conleyclan
Guru
Hello,
How would you code this. Codes 33860 and 33870 hit an edit, but I could add a modifier.
Thanks
PREOPERATIVE DIAGNOSIS: Ascending aortic aneurysm, thoracoabdominal
aneurysm.
PROCEDURE: Repair of the aortic valve with resizing of sinotubular
junction with a 24 mm Gelweave graft, replacement of the ascending aorta
with a 34 mm Gelweave graft, total arch replacement with an elephant trunk
with a 34 mm Gelweave graft and bypass of the innominate artery, the left
carotid artery and the left subclavian artery using a 14 x 8 x 8 Spielvogel
branch graft.
POSTOPERATIVE DIAGNOSES: Ascending aortic aneurysm, thoracoabdominal
aneurysm.
CLINICAL NOTE: This is a 63-year-old female, who I have been following for
several years, who has aneurysms of the ascending and thoracoabdominal
areas and they have continued to expand since our initial index visit.
Today, as part of this plan strategy, she had a total arch replacement with
an elephant trunk procedure as part of a staged strategy to treat her
aneurysms. Today, neurophysiologic data include the following: She had
antegrade ____ perfusion as an adjunct for 39 minutes, which correlated
with 35 minutes of body circulatory arrest. She was isoelectric to
baseline after 89 minutes, she was cooling to isoelectric after 60 minutes
and then in warming, she reached 100% of baseline at 35.6 degrees Celsius,
her coldest temperature. Bladder was 20.9 degrees in which she was
isoelectric. Overall, she tolerated the procedure well and was left with
mild aortic insufficiency of a trileaflet valve.
OPERATIVE NOTE: Once the patient was brought to operative suite, she was
prepped and draped in sterile fashion. Sternotomy was performed. The
patient was heparinized. She was placed on cardiopulmonary bypass by
cannulation of distal ascending aorta and 2-stage venous cannula. We
stapled off the innominate artery and anastomosis to the 14 mm limb of a
Spielvogel graft and this was perfused off the Y off the arterial head
through an 18-French Fem-Flex cannula. This was done as the patient was
being cooled. Next, we used the same strategy for the left carotid artery,
in which the carotid was clamped and anastomosed to the 8 mm limb. Once we
are at this point, the heart had fibrillated. We placed a crossclamp on
the aorta, cut the ascending aorta and decompressed the ventricle. We then
continued to cool and once patient was isoelectric, we used antegrade
cerebral perfusion and anastomosed the remaining limb of the 8 mm
Spielvogel graft to the subclavian artery using a 5-0 Prolene suture.
Then, we turned our attention to the proximal descending thoracic aorta on
arch and created an elephant trunk graft by invaginating a 34 mm Gelweave
graft and sewing this at the level of the subclavian artery using 3-0
Prolene. After we had done so, we pulled the graft back through to
straighten the graft out and then we ensured that the elephant trunk was
opened and coursing down into the descending thoracic aorta. The length of
this trunk was approximately 10 cm. Then, the trunk was recannulated and
perfusion was restarted. The patient was rewarmed and during the interval
of rewarming, we anastomosed the 14 mm inflow to the 34 mm Gelweave graft
using ophthalmic cautery and 2-0 Prolene. At this point, we turned our
attention to the root, in which we noted a trileaflet valve that was
relatively intact and sized the LVOT for approximately 21 mm. We then
selected a 24 mm Gelweave graft and resized the sinotubular junction to
this dimension. We sewed this with a 48-inch 4-0 Prolene suture. Then, we
provided antegrade flow into the graft to test its competency and appeared
relatively competent. Then the graft was beveled and sewn to the 34 mm
Gelweave graft using 2-0 Prolene suture. Once we had done so, the root was
vented and the cross-clamp was removed. Over the next several minutes, she
was weaned from cardiopulmonary bypass without difficulty using atrial
pacing. Protamine was administered and all cannulas were removed. Once
hemostasis had been achieved, chest was then closed in standard fashion. I
was present for the entire duration of this operation.
How would you code this. Codes 33860 and 33870 hit an edit, but I could add a modifier.
Thanks
PREOPERATIVE DIAGNOSIS: Ascending aortic aneurysm, thoracoabdominal
aneurysm.
PROCEDURE: Repair of the aortic valve with resizing of sinotubular
junction with a 24 mm Gelweave graft, replacement of the ascending aorta
with a 34 mm Gelweave graft, total arch replacement with an elephant trunk
with a 34 mm Gelweave graft and bypass of the innominate artery, the left
carotid artery and the left subclavian artery using a 14 x 8 x 8 Spielvogel
branch graft.
POSTOPERATIVE DIAGNOSES: Ascending aortic aneurysm, thoracoabdominal
aneurysm.
CLINICAL NOTE: This is a 63-year-old female, who I have been following for
several years, who has aneurysms of the ascending and thoracoabdominal
areas and they have continued to expand since our initial index visit.
Today, as part of this plan strategy, she had a total arch replacement with
an elephant trunk procedure as part of a staged strategy to treat her
aneurysms. Today, neurophysiologic data include the following: She had
antegrade ____ perfusion as an adjunct for 39 minutes, which correlated
with 35 minutes of body circulatory arrest. She was isoelectric to
baseline after 89 minutes, she was cooling to isoelectric after 60 minutes
and then in warming, she reached 100% of baseline at 35.6 degrees Celsius,
her coldest temperature. Bladder was 20.9 degrees in which she was
isoelectric. Overall, she tolerated the procedure well and was left with
mild aortic insufficiency of a trileaflet valve.
OPERATIVE NOTE: Once the patient was brought to operative suite, she was
prepped and draped in sterile fashion. Sternotomy was performed. The
patient was heparinized. She was placed on cardiopulmonary bypass by
cannulation of distal ascending aorta and 2-stage venous cannula. We
stapled off the innominate artery and anastomosis to the 14 mm limb of a
Spielvogel graft and this was perfused off the Y off the arterial head
through an 18-French Fem-Flex cannula. This was done as the patient was
being cooled. Next, we used the same strategy for the left carotid artery,
in which the carotid was clamped and anastomosed to the 8 mm limb. Once we
are at this point, the heart had fibrillated. We placed a crossclamp on
the aorta, cut the ascending aorta and decompressed the ventricle. We then
continued to cool and once patient was isoelectric, we used antegrade
cerebral perfusion and anastomosed the remaining limb of the 8 mm
Spielvogel graft to the subclavian artery using a 5-0 Prolene suture.
Then, we turned our attention to the proximal descending thoracic aorta on
arch and created an elephant trunk graft by invaginating a 34 mm Gelweave
graft and sewing this at the level of the subclavian artery using 3-0
Prolene. After we had done so, we pulled the graft back through to
straighten the graft out and then we ensured that the elephant trunk was
opened and coursing down into the descending thoracic aorta. The length of
this trunk was approximately 10 cm. Then, the trunk was recannulated and
perfusion was restarted. The patient was rewarmed and during the interval
of rewarming, we anastomosed the 14 mm inflow to the 34 mm Gelweave graft
using ophthalmic cautery and 2-0 Prolene. At this point, we turned our
attention to the root, in which we noted a trileaflet valve that was
relatively intact and sized the LVOT for approximately 21 mm. We then
selected a 24 mm Gelweave graft and resized the sinotubular junction to
this dimension. We sewed this with a 48-inch 4-0 Prolene suture. Then, we
provided antegrade flow into the graft to test its competency and appeared
relatively competent. Then the graft was beveled and sewn to the 34 mm
Gelweave graft using 2-0 Prolene suture. Once we had done so, the root was
vented and the cross-clamp was removed. Over the next several minutes, she
was weaned from cardiopulmonary bypass without difficulty using atrial
pacing. Protamine was administered and all cannulas were removed. Once
hemostasis had been achieved, chest was then closed in standard fashion. I
was present for the entire duration of this operation.