maine4me
Guru
I am new to cardiovascular coding and have been asked to audit some notes for our vascular surgeon. I would appreciate someone reviewing these notes and clarifying my coding choices. I have also given the codes which were billed by the outside billing company.
PREOPERATIVE DIAGNOSIS: Enlarging abdominal aortic aneurysm
POSTOPERATIVE DIAGNOSIS: Enlarging abdominal aortic aneurysm
OPERATION: Endovascular aneurysm repair utilizing Zenith graft
ANESTHESIA: General
FINDINGS: Adequate deployment of endograft without evidence of type 1, 2, 3 or 4 endoleak
ESTIMATED BLOOD LOSS: 1 unit
REPLACEMENT: None
TUBES AND DRAINS: None
INDICATION FOR PROCEDURE: This is an 83-year-old Caucasian male with an enlarging
abdominal aortic aneurysm. His anatomy was suitable for endovascular repair. He was
felt a candidate for the same.
PROCEDURE AND FINDINGS: Patent was taken to the operating room and placed in the supine
position. Time out was called, patient positively identified, procedure reviewed. After
adequate induction of general endotracheal anesthesia, Foley catheter was placed, abdomen
and groin prepped and draped in sterile fashion. Incision was made above the right
inguinal crease and extended through subcutaneous tissue. The external iliac and common
femoral artery were dissected out and circled with vessel loops. Side branches were
controlled with 0 silk. Lymphatics were ligated as they were encountered. We then
turned our attempt to the left femoral dissection. Similarly and incision was made above
the left inguinal crease and extended to subcutaneous tissue. Lymphatics were ligated as
they were encountered. The external iliac and common femoral arteries were dissected out
circumferentially. Side branches controlled with vessel loops. Patient was systemically
heparinized with about 7500 units of heparin. During the course of the procedure ACTs
were obtained. The first one was less than 200, and the second 2500 units of heparin
were given. The right femoral artery was cannulated with an introducing needle, a wire
threaded in retrograde fashion. We had to use the UF catheter and a hydrophilic wire
because of the tortuosity of the iliac system. We were eventually able to get a wire in
the suprarenal aorta. We then passed the universal flush catheter in the suprarenal
aorta following which the glide catheter was removed and a stiff working wire was passed
without difficulty. The tip of the wire was positioned in the mid thoracic aorta. A
mark was placed on the back table so we could monitor migration of the wire. An 8 French
sheath was placed in the right femoral wire prior to placement of the stiff wire. The
left femoral artery was then cannulated with introducing needle, wire threaded in
retrograde fashion. A long 8 French sheath was then passed over the wire into the
aneurysm sac. The UF catheter was then placed in the suprarenal aorta and it was
connected to the power injector. We then obtained the main body of the device which was
a TFFB3695ZT. Given the tortuosity of the vessels it appeared as though we needed to
flip the limbs. Therefore it was positioned appropriately with the contralateral limb
coming off the right side rather than left side. The 8 French sheath was then removed
from the right femoral access site. The delivery system for the main body was placed
over the stiff working wire. A transverse arteriotomy was made with the 11 blade as we
placed it into the artery so that we had a controlled arteriotomy. Under fluoroscopic
guidance we were then able to pass the delivery system to the level of the lowest renal
artery. The lowest renal artery was the left. The graft was then deployed to the
position of the contralateral gate exposure. We were satisfied with the location after
two subsequent angiograms and the suprarenal struts were then positioned. Prior to doing
this the UF catheter was withdrawn into the distal aortic sac. We were then able to
cannulate the contralateral limb with moderate difficulty. UF catheter was placed into
the aneurysm sac and utilizing the spin technique we were able to document that we were
within the graft. A stiff working wire was then passed through this catheter and
positioned appropriately in the mid descending thoracic aorta. Again, it was monitored
on the back table for position. We then obtained the contralateral limb TFLE20-73ZT.
Retrograde angiogram was performed in the RAO projection with splayed out the iliac
bifurcation nodularly allowing us to determine our landing zone. The limb was then
passed over the wire, positioned appropriately and deployed without difficulty. The
ipsilateral limb was then fully deployed following which we captured the cone and
withdrew it. Retrograde angiogram was then performed through the sheath in the usual
fashion again displaying the ipsilateral bifurcation nicely. We then obtained the
ipsilateral limb TFLE2056ZT. It was passed over the wire and deployed without
difficulty. It landed just above the iliac bifurcatio. A coated balloon was then
obtained and inflated it in all sealed areas proximally, the body of the graft, and
throughout both limbs of the graft. It was then withdrawn. Completion angiogram showed
no type 1, 2, 3, or 4 endoleak. Both internal iliacs remained patent. All catheters and
wires were then removed and the vessels clamps. The arteriotomies were closed in
transverse fashion with interrupted 5-0 Prolene. Prior to completing the anastomosis the
vessels were forward bled, back bled, and suctioned out. Flow as then established
distally. Good pulses and Doppler signals were noted. 25 mg of Protamine was given for
partial reversal of the heparin. Wounds were irrigated with copious amounts of
antibiotic solution. Gelfoam and Thrombin were placed in anastomotic site. Wound then
closed in multiple layers of running 2-0 and 3-0 Vicryl suture. Skin was approximated
with skin clips. Both femoral incisions were blocked with 0.5% Marcaine. Patient
tolerated the procedure well.
Billed codes -- 34803, 34812, 35226, 36200, 75952
My code choices -- 34803, 34812 - 51,50, 75952-26
PREOPERATIVE DIAGNOSIS: Enlarging abdominal aortic aneurysm
POSTOPERATIVE DIAGNOSIS: Enlarging abdominal aortic aneurysm
OPERATION: Endovascular aneurysm repair utilizing Zenith graft
ANESTHESIA: General
FINDINGS: Adequate deployment of endograft without evidence of type 1, 2, 3 or 4 endoleak
ESTIMATED BLOOD LOSS: 1 unit
REPLACEMENT: None
TUBES AND DRAINS: None
INDICATION FOR PROCEDURE: This is an 83-year-old Caucasian male with an enlarging
abdominal aortic aneurysm. His anatomy was suitable for endovascular repair. He was
felt a candidate for the same.
PROCEDURE AND FINDINGS: Patent was taken to the operating room and placed in the supine
position. Time out was called, patient positively identified, procedure reviewed. After
adequate induction of general endotracheal anesthesia, Foley catheter was placed, abdomen
and groin prepped and draped in sterile fashion. Incision was made above the right
inguinal crease and extended through subcutaneous tissue. The external iliac and common
femoral artery were dissected out and circled with vessel loops. Side branches were
controlled with 0 silk. Lymphatics were ligated as they were encountered. We then
turned our attempt to the left femoral dissection. Similarly and incision was made above
the left inguinal crease and extended to subcutaneous tissue. Lymphatics were ligated as
they were encountered. The external iliac and common femoral arteries were dissected out
circumferentially. Side branches controlled with vessel loops. Patient was systemically
heparinized with about 7500 units of heparin. During the course of the procedure ACTs
were obtained. The first one was less than 200, and the second 2500 units of heparin
were given. The right femoral artery was cannulated with an introducing needle, a wire
threaded in retrograde fashion. We had to use the UF catheter and a hydrophilic wire
because of the tortuosity of the iliac system. We were eventually able to get a wire in
the suprarenal aorta. We then passed the universal flush catheter in the suprarenal
aorta following which the glide catheter was removed and a stiff working wire was passed
without difficulty. The tip of the wire was positioned in the mid thoracic aorta. A
mark was placed on the back table so we could monitor migration of the wire. An 8 French
sheath was placed in the right femoral wire prior to placement of the stiff wire. The
left femoral artery was then cannulated with introducing needle, wire threaded in
retrograde fashion. A long 8 French sheath was then passed over the wire into the
aneurysm sac. The UF catheter was then placed in the suprarenal aorta and it was
connected to the power injector. We then obtained the main body of the device which was
a TFFB3695ZT. Given the tortuosity of the vessels it appeared as though we needed to
flip the limbs. Therefore it was positioned appropriately with the contralateral limb
coming off the right side rather than left side. The 8 French sheath was then removed
from the right femoral access site. The delivery system for the main body was placed
over the stiff working wire. A transverse arteriotomy was made with the 11 blade as we
placed it into the artery so that we had a controlled arteriotomy. Under fluoroscopic
guidance we were then able to pass the delivery system to the level of the lowest renal
artery. The lowest renal artery was the left. The graft was then deployed to the
position of the contralateral gate exposure. We were satisfied with the location after
two subsequent angiograms and the suprarenal struts were then positioned. Prior to doing
this the UF catheter was withdrawn into the distal aortic sac. We were then able to
cannulate the contralateral limb with moderate difficulty. UF catheter was placed into
the aneurysm sac and utilizing the spin technique we were able to document that we were
within the graft. A stiff working wire was then passed through this catheter and
positioned appropriately in the mid descending thoracic aorta. Again, it was monitored
on the back table for position. We then obtained the contralateral limb TFLE20-73ZT.
Retrograde angiogram was performed in the RAO projection with splayed out the iliac
bifurcation nodularly allowing us to determine our landing zone. The limb was then
passed over the wire, positioned appropriately and deployed without difficulty. The
ipsilateral limb was then fully deployed following which we captured the cone and
withdrew it. Retrograde angiogram was then performed through the sheath in the usual
fashion again displaying the ipsilateral bifurcation nicely. We then obtained the
ipsilateral limb TFLE2056ZT. It was passed over the wire and deployed without
difficulty. It landed just above the iliac bifurcatio. A coated balloon was then
obtained and inflated it in all sealed areas proximally, the body of the graft, and
throughout both limbs of the graft. It was then withdrawn. Completion angiogram showed
no type 1, 2, 3, or 4 endoleak. Both internal iliacs remained patent. All catheters and
wires were then removed and the vessels clamps. The arteriotomies were closed in
transverse fashion with interrupted 5-0 Prolene. Prior to completing the anastomosis the
vessels were forward bled, back bled, and suctioned out. Flow as then established
distally. Good pulses and Doppler signals were noted. 25 mg of Protamine was given for
partial reversal of the heparin. Wounds were irrigated with copious amounts of
antibiotic solution. Gelfoam and Thrombin were placed in anastomotic site. Wound then
closed in multiple layers of running 2-0 and 3-0 Vicryl suture. Skin was approximated
with skin clips. Both femoral incisions were blocked with 0.5% Marcaine. Patient
tolerated the procedure well.
Billed codes -- 34803, 34812, 35226, 36200, 75952
My code choices -- 34803, 34812 - 51,50, 75952-26
