dvance4210
Networker
Could someone please take a look at this one... I feel that the code is 33860 but the physician feels that there should be another code with it. I could see anything else to bill other than adding a 22 modifier.....
The incision was extended through the subcutaneous tissue with Bovie. The femoral artery was visualized and was isolaed. Proximal distal control was obtained. A 5 of Prolene was utized with pursestring. The femoral artery was cannulated using the Seldinger technique and the Medtronic femoral cannula. The cannula was inserted and it was tested and it appears to be in good position. I should mention that the patient has been heparinized for an ICT greater than 400. The median sternotomy was performed. The mediastinum was visualized. There were some bruises and clots already in the mediastinal fat. The pericardium was incised and bright red blood was drained. We also drained a long fresh clot as well. The pericarium was marsupialized. We noticed an enormous amount of adventitia, mottling, and clots that was also affecting the adventitia of the pumonary artery. The right atrial appendage was cannulated and the patient was placed in cardiopulmonary bypass. We started cooling to the temperature of 25 degrees initially. Retrograde cardioplegia cannula was also inserted as well as the true lumen of the aorta. The ascending aorta was incised and we noticed the false lumen as well as the true lumen of the aortic. The ascending aortic was inspected, looking for a tear. We could not find a tear but the false lumen was extended down toward the valve but it spared the sinotubular junction as well as the valve. The valve was intact and had no leakage. At this point, we proceeded to place a Teflon circular piece around the adventitia of the vessel. This Teflon segment was secured to the full thickness wall of the proximal ascending aorta utilizing interruped 3-0 Prolene. Once we had created a solid proximal cuff, we proceeded to sew a #26 InterGard interposition graft between the proximal cuff of the ascending aorta and the graft. This was performed in an end-to-end fashion with 3-0 Prolene. Once we had finished the proximal, we were ready for the circulatory arrest. I should mention that the edges of the ascending aorta just proximal to the clamp were obviously affected by the dissection, so hypothermic arrest was mandatory. At this time, the temperature of th patient was around 16 degrees and we proceeded to perfom the hypothermic circulatory arrest. The cross clamp was removed and we were able then to evaluated that the tear started in the proximal portion of the arch and there was a linear extension of the tear toward the innominate artery. We proceeded to reapproximate that linear tear with a running 3-0 Prolene reinforced with 2 pieces of InterGard graft in the adventitia. This InterGard graft was to prevent any tear created by the suture.
Once we have clearly approximated the full thickness of the linear tear toward the edge of the transected distal aorta, we proceeded then to perfom the distal anastomsis in an end-to end fashion with 3-0 Prolene between the InterGard graft and the proximal arch. This anastomosis was performed in running fashion with 3-0 Prolene. A couple of reinforcing stitches were placed to secure the suture line.
Thanks for any thoughts on this.
The incision was extended through the subcutaneous tissue with Bovie. The femoral artery was visualized and was isolaed. Proximal distal control was obtained. A 5 of Prolene was utized with pursestring. The femoral artery was cannulated using the Seldinger technique and the Medtronic femoral cannula. The cannula was inserted and it was tested and it appears to be in good position. I should mention that the patient has been heparinized for an ICT greater than 400. The median sternotomy was performed. The mediastinum was visualized. There were some bruises and clots already in the mediastinal fat. The pericardium was incised and bright red blood was drained. We also drained a long fresh clot as well. The pericarium was marsupialized. We noticed an enormous amount of adventitia, mottling, and clots that was also affecting the adventitia of the pumonary artery. The right atrial appendage was cannulated and the patient was placed in cardiopulmonary bypass. We started cooling to the temperature of 25 degrees initially. Retrograde cardioplegia cannula was also inserted as well as the true lumen of the aorta. The ascending aorta was incised and we noticed the false lumen as well as the true lumen of the aortic. The ascending aortic was inspected, looking for a tear. We could not find a tear but the false lumen was extended down toward the valve but it spared the sinotubular junction as well as the valve. The valve was intact and had no leakage. At this point, we proceeded to place a Teflon circular piece around the adventitia of the vessel. This Teflon segment was secured to the full thickness wall of the proximal ascending aorta utilizing interruped 3-0 Prolene. Once we had created a solid proximal cuff, we proceeded to sew a #26 InterGard interposition graft between the proximal cuff of the ascending aorta and the graft. This was performed in an end-to-end fashion with 3-0 Prolene. Once we had finished the proximal, we were ready for the circulatory arrest. I should mention that the edges of the ascending aorta just proximal to the clamp were obviously affected by the dissection, so hypothermic arrest was mandatory. At this time, the temperature of th patient was around 16 degrees and we proceeded to perfom the hypothermic circulatory arrest. The cross clamp was removed and we were able then to evaluated that the tear started in the proximal portion of the arch and there was a linear extension of the tear toward the innominate artery. We proceeded to reapproximate that linear tear with a running 3-0 Prolene reinforced with 2 pieces of InterGard graft in the adventitia. This InterGard graft was to prevent any tear created by the suture.
Once we have clearly approximated the full thickness of the linear tear toward the edge of the transected distal aorta, we proceeded then to perfom the distal anastomsis in an end-to end fashion with 3-0 Prolene between the InterGard graft and the proximal arch. This anastomosis was performed in running fashion with 3-0 Prolene. A couple of reinforcing stitches were placed to secure the suture line.
Thanks for any thoughts on this.
