conleyclan
Guru
Any suggestions on how this report would be coded? I have the 33475 for the pulmonary valve replacement, but am not sure about the RVOT repair. Thank you!!
PREOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
STERNAL NONUNION
POSTOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
STERNAL NONUNION
OPERATION
PULMONARY VALVE REPLACEMENT
LEFT GROIN EXPLORATION AND EXPOSURE OF THE FEMORAL VESSELS
STERNAL CLOSURE PERFORMED BY THE PLASTIC SURGERY
ANESTHESIA
GENERAL
ANESTHESIOLOGIST
IMPLANTS
1. 27 mm Medtronic Mosaic valve.
2. Gore-Tex patch of right ventricular outflow tract.
SPECIMENS
None.
DESCRIPTION OF PROCEDURE
After informed consent was obtained he was brought to the Operating Room
placed on the table in supine position. Anesthesia monitors were attached
general anesthesia was obtained. His chest and abdomen and groins were then
prepped and draped in usual sterile fashion. Because of my significant
concerns about sternal reentry I dissected out the left groin. I chose left
groin because the right colon had a previous incision at this location. We
then identified the femoral artery and vein and we obtained proximal and
distal control of these vessels. With this undertaken I next reentered the
previous midline incision and carried the dissection down to the height of the
remnant of the sternal bone. There was no sternal bone in the midline. I then
began dissection at the lowest aspect of the wound to the posterior aspect of
the sternum and into the mediastinum. Proceeding in a slow and tedious process
we were able to fully open the area of sternal nonunion. I then carried out
dissection of the posterior aspects of the sternum on both sides. A retractor
was inserted. There was significant inflammation and adhesions within the
mediastinum itself and the mediastinum seemed somewhat contracted because of
this. I was able to dissect out the ascending aorta and the right atrium. A
full heparinizing dose was given. Cannulas were inserted in these and
cardiopulmonary bypass was instituted. I again carried out dissection to
identify the right ventricular outflow tract and this was entered. I could not
obtain adequate control of venous return with only the two-stage cannula in
the right atrium and for this reason I dissected out the superior vena cava
and inferior vena cava. I placed cannulas in these structures and I changed my
cannulation strategy here. I placed tapes around the SVC and the IVC and these
tapes were taken down. This provided me much better visualization. I did ask
the perfusionist to cool as well. I then opened the right ventricular outflow
tract as well and extended this towards the bifurcation of the pulmonary
arteries. This was to the right lateral aspect of the previous patch, but it
was exceedingly difficult to dissect out the entirety of the pulmonary artery.
I could not dissect out the heart because of the dense adhesions. I was
concerned that I have injured the phrenic nerve or coronary artery. For this
reason, I elected to undertake valve replacement of the exposure that I have.
I sized for a 27 mm Mosaic valve and this was prepared at the back table. I
then placed valve sutures posteriorly at the junction of the ventricle and
pulmonary artery. There was no remnant of the pulmonary valve visualized. When
the valve was prepared at the back table I next brought it forward and I used
valve sutures to place through the sewing ring and I seated the valve in the
outflow tract posteriorly. When this was completed I then took a Gore-Tex
patch and patched the pulmonary artery and right ventricular outflow tract
anteriorly. The Gore-Tex patch was sewed in place with a running 4 0 Prolene
suture. The valve was secured anteriorly to the Gore-Tex patch. When this was
completed CoSeal was applied and I asked the perfusionist to began rewarming
to normothermia. During this period of time we also closed the wound in the
left groin. This was closed in three layers and a Dermabond dressing was
applied. Once we had reached normothermia, we weaned from cardiopulmonary
bypass without difficulty. All the cannulas were removed and the pursestrings
were tied and each was reinforced with an additional suture. I placed a
24-French Blake drain through a separate stab incision as did a right atrial
pacing wire. Once I ensured that there was hemostasis the plastic surgeons
came to the room and they completed the sternal closure and that is dictated
elsewhere. I remained in the Operating Room for the entirety of this closure
as well. When this was done ........... was transported to the ICU extubated in
stable condition. Please note that we did not to use the right groin vessels
for cannulation. It should also be noted that CoSeal glue was applied to the
anterior surface of the heart prior to closure of the chest to aid for sternal
reentry should this be necessary.
"I understand that section 1842 (b) (7) (D) of the Social Security Act
generally prohibits Medicare physician fee schedule payment for the services
of assistants at surgery in teaching hospitals when qualified residents are
available to furnish such services. I certify that the services for which
payment is claimed were medically necessary and that no qualified resident was
available to perform the services. I further understand that these services
are subject to post payment review by the Medicare carrier."
PREOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
STERNAL NONUNION
POSTOPERATIVE DIAGNOSIS
FREE PULMONARY INSUFFICIENCY
STERNAL NONUNION
OPERATION
PULMONARY VALVE REPLACEMENT
LEFT GROIN EXPLORATION AND EXPOSURE OF THE FEMORAL VESSELS
STERNAL CLOSURE PERFORMED BY THE PLASTIC SURGERY
ANESTHESIA
GENERAL
ANESTHESIOLOGIST
IMPLANTS
1. 27 mm Medtronic Mosaic valve.
2. Gore-Tex patch of right ventricular outflow tract.
SPECIMENS
None.
DESCRIPTION OF PROCEDURE
After informed consent was obtained he was brought to the Operating Room
placed on the table in supine position. Anesthesia monitors were attached
general anesthesia was obtained. His chest and abdomen and groins were then
prepped and draped in usual sterile fashion. Because of my significant
concerns about sternal reentry I dissected out the left groin. I chose left
groin because the right colon had a previous incision at this location. We
then identified the femoral artery and vein and we obtained proximal and
distal control of these vessels. With this undertaken I next reentered the
previous midline incision and carried the dissection down to the height of the
remnant of the sternal bone. There was no sternal bone in the midline. I then
began dissection at the lowest aspect of the wound to the posterior aspect of
the sternum and into the mediastinum. Proceeding in a slow and tedious process
we were able to fully open the area of sternal nonunion. I then carried out
dissection of the posterior aspects of the sternum on both sides. A retractor
was inserted. There was significant inflammation and adhesions within the
mediastinum itself and the mediastinum seemed somewhat contracted because of
this. I was able to dissect out the ascending aorta and the right atrium. A
full heparinizing dose was given. Cannulas were inserted in these and
cardiopulmonary bypass was instituted. I again carried out dissection to
identify the right ventricular outflow tract and this was entered. I could not
obtain adequate control of venous return with only the two-stage cannula in
the right atrium and for this reason I dissected out the superior vena cava
and inferior vena cava. I placed cannulas in these structures and I changed my
cannulation strategy here. I placed tapes around the SVC and the IVC and these
tapes were taken down. This provided me much better visualization. I did ask
the perfusionist to cool as well. I then opened the right ventricular outflow
tract as well and extended this towards the bifurcation of the pulmonary
arteries. This was to the right lateral aspect of the previous patch, but it
was exceedingly difficult to dissect out the entirety of the pulmonary artery.
I could not dissect out the heart because of the dense adhesions. I was
concerned that I have injured the phrenic nerve or coronary artery. For this
reason, I elected to undertake valve replacement of the exposure that I have.
I sized for a 27 mm Mosaic valve and this was prepared at the back table. I
then placed valve sutures posteriorly at the junction of the ventricle and
pulmonary artery. There was no remnant of the pulmonary valve visualized. When
the valve was prepared at the back table I next brought it forward and I used
valve sutures to place through the sewing ring and I seated the valve in the
outflow tract posteriorly. When this was completed I then took a Gore-Tex
patch and patched the pulmonary artery and right ventricular outflow tract
anteriorly. The Gore-Tex patch was sewed in place with a running 4 0 Prolene
suture. The valve was secured anteriorly to the Gore-Tex patch. When this was
completed CoSeal was applied and I asked the perfusionist to began rewarming
to normothermia. During this period of time we also closed the wound in the
left groin. This was closed in three layers and a Dermabond dressing was
applied. Once we had reached normothermia, we weaned from cardiopulmonary
bypass without difficulty. All the cannulas were removed and the pursestrings
were tied and each was reinforced with an additional suture. I placed a
24-French Blake drain through a separate stab incision as did a right atrial
pacing wire. Once I ensured that there was hemostasis the plastic surgeons
came to the room and they completed the sternal closure and that is dictated
elsewhere. I remained in the Operating Room for the entirety of this closure
as well. When this was done ........... was transported to the ICU extubated in
stable condition. Please note that we did not to use the right groin vessels
for cannulation. It should also be noted that CoSeal glue was applied to the
anterior surface of the heart prior to closure of the chest to aid for sternal
reentry should this be necessary.
"I understand that section 1842 (b) (7) (D) of the Social Security Act
generally prohibits Medicare physician fee schedule payment for the services
of assistants at surgery in teaching hospitals when qualified residents are
available to furnish such services. I certify that the services for which
payment is claimed were medically necessary and that no qualified resident was
available to perform the services. I further understand that these services
are subject to post payment review by the Medicare carrier."