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Axillary artery cannulation

angie

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I have a surgeon who performed the following, and I am stumped on #4. Does anyone know if there is a CPT code for this? So far, the codes I have is 33405, and 33860, but I think the repair of the axillary should be reported separately, but I cannot find a code for it. I included the report, so any guidance would be appreciated. Thanks!!! Angie

PROCEDURES PERFORMED
1. Emergent resection and repair of the ascending aorta with a 28-mm graft.
2. Aortic root replacement with a 25-mm mechanical valve conduit.
3. Replacement and repair of the proximal hemitransverse aorta under deep hypothermia with circulatory arrest with antegrade cerebral perfusion.
4. Exposure, cannulation, and repair of the right axillary artery, extrathoracic.

DETAILED DESCRIPTION OF PROCEDURE
Following prepping and draping, small transverse incision was made below the clavicle laterally. The pectoralis major and minor muscles were divided and the right axillary artery was dissected out with proximal and distal control. We then did a median sternotomy. The pericardium was opened. Hemorrhagic pericardial effusion was present. The ascending aorta had hemorrhagic changes with a hematoma extending into the pulmonary artery and the base of the heart. Following systemic heparinization, we cannulated the axillary artery with a 24-mm inflow cannula and placed a three-stage venous cannula into the right atrium. We went on cardiopulmonary bypass and initially went on moderate hypothermia. Retrograde cardioplegic catheter was inserted into the coronary sinus as well as the left atrial into the right superior pulmonary vein. The aorta was cross-clamped and cardiac arrest was induced by retrograde, followed by antegrade, crystalloid cardioplegia given directly through the coronary ostia. Topical cooling and intermittent retrograde blood cardioplegia was given thereafter. The ascending aorta was completely dissected and was resected extensively. We started cooling because a longitudinal tear in the flap extended up to and beyond the cross-clamp. While we were cooling down, we started the proximal aortic work. The leaflets were excised and the annulus was debrided. Coronary buttons were created for the both left and right coronary arteries. Horizontal mattress sutures were placed in the annulus. The annulus was sized to a 25-mm CarboMedics valve sizer and a valve contoured to the same size was sutured in. By this time, we had reached a core bladder temperature of 18 degrees centigrade. We turned off circulation and drained the patient with him in deep Trendelenburg position. The aortic cross-clamp was released and the ascending aorta and undersurface of the arch was excised. Then, we started perfusion through the axillary artery cannula at about a liter per minute and clamped the innominate artery. There was a good return through the left common carotid artery; therefore, unihemispheric perfusion was maintained. Under antegrade cerebral perfusion, we did our distal anastomosis. The two layers of the aorta were approximated over a felt strip as a sandwich. This was reinforced with CoSeal. A 28-mm Dacron draft was and anastomosed to this aortic arch directly. CoSeal was used externally for hemostasis. We then started deairing the aorta and went onto full flow. A cross-clamp was then applied to the graft. While we were rewarming, we completed the anastomosis with coronary buttons to the aortic mechanical root valve conduit after completion of the ascending graft and root graft anastomosis. We then rewarmed up to a core temperature of 34 degrees centigrade and by this time, the heart had resuscitated nicely. We came off cardiopulmonary bypass on low-dose inotropic support. We then reversed heparin with protamine and decannulated. Severe coagulopathy was present and extensive hemostasis was performed, which pretty much controlled the bleeding satisfactorily. Small amount of blood products were used to aid with the coagulation. After the bleeding came to a slow ooze, the sternum was closed with a stainless steel wire and the incision was closed in layers. Mediastinal chest tube and a right ventricular pacing wire were placed and anchored to the skin.
 

lisigirl

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I wouldn't bill for the cannulation or repair of the axillary artery because this was done in order to put the patient on cardiopulmonary bypass and therefore not separately billable.

I question the documentation in regards to one thing. The title says that the aortic root was replaced, which would be CPT 33863 rather than the 33860 + 33405. However, when the surgeon does replace the root, he usually states that the new valve was sewn into the bottom of the new aortic graft, which this note does not say.

Its up to you but I would confirm with the surgeon whether he really replaced the root or just the valve. Had he written that the ascending aorta was dissected above the sinotubular junction, I would think your codes are right but since its not clear, I would probably questioned him for clarification.

Hope that helped & didn't make things more confusing :)

Lisi, CPC
eharkler@nmh.org
 
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