Below are the codes, I figured out...My physician wants me to include CPT 34813 for large bore closure...But it is an add-on code for CPT 34812 which is not performed. Can someone correct me if I am wrong or should I go with coding CPT 34813?
37236-LT, XU
33880
34834-LT, XU
76937-26
Preoperative Diagnosis: Type 1A endoleak; thoracic aortic aneurysm
Postoperative Diagnosis: * Thoracic aortic aneurysm, without rupture (HCC) [I71.2]
Procedure(s):
THORACIC ENDOVASCULAR ANEURYSM REPAIR WITH COVERAGE OF LEFT SUBCLAVIAN ARTERY (TEVAR)
LEFT BRACHIAL ARTERY CUTDOWN; REPAIR OF LEFT BRACHIAL ARTERIOTOMY
PERCUTANEOUS LARGE BORE RIGHT FEMORAL ARTERY ACCESS AND CLOSURE
ANGIOPLASTY AND STENTING OF LEFT SUBCLAVIAN ARTERY
Operative Indication: The patient is a 91 y.o. female with a history of ruptured thoracic aortic aneurysm s/p TEVAR distal to the LSCA with successful results approximately 2 months ago.
Operative Findings: Type 1a endoleak just distal to the subclavian artery
Operative Description:
A longitudinal incision was made over the distal brachial artery just proximal to the antecubital fossa, and this incision was deepened through subcutaneous tissue using Bovie electrocautery. The brachial sheath was incised longitudinally, and the brachial artery was dissected free of surrounding tissue by sharp dissection. A vessel loop was used to secure arterial access. A pursestring 6-0 Prolene suture was placed over the presumed site of the arteriotomy.
Right common femoral access was then obtained under ultrasound guidance using 5F micropuncture kit and the Seldinger technique. A 6F sheath was placed over an 035 Benson wire. The groin were "pre-closed" with 2 Perclose devices. 8,000 units of IV heparin was administered. A 9F sheath was then inserted in the groin. A marker pigtail was then used to perform an arch angiogram to determine location of the great vessels and the endoleak. This demonstrated widely patent great vessels with the pre-diagnosed endoleak proximally.
Through the pigtail catheter in the ascending aorta, the wire was exchanged for a super stiff double curved Lunderquist wire.
At this point, a 4F micropuncture was used to directly puncture the left brachial artery that was previously exposed. Over an 035 system, the sheath was upsized to a long 7F Destination sheath to the proximal left subclavian artery. The wire was exchanged for an 014 wire.
From the femoral access, a repeat arch angiogram was performed. The great vessels were all marked, taking care to especially mark out the left subclavian artery. This aortogram was performed in an LAO view of 46 degrees. A 38 x 217 mm Cook alpha endograft was then deployed just distal to the left common carotid artery, intentionally covering the left subclavian artery.
From the left arm access, a 2.0 Spectranetics laser was then used to create a fenestration for the subclavian artery. An 014 wire was then advanced into the aorta. This was confirmed with a selective catheter angiogram to ensure positioning in the descending thoracic aorta. The fenestration was then serially dilated to 2.5 mm, then 7 mm by angioplasty. Finally, the 014 wire was exchanged for an 035 wire, and an 8 mm x 39 mm VBX was inserted into the proximal subclavian artery, bridging into the thoracic stent graft.
Prior to deployment of the VBX, a 46 mm CODA balloon was used to create a seal proximally and distally on the thoracic endograft. The VBX was then deployed to nominal diameter of 8 mm. The small portion within the aortic endograft was post dilated to 10 mm.
An aortogram afterwards demonstrated widely patent great vessels, subclavian stent graft, and complete seal of the thoracic component of the aneurysm. Abdominal aortography was performed both in lateral and AP views, which demonstrated widely patent celiac, superior mesenteric, and bilateral renal arteries with no abnormal findings.
All devices and sheaths were then removed from the right groin access from below. The right groin large bore sheath arteriotomy was sealed with two closure devices, and pressure was held on the groin for 5 minutes afterwards. Hemostasis was achieved. The skin incision was closed with a single interrupted Monocryl stitch.
37236-LT, XU
33880
34834-LT, XU
76937-26
Preoperative Diagnosis: Type 1A endoleak; thoracic aortic aneurysm
Postoperative Diagnosis: * Thoracic aortic aneurysm, without rupture (HCC) [I71.2]
Procedure(s):
THORACIC ENDOVASCULAR ANEURYSM REPAIR WITH COVERAGE OF LEFT SUBCLAVIAN ARTERY (TEVAR)
LEFT BRACHIAL ARTERY CUTDOWN; REPAIR OF LEFT BRACHIAL ARTERIOTOMY
PERCUTANEOUS LARGE BORE RIGHT FEMORAL ARTERY ACCESS AND CLOSURE
ANGIOPLASTY AND STENTING OF LEFT SUBCLAVIAN ARTERY
Operative Indication: The patient is a 91 y.o. female with a history of ruptured thoracic aortic aneurysm s/p TEVAR distal to the LSCA with successful results approximately 2 months ago.
Operative Findings: Type 1a endoleak just distal to the subclavian artery
Operative Description:
A longitudinal incision was made over the distal brachial artery just proximal to the antecubital fossa, and this incision was deepened through subcutaneous tissue using Bovie electrocautery. The brachial sheath was incised longitudinally, and the brachial artery was dissected free of surrounding tissue by sharp dissection. A vessel loop was used to secure arterial access. A pursestring 6-0 Prolene suture was placed over the presumed site of the arteriotomy.
Right common femoral access was then obtained under ultrasound guidance using 5F micropuncture kit and the Seldinger technique. A 6F sheath was placed over an 035 Benson wire. The groin were "pre-closed" with 2 Perclose devices. 8,000 units of IV heparin was administered. A 9F sheath was then inserted in the groin. A marker pigtail was then used to perform an arch angiogram to determine location of the great vessels and the endoleak. This demonstrated widely patent great vessels with the pre-diagnosed endoleak proximally.
Through the pigtail catheter in the ascending aorta, the wire was exchanged for a super stiff double curved Lunderquist wire.
At this point, a 4F micropuncture was used to directly puncture the left brachial artery that was previously exposed. Over an 035 system, the sheath was upsized to a long 7F Destination sheath to the proximal left subclavian artery. The wire was exchanged for an 014 wire.
From the femoral access, a repeat arch angiogram was performed. The great vessels were all marked, taking care to especially mark out the left subclavian artery. This aortogram was performed in an LAO view of 46 degrees. A 38 x 217 mm Cook alpha endograft was then deployed just distal to the left common carotid artery, intentionally covering the left subclavian artery.
From the left arm access, a 2.0 Spectranetics laser was then used to create a fenestration for the subclavian artery. An 014 wire was then advanced into the aorta. This was confirmed with a selective catheter angiogram to ensure positioning in the descending thoracic aorta. The fenestration was then serially dilated to 2.5 mm, then 7 mm by angioplasty. Finally, the 014 wire was exchanged for an 035 wire, and an 8 mm x 39 mm VBX was inserted into the proximal subclavian artery, bridging into the thoracic stent graft.
Prior to deployment of the VBX, a 46 mm CODA balloon was used to create a seal proximally and distally on the thoracic endograft. The VBX was then deployed to nominal diameter of 8 mm. The small portion within the aortic endograft was post dilated to 10 mm.
An aortogram afterwards demonstrated widely patent great vessels, subclavian stent graft, and complete seal of the thoracic component of the aneurysm. Abdominal aortography was performed both in lateral and AP views, which demonstrated widely patent celiac, superior mesenteric, and bilateral renal arteries with no abnormal findings.
All devices and sheaths were then removed from the right groin access from below. The right groin large bore sheath arteriotomy was sealed with two closure devices, and pressure was held on the groin for 5 minutes afterwards. Hemostasis was achieved. The skin incision was closed with a single interrupted Monocryl stitch.