smerriweather1
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Hello,
I'm in need of a second opinion. I have coded this for the Operative Note that follows. Am I correct with the new EVAR coding(2018) or am I missing something? Thanks!
34703
34812-50
Diagnosis Code is I71.4
PROCEDURES PERFORMED:
1. Bilateral common femoral artery exploration.
2. Endovascular repair of AAA aneurysm with Gore graft, right main body 31 mm x 14.5 mm x 13 cm.
3. Left contralateral bell bottom 18 mm x 11.5 cm.
4. Right ipsilateral extension bell bottom 20 mm x 11.5 cm.
ANESTHESIA: General endotracheal anesthesia.
INTRAVENOUS FLUIDS: 1500 mL.
ESTIMATED BLOOD LOSS: 100 mL.
URINE OUTPUT: 100 mL.
SPECIMEN OBTAINED: None.
DISPOSITION: PACU.
FINDINGS: The infrarenal abdominal aortic aneurysm was sealed with the stent graft and there was no endoleak noted at the end of the case.
INDICATIONS FOR PROCEDURE: The patient is an 83-year-old male who was noted to have an enlarging infrarenal saccular aneurysm, which was initially noted on a CT scan. He was noted in September 2017 to have aneurysm measurements 4.15 x 4.39 cm and in December 2017, he had a CT abdomen and pelvis done without contrast and at that time 0.2 cm.
Given this enlargement in the aneurysm, the patient was then booked and consented for the above-mentioned procedure. The patient was explained the risks and benefits of procedure, bleeding, infection, wound breakdown, possibility of conversion to open, possibility of bowel ischemia, paralysis, long ICU stay, kidney failure, and the patient gave informed consent.
DETAILS OF PROCEDURE: On the date of the surgery, the patient was brought to the operating room and laid down supine on the operating table. General anesthesia was provided by the anesthesia department. A Foley catheter was placed by the anesthesia department as well. The patient was given Ancef 2 g by the anesthesia department. A Foley catheter was placed. The patient's bilateral groins and abdomen were prepped and draped in sterile fashion.
A time-out was obtained by the attending physician. We started by making transfer incisions on the bilateral groins to expose the common femoral artery. The common femoral artery was then dissected circumferentially. Proximal umbilical tape was placed distally. A vessel loop was placed. The patient was then given 5000 units of IV by the anesthesia department. Access was then obtained in the bilateral groins using Potts needle. A 0.035 wire was then placed through the needle and using Seldinger technique, a short 6-French sheath were then placed bilaterally. We started by placing 0.035 wire through the right-sided sheath and a pigtail was placed over it. We then obtained aortogram and bilateral pelvicogram to look at the renals and the length of the neck and measure the length from the renals to the bifurcation as well as to the right common iliac bifurcation. After this was done, a stiff Lunderquist wire was then placed through the pigtail and placed in the patient's thoracic aorta. The tip of the catheter was then removed. The short 6-French sheath was then removed and then on the right side 18-French sheath was then placed into the patient's infrarenal aorta.
A 0.035 wire and a Kumpe catheter was then placed into the patient's thoracic aorta coming from the left side. The 0.035 Glidewire was then switched for a 0.035 Lunderquist wire. The tip of the Lunderquist wire was then placed in the patient's thoracic aorta. The short sheath was then removed and then switched for a 12-French long sheath, which was also placed then to the level of the infrarenal aorta. Next, the pigtail catheter was then placed through the left-sided sheath into the patient's abdominal aorta. The main body was then placed via the right side through the sheath to the level of the infrarenal aorta. Fluoroscopy machine was then angled craniocaudal for para lacks. Aortogram was then performed and the renal arteries were marked on the screen. The main body of the graft was then opened up partially to deploy the proximal part of the graft and open the gate. The open was then gated about 10 o'clock position. A 0.035 Glide Advantage was then placed to the pigtail catheter and the pigtail was pulled back over it. We then made several attempts, the gate with the help of a Kumpe catheter and 0.035 Glide Advantage wire coming via the left-sided sheath. We noted that we have to remove our graft gate more lateral so the graft was free constrained and rotated and repositioned again with the help of fluoroscopy. Once that was sent, we again used a 0.035 Glide Advantage and the Kumpe catheter coming from the left-sided sheath to cannulate the gate. At this time, we were able to do so. The pigtail catheter was then placed after removing the Kumpe catheter and we rotated the pigtail catheter inside the graft, making sure that we were within the graft, which we were. Next, keeping the pigtail in place, we then pulled back on the left sheath to where it was below the bifurcation of the left common iliac artery. A run was then performed to get the measurements for the length of the contralateral limb. We then obtained an 18 mm x 11.5 cm bell bottom contralateral stent graft and placed it over the left-sided Lunderquist wire and thereafter the 18 x 11.5 cm stent graft was then deployed from under fluoroscopy. Once that was done, we then pulled back the sheath on the right side and completed the deployment of the main body on the right side. We then obtained the 12 mm x 11.5 cm bell bottom and it was placed on the right side after we did a run to mark the right common iliac artery bifurcation. Once that was done, we then obtained a Q50 Gore balloon and the balloon was then inflated and then the aortic graft was then sealed at the proximal end at the gate and at the distal ends as well as the distal end in the common iliac artery. Once that was done, the pigtail catheter was then placed via the left-sided limb and a completion aortogram was then obtained. No EndoClips was noted. The deployment of the graft was proper. The graft was distal to the left renal, which was the lowest renal and distally graft was at the level of the bifurcation bilaterally and the common iliac arteries.
After that was done, proximal and distal control was obtained after pulling the sheath and the common femoral arteries. Bilateral arteriotomy was then repaired using interrupted CV-6 suture. The sutures were then tied down after doing forward and backward flushing. The wounds were then checked for hemostasis. The wounds were then closed in multiple layers using 2-0, 3-0, and 4-0 Monocryl sutures. Dermabond was then applied to the incision. The patient was then extubated and transferred in stable condition. The patient continued to have palpable pedal pulses. All the instruments and needle counts were correct at the end of the procedure.
I'm in need of a second opinion. I have coded this for the Operative Note that follows. Am I correct with the new EVAR coding(2018) or am I missing something? Thanks!
34703
34812-50
Diagnosis Code is I71.4
PROCEDURES PERFORMED:
1. Bilateral common femoral artery exploration.
2. Endovascular repair of AAA aneurysm with Gore graft, right main body 31 mm x 14.5 mm x 13 cm.
3. Left contralateral bell bottom 18 mm x 11.5 cm.
4. Right ipsilateral extension bell bottom 20 mm x 11.5 cm.
ANESTHESIA: General endotracheal anesthesia.
INTRAVENOUS FLUIDS: 1500 mL.
ESTIMATED BLOOD LOSS: 100 mL.
URINE OUTPUT: 100 mL.
SPECIMEN OBTAINED: None.
DISPOSITION: PACU.
FINDINGS: The infrarenal abdominal aortic aneurysm was sealed with the stent graft and there was no endoleak noted at the end of the case.
INDICATIONS FOR PROCEDURE: The patient is an 83-year-old male who was noted to have an enlarging infrarenal saccular aneurysm, which was initially noted on a CT scan. He was noted in September 2017 to have aneurysm measurements 4.15 x 4.39 cm and in December 2017, he had a CT abdomen and pelvis done without contrast and at that time 0.2 cm.
Given this enlargement in the aneurysm, the patient was then booked and consented for the above-mentioned procedure. The patient was explained the risks and benefits of procedure, bleeding, infection, wound breakdown, possibility of conversion to open, possibility of bowel ischemia, paralysis, long ICU stay, kidney failure, and the patient gave informed consent.
DETAILS OF PROCEDURE: On the date of the surgery, the patient was brought to the operating room and laid down supine on the operating table. General anesthesia was provided by the anesthesia department. A Foley catheter was placed by the anesthesia department as well. The patient was given Ancef 2 g by the anesthesia department. A Foley catheter was placed. The patient's bilateral groins and abdomen were prepped and draped in sterile fashion.
A time-out was obtained by the attending physician. We started by making transfer incisions on the bilateral groins to expose the common femoral artery. The common femoral artery was then dissected circumferentially. Proximal umbilical tape was placed distally. A vessel loop was placed. The patient was then given 5000 units of IV by the anesthesia department. Access was then obtained in the bilateral groins using Potts needle. A 0.035 wire was then placed through the needle and using Seldinger technique, a short 6-French sheath were then placed bilaterally. We started by placing 0.035 wire through the right-sided sheath and a pigtail was placed over it. We then obtained aortogram and bilateral pelvicogram to look at the renals and the length of the neck and measure the length from the renals to the bifurcation as well as to the right common iliac bifurcation. After this was done, a stiff Lunderquist wire was then placed through the pigtail and placed in the patient's thoracic aorta. The tip of the catheter was then removed. The short 6-French sheath was then removed and then on the right side 18-French sheath was then placed into the patient's infrarenal aorta.
A 0.035 wire and a Kumpe catheter was then placed into the patient's thoracic aorta coming from the left side. The 0.035 Glidewire was then switched for a 0.035 Lunderquist wire. The tip of the Lunderquist wire was then placed in the patient's thoracic aorta. The short sheath was then removed and then switched for a 12-French long sheath, which was also placed then to the level of the infrarenal aorta. Next, the pigtail catheter was then placed through the left-sided sheath into the patient's abdominal aorta. The main body was then placed via the right side through the sheath to the level of the infrarenal aorta. Fluoroscopy machine was then angled craniocaudal for para lacks. Aortogram was then performed and the renal arteries were marked on the screen. The main body of the graft was then opened up partially to deploy the proximal part of the graft and open the gate. The open was then gated about 10 o'clock position. A 0.035 Glide Advantage was then placed to the pigtail catheter and the pigtail was pulled back over it. We then made several attempts, the gate with the help of a Kumpe catheter and 0.035 Glide Advantage wire coming via the left-sided sheath. We noted that we have to remove our graft gate more lateral so the graft was free constrained and rotated and repositioned again with the help of fluoroscopy. Once that was sent, we again used a 0.035 Glide Advantage and the Kumpe catheter coming from the left-sided sheath to cannulate the gate. At this time, we were able to do so. The pigtail catheter was then placed after removing the Kumpe catheter and we rotated the pigtail catheter inside the graft, making sure that we were within the graft, which we were. Next, keeping the pigtail in place, we then pulled back on the left sheath to where it was below the bifurcation of the left common iliac artery. A run was then performed to get the measurements for the length of the contralateral limb. We then obtained an 18 mm x 11.5 cm bell bottom contralateral stent graft and placed it over the left-sided Lunderquist wire and thereafter the 18 x 11.5 cm stent graft was then deployed from under fluoroscopy. Once that was done, we then pulled back the sheath on the right side and completed the deployment of the main body on the right side. We then obtained the 12 mm x 11.5 cm bell bottom and it was placed on the right side after we did a run to mark the right common iliac artery bifurcation. Once that was done, we then obtained a Q50 Gore balloon and the balloon was then inflated and then the aortic graft was then sealed at the proximal end at the gate and at the distal ends as well as the distal end in the common iliac artery. Once that was done, the pigtail catheter was then placed via the left-sided limb and a completion aortogram was then obtained. No EndoClips was noted. The deployment of the graft was proper. The graft was distal to the left renal, which was the lowest renal and distally graft was at the level of the bifurcation bilaterally and the common iliac arteries.
After that was done, proximal and distal control was obtained after pulling the sheath and the common femoral arteries. Bilateral arteriotomy was then repaired using interrupted CV-6 suture. The sutures were then tied down after doing forward and backward flushing. The wounds were then checked for hemostasis. The wounds were then closed in multiple layers using 2-0, 3-0, and 4-0 Monocryl sutures. Dermabond was then applied to the incision. The patient was then extubated and transferred in stable condition. The patient continued to have palpable pedal pulses. All the instruments and needle counts were correct at the end of the procedure.
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