deeva456
Expert
Hello,
I need some assistance coding a vascular surgery. The CPT code I found that describes the procedure is 36819 but the physician did not do the arteriovenous anastomosis. here is the report.
I appreciate any advice, comments.
Thank you!
Dolores CPC - CCC
INDICATION: The patient is a 62-year-old female who had a left
upper arm fistula created. Then due to ischemia had a DRIL
procedure, but the vein despite the large size on venogram is too
deep. The patient is taken to surgery for superficialization and
transposition.
OPERATIVE REPORT: The patient was placed on the operating table in
the supine position. The patient was induced under general
anesthesia. The left arm was prepped and draped in the standard
fashion and standard antibiotics were given. He was under monitored
anesthesia. The patient's left arm was prepped and draped in a
standard fashion, and Marcaine was used 20 mL to anesthetize over
the cephalic vein. Using incisions about 3 to 4 cm in length the
vein was mobilized, superficialized, and then the subcu layer was
closed underneath to make sure the vein was very superficial, and
the skin was closed with 3-0 Monocryl followed by skin staples. The
patient transferred to recovery in stable condition after successful
transposition of the vein to a more superficial level. Blood loss
is minimal, maybe 50 mL. The patient received 300 mL of crystalloid
intraoperatively. Instrument and sponge counts correct.
I need some assistance coding a vascular surgery. The CPT code I found that describes the procedure is 36819 but the physician did not do the arteriovenous anastomosis. here is the report.
I appreciate any advice, comments.
Thank you!
Dolores CPC - CCC
INDICATION: The patient is a 62-year-old female who had a left
upper arm fistula created. Then due to ischemia had a DRIL
procedure, but the vein despite the large size on venogram is too
deep. The patient is taken to surgery for superficialization and
transposition.
OPERATIVE REPORT: The patient was placed on the operating table in
the supine position. The patient was induced under general
anesthesia. The left arm was prepped and draped in the standard
fashion and standard antibiotics were given. He was under monitored
anesthesia. The patient's left arm was prepped and draped in a
standard fashion, and Marcaine was used 20 mL to anesthetize over
the cephalic vein. Using incisions about 3 to 4 cm in length the
vein was mobilized, superficialized, and then the subcu layer was
closed underneath to make sure the vein was very superficial, and
the skin was closed with 3-0 Monocryl followed by skin staples. The
patient transferred to recovery in stable condition after successful
transposition of the vein to a more superficial level. Blood loss
is minimal, maybe 50 mL. The patient received 300 mL of crystalloid
intraoperatively. Instrument and sponge counts correct.