Question 33415 and/or 33416


Galloway, OH
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I need opinions on this op note. Would it be appropriate to code both 33415 and 33416,59? Any help is appreciated.

Post-op Diagnosis

Cardiomyopathy Obstructive Hypertrophic (HCC)
Subaortic membrane
Exertional dyspnea, NYHA class 2


1. Resection of the subaortic membrane

2. Extended septal myectomy

3. Excision of the false cord

The patient underwent a general anesthesia without complication. Appropriate monitoring lines were placed by the Anesthesia Team. The patient's neck chest abdomen groins and legs were prepped and draped in the usual sterile fashion. Preoperative antibiotics was given 30 minutes prior to the skin incision. A surgical time-out was performed.

A midline sternotomy incision was performed with a 10. Blade and incision deepened with the Bovie electrocautery. The sternum was divided with electric saw and hemostasis obtained on the sternotomy. A chest retractor was put in place. The thymus was divided, the pericardium was opened and the heart was suspended in the pericardial cradle, and the pericardial cradle was flooded with carbon dioxide.

At this point the patient was systematically heparinized and heparin was allowed to circulate for 3 minutes. The ascending aorta was carefully evaluated with visual inspection,digital palpation, and it was appropriate for cannulation. The distal ascending aorta was cannulated with a 24 French Edwards EZ Glide aortic cannula and venous cannulation was accomplished using a dual stage venous cannula with the right atrium. The following vents were used for cardioplegia delivery cardiac decompression: Aortic root. My systemic hypothermia was used the lowest systemic temperature was 34° C. Prior to commencing cardiopulmonary bypass hemodynamic measurement was performed with the placement of short and long spinal needle into the aorta and the left ventricle across the right ventricle and transseptal route. There was significant resting gradient between the LV and aorta which was significantly accentuated during post PVC beat indicating an element of dynamic obstruction as well.

At this point ACT was above 450, the cardiopulmonary bypass was initiated. During cardiopulmonary bypass the patient's mean artery blood pressure was kept above 65 mm of mercury with a cardiac index above 2.6.

The pulmonary artery was separated from the aorta, and aortic cross-clamp site was prepared. Aortic occlusion was performed using a single clamp, and the heart was arrested with cold Del Nido cardioplegia solution delivered antegrade. The quality of the myocardial protection was excellent.

The ascending aorta was opened in oblique fashion at the level of the right pulmonary artery, and it was extended towards the noncoronary cusp. Aortic retraction sutures were placed to facilitate the exposure of the left ventricular outflow tract. Patient had a tricuspid aortic valve with normal coronary anatomy. The aortic valve leaflets were gently retracted to expose and inspect the LVOT. There was a near thick circumferential fibrotic subaortic membrane extending to the anterior mitral leaflet, aortic leaflets causing severe fixed obstruction of the LVOT. With the help of the Freer elevator, the plane between the subaortic membrane and the muscular septum was developed and using careful clockwise and counter-clockwise dissection the membrane was peeled off in its entirety, freeing up the entire anterior mitral leaflet, aorto-mitral continuity and the left and noncoronary cusp. Thickened accessory cord from the anterolateral papillary muscle going to the anterior mitral leaflet was excised as well.

We then performed an extended septal myectomy beginning with an incision in the septum just to the right of the nadir of the right aortic sinus. This incision in the septum was carried upward and leftward over to the anterior leaflet of the mitral valve. The area of septal excision was deepened and lengthened towards the apex of the heart until we had removed all obstructing muscle. The LVOT was copiously irrigated with cold saline solution to remove any microscopic debris is. The aortotomy was closed in 2 layers with running 4-0 Prolene sutures.

After careful maneuvers to evacuate air from aorta and heart the cross-clamp was removed, while the patient was in steep Trendelenburg position, and forward flow was fully reestablished to the heart. Atrial and ventricular pacing wires were placed in the right atrium and right ventricle. After appropriate time of reperfusion and rewarming the patient was weaned off the cardiopulmonary bypass without any difficulty. Repeat hemodynamic measurement was performed between the aorta left ventricle which showed complete resolution of the fixed and near complete resolution of the dynamic obstruction across the LVOT. Echocardiogram showed residual mid-ventricular gradient at the level of the base of the papillary muscles with a peak gradient during provocative maneuver 25 mm Hg. All cannulas were removed, and the cannulation sites were reinforced. The heparin was reversed with protamine. The chest was copiously irrigated with cold antibiotic containing saline solution. All surgical sites were inspected appeared to be hemostatic. Chest was closed in multiple layers stenosis device for the sternum, multiple layers of PDS for the subcutaneous tissue and 4 Monocryl for the skin.

All instrument sponge and needle counts were correct x2 there was no surgical complication after surgery patient was transferred in stable condition to intensive care unit.


Cary, NC
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33416 is bundled into 33415 per NCCI edits. While a modifier is allowed for unbundling, this documentation does not support use of 59/x modifiers as the initial subvalvular membrane and subsequent myectomy were both performed via the same incision and are in the same anatomical area. Since the diagnosis provided is HOCM and no mention of subaortic stenosis, I would lean toward reporting 33416 alone. Hope that helps!