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Aortobifemoral bypass and right common femoral and superficial femoral artery.

DebRush

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How would you code this? I came up with 35646, but surgeon replied that it was missing a right CFA endarterectomy. I'm not sure if there was a 2nd endarterectomy from the one that is included in the bypass. If so, I was looking at billing 35646 and 35371-59, RT? Please advise. Thanks!

DESCRIPTION OF THE PROCEDURE IN DETAIL:
After obtaining informed consent, the patient was taken to the operating room and laid supine on the table. An epidural catheter for anesthesia was placed and the patient was then induced. Next, a radial A-line was placed for intraoperative hemodynamic monitoring and a right IJ Cordis was placed for resuscitation intraoperatively by the Anesthesia team. Bilateral groins were clipped of hair and the patient was placed in the right partial lateral decubitus position with his hips flat. The procedure commenced with bilateral common femoral artery cutdowns on the left. The previous endarterectomy incision was used and the interposition bypass graft was identified and dissected circumferentially. Distally, the superficial femoral artery was identified and dissected circumferentially as was the profunda. These were well controlled with vessel loops and attention was turned towards the right groin which was dissected to the common femoral artery sheath which bifurcation at the superficial femoral artery and the profunda was also isolated with vessel loops. Proximally, towards the external iliac arteries, tunnels were formed extending into the abdomen. Attention was then turned towards the abdominal incision. A left flank incision was made at the level of the 10th rib extending in a lateral-to-medial fashion just short of the umbilicus. Dissection was carried down through the external and internal obliques as well as the transversalis fascia. The retroperitoneum was entered and the contents of the peritoneal cavity were retracted medially. The psoas muscle was identified and the contents of the peritoneal sac were further elevated anteriorly as well as the left kidney. An Omni retractor was placed for exposure. The left common iliac artery was easily palpable and this was traced proximally towards the aorta. The aorta was dissected of its retroperitoneal tissue. The left renal artery was identified and controlled with a vessel loop. Dissection then proceeded superior to that of the aorta and circumferential control of the suprarenal aorta was obtained and this was marked with a Silastic loop. Next, the inferior mesenteric artery was identified and also dissected circumferentially for a length of 5 cm. This was also marked with a Silastic loop. Finally, attention was turned towards creation of the tunnels for the iliac limbs of the bifurcated graft and these were tunneled directly anterior to the common iliac arteries bilaterally and marked with Silastic loops. The patient was then systemically heparinized and once an ACT was greater than 250, the aorta was clamped above the level of the left renal artery and just above the inferior mesenteric artery. A transverse incision was made in the infrarenal abdominal aorta and this was transected with Metzenbaum scissors. An endarterectomy was performed of the proximal aortic cuff and next, an end-to-end anastomosis was created with 3-0 Prolene suture to a 14 x 7 mm graft. The anastomosis was inspected for hemostasis and this was achieved with further interrupted 3-0 Prolene sutures with felt pledgets. The clamp was then removed off of the aorta and placed on the graft. Attention was turned towards suture ligation of the distal transected aorta and this was accomplished with a running 3-0 Prolene suture after having previously attempted transection with an Endo-GIA with a vascular reload stapler. Next, the bilateral iliac limbs were brought through the previously constricted tunnels. On the left, an end-to-side anastomosis was created to the distal common femoral artery extending onto the superficial femoral artery with a 5-0 Prolene suture. On the right, an arteriotomy was made. An endarterectomy was performed of the common femoral artery superficial femoral artery. Next, an end-to-side anastomosis was created with running 5-0 Prolene sutures. At the completion of the anastomoses, all limbs including the iliac limb of the graft were flushed and finally perfusion was restored to bilateral lower extremities. Doppler signals were assessed intraoperatively and they were present x4. Next, attention was turned towards obtaining hemostasis. The patient's heparin was reversed with protamine. He also received 2 units of FFP. Nu-Knit was applied to all raw surfaces and the anastomosis. Once his coagulopathy was corrected, the incisions appeared to be satisfactorily hemostatic and attention was turned towards closure of the incisions. Bilateral groin incisions were closed with interrupted layers of 2-0 and 3-0 Vicryl sutures. The skin edges were approximated with 4-0 Monocryl. In the abdomen, the anastomosis was again inspected as was the ligated aortic stump and this too appeared to be hemostatic. Attention was turned towards closure of this incision with 0 looped PDS sutures. The transected edges of the muscles were approximated and the skin edges were closed with staples. A Prevena VAC dressing was applied to the 3 wounds and the patient was successfully extubated in the operating room. Doppler signals were, again, assessed present. The instrument, sponge, and lap count were accurate at the end of the case and I was present throughout the entirety of the case.
 
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