bennieyoung
Guru
PREOPERATIVE DIAGNOSIS: Acute type A aortic dissection.
I coded this 33858. I am being audited and the auditor suggested that I add 33362. I think that's wrong. They didn’t do a TAVR and there isn't documentation for a TAVR. They do open the skin for the femoral artery and vein but that’s for the bypass. Is she right? or do I have an argument? How would you code this?
POSTOPERATIVE DIAGNOSIS: Acute type A aortic dissection.
PROCEDURE PERFORMED: Emergency resection and repair of the ascending aorta and aortic valve replacement with a 23 mm Magna Ease bovine pericardial valve.
FINDINGS: The aortic valve was then competent. There was a small tear in the proximal ascending aorta, which appeared to be almost pinpoint in nature and almost sealed.
INDICATIONS: This is a 64-year-old gentleman with a history of multiple previous dissections including an aneurysm of his SMA, which required endovascular repair. This patient presented with severe back pain. He underwent CT angiography revealing what appears to be a type A aortic dissection.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in supine position. After the induction of general anesthesia and a single-lumen endotracheal tube intubation, the patient was prepped and draped sterilely. We then cutdown and exposed the right common femoral artery and vein. We cannulated the common femoral vein with a long 22-French venous cannula and positioned it in the superior vena cava under both fluoroscopic and echocardiographic guidance. With the patient fully heparinized, we now placed the 19-French Bio-Medicus cannula into the right common femoral artery, which appeared normal on examination. The chest was then opened and cardiopulmonary bypass was instituted. We applied the cross-clamp up high in the ascending aorta, where there did not appear to be any acute injury. We opened the aorta and delivered cardioplegia directly into the coronary ostia of both the right and left coronary arteries. We then resected the ascending aorta. Distally, just proximal to the cross-clamp, the aorta appeared essentially normal. Proximally, there was hematoma in the ascending aorta. A small tear, probably 2 mm in size, was identified, and this was associated with a significant hematoma. The sinuses of Valsalva were uninvolved. The aortic valve, however, had moderate aortic regurgitation present on the echo, so this was excised and then replaced with a 23 mm valve. We then sized to a 28 mm graft, and this graft was then sewn 1st proximally, then distally using a felt reinforcement. Next, the cross-clamp was removed. The patient was separated from bypass without difficulty. The protamine was administered, as were blood products. Once hemostasis had been achieved and we had placed 2 ventricular pacing wires, as well as mediastinal and right pleural chest tube, the protamine was administered and the patient was decannulated. The right common femoral artery was repaired directly and confirmed to be open by Doppler ultrasound. Once hemostasis had been achieved, the heart was then covered with pericardium and fat. The chest was closed with #6 stainless steel wires. The subcutaneous tissue and skin were closed with running Vicryl suture.
I coded this 33858. I am being audited and the auditor suggested that I add 33362. I think that's wrong. They didn’t do a TAVR and there isn't documentation for a TAVR. They do open the skin for the femoral artery and vein but that’s for the bypass. Is she right? or do I have an argument? How would you code this?
POSTOPERATIVE DIAGNOSIS: Acute type A aortic dissection.
PROCEDURE PERFORMED: Emergency resection and repair of the ascending aorta and aortic valve replacement with a 23 mm Magna Ease bovine pericardial valve.
FINDINGS: The aortic valve was then competent. There was a small tear in the proximal ascending aorta, which appeared to be almost pinpoint in nature and almost sealed.
INDICATIONS: This is a 64-year-old gentleman with a history of multiple previous dissections including an aneurysm of his SMA, which required endovascular repair. This patient presented with severe back pain. He underwent CT angiography revealing what appears to be a type A aortic dissection.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the operating table in supine position. After the induction of general anesthesia and a single-lumen endotracheal tube intubation, the patient was prepped and draped sterilely. We then cutdown and exposed the right common femoral artery and vein. We cannulated the common femoral vein with a long 22-French venous cannula and positioned it in the superior vena cava under both fluoroscopic and echocardiographic guidance. With the patient fully heparinized, we now placed the 19-French Bio-Medicus cannula into the right common femoral artery, which appeared normal on examination. The chest was then opened and cardiopulmonary bypass was instituted. We applied the cross-clamp up high in the ascending aorta, where there did not appear to be any acute injury. We opened the aorta and delivered cardioplegia directly into the coronary ostia of both the right and left coronary arteries. We then resected the ascending aorta. Distally, just proximal to the cross-clamp, the aorta appeared essentially normal. Proximally, there was hematoma in the ascending aorta. A small tear, probably 2 mm in size, was identified, and this was associated with a significant hematoma. The sinuses of Valsalva were uninvolved. The aortic valve, however, had moderate aortic regurgitation present on the echo, so this was excised and then replaced with a 23 mm valve. We then sized to a 28 mm graft, and this graft was then sewn 1st proximally, then distally using a felt reinforcement. Next, the cross-clamp was removed. The patient was separated from bypass without difficulty. The protamine was administered, as were blood products. Once hemostasis had been achieved and we had placed 2 ventricular pacing wires, as well as mediastinal and right pleural chest tube, the protamine was administered and the patient was decannulated. The right common femoral artery was repaired directly and confirmed to be open by Doppler ultrasound. Once hemostasis had been achieved, the heart was then covered with pericardium and fat. The chest was closed with #6 stainless steel wires. The subcutaneous tissue and skin were closed with running Vicryl suture.