumpe catheter and angled Glidewire were used to
access the superior mesenteric artery. We confirmed placement of the
superior mesenteric artery with popliteal angiography. At that time,
a 6 x 20 balloon was placed into the orifice, which did not show too
much deformity. Subsequent 7 x 40 balloon was placed into the orifice
and this did show deformity of the balloon with movement of the stent
graft orifice to handle the balloon.

At that time, the 7-French sheath was advanced into the superior
mesenteric artery. A 7 mm x 22 mm iCAST balloon expandable covered
stent was placed across the shutter portion into the orifice of the
superior mesenteric artery with one-third back into the aorta and this
was expanded fully. It did not appear that there was any recoil in
the stent graft. It appeared that the SMA orifice was widely patent.

We shot a completion angiography, which showed excellent filling into
the superior mesenteric artery and the celiac artery. It was decided
against performing any intervention on the celiac artery at this time.

At that point, the wires and catheters were removed. The puncture
site in the left arm was closed directly with multiple 7-0 interrupted
suture in the brachial artery. The subcutaneous tissue was closed
using 3-0 Vicryl and the skin was closed using 4-0 Monocryl.

 

[cpc2007]

After reviewing the documentation, I would not report CPT codes 34803, 34825, or 34826 as suggested because there is no treatment of an aneurysm performed during this surgery (the header is indicating that the patient previously had a fenestrated graft placed for an abdominal aortic aneurysm, but during this particular surgery, the doctor is stenting the superior mesenteric artery only for an area of stenosis that is in part caused by the presence of that previously placed fenestrated graft). It is not clear from the report if the angiogram shot at the start of the case is truly diagnostic and determined the need for intervention or if they had prior studies and were simply shooting a confirmatory/guiding shot (which is bundled to 37236), so I would not report radiology S&I codes here. The only codes I would report are 37236 for the one stent placement in the SMA which extends into the aorta but is considered one intervention per CPT guidelines as well as 36245 for the selective catheter placement from the brachial artery into the SMA.

I hope that helps