Question EVAR

heart123

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would this be 34705, 34713, 50,34812,50, and 36245,50 Thanks

The patient was intubated. A central venous line was inserted in his right IJ under ultrasound guidance using a modified Seldinger technique. We then accessed the right and left common femoral arteries and placed a 7-French sheaths. We then gave heparin. We then placed 2 Perclose sutures in each right and left femoral arteries. We placed a 6-French sheath on the right and a 12-French sheath on the left. We did an abdominal aortogram which revealed the location of renal arteries. We then deployed the main body. We then cannulated the contralateral gate. We then placed a contralateral limb. We then finished deploying the main body and limb and ballooned the proximal and distal attachment zones. Completion angiogram showed complete exclusion aneurysm. The wires and sheaths were removed. We tied down a preclose sutures. Good hemostasis. There were good pulses distally. We closed the wound with interrupted 4-0 Monocryl sutures. The patient tolerated the procedure well.
 

kathrynw

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Hi,
With the information given these appear to be the correct codes. But review the following lay terms and clinical responsibilities to help you decide as the documentation is slim. You may need to query the physician for clarification. I also included a link to a PowerPoint that might prove helpful in determining aorto-uni-iliac vs aorto-bi-iliac.
https://slideplayer.com/slide/6853911/
Make sure to check the NCCI edits for the codes you pick, right now 34713 and 34812 would need modifiers.
34703 Lay Terms:
The provider places an aorto–uni–iliac endograft (a tube graft that extends from inside the aorta down one limb of the iliac arteries) to repair the infrarenal aorta or iliac artery for reasons other than rupture or injury. This code covers pre–procedure sizing and device selection, any nonselective catheterization, angioplasty/stenting, any endograft extensions performed from the renal arteries to the iliac bifurcation and all radiological supervision and interpretation.
Clinical Responsibility
The provider may perform endovascular repair when the infrarenal aorta develops an aneurysm (bulging of the arterial wall due to a weakening of the artery walls), pseudoaneurysm, or for a penetrating ulcer or dissection (linear tear in the intima, or lining, of the arterial wall).

After the patient is appropriately prepped and anesthetized, the provider makes an incision in the groin and dissects down to expose the aorta and iliac arteries. He may perform angioplasty or place a stent to open up or widen the lumen of the aorta or iliac arteries. Then, under imaging guidance, he inserts a catheter into the artery and threads it all the way to the site of the aneurysm, pseudoaneurysm, dissection, or penetrating ulcer. The provider then guides a tube endograft through the catheter, inserting one end into the aorta and the other down one the iliac arteries so that the tube extends into healthy areas on both sides of the defect. If the tube endograft isn’t long enough, he may add extensions up the aorta as far as the renal arteries and down as far as the iliac bifurcation where the common iliac arteries branch into the smaller internal and external iliac arteries. When expanded, the prosthesis reinforces the artery walls, preventing the aneurysm from rupturing or swelling and improving blood flow. The provider withdraws the catheter, checks for bleeding, and closes all incisions.


34705 Lay Terms:
The provider places an aorto–bi–iliac endograft (a Y–shaped tube graft that extends from inside the aorta down both iliac arteries) to repair the infrarenal aorta or iliac artery for reasons other than rupture or injury. This code covers pre–procedure sizing and device selection, any nonselective catheterization, angioplasty/stenting, any endograft extensions performed from the renal arteries to the iliac bifurcation and all radiological supervision and interpretation.
Clinical Responsibility
The provider may perform endovascular repair when the infrarenal aorta develops an aneurysm (bulging of the arterial wall due to a weakening of the artery walls), pseudoaneurysm, or for a penetrating ulcer or dissection (linear tear in the intima, or lining, of the arterial wall).
After the patient is appropriately prepped and anesthetized, the provider makes an incision in the groin and dissects down to expose the aorta and iliac arteries. He may perform angioplasty or place a stent to open up or widen the lumen of the aorta or iliac arteries. Then, under imaging guidance, he inserts a catheter into the aorta. The provider then guides a Y–shaped tube endograft through the catheter, inserting the single end into the aorta and each arm of the Y down an iliac artery so that the tube extends into healthy areas on both sides of the defect. If the tube endograft isn’t long enough, the provider may place extensions up the aorta to the level of the renal arteries and down to the iliac bifurcation where the common iliac arteries branch into the smaller internal and external iliac arteries. When expanded, the prosthesis reinforces the artery walls, preventing the aneurysm from rupturing or swelling and improving blood flow. The provider withdraws the catheter, checks for bleeding, and closes all incisions.
 

deeva456

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Based on this report you may only code for the aorto-uniliac stent graft and 34713x 1. Bilateral cutdown is not supported in the report and only one 12 French sheath was placed in the left femoral. Best to ask the physician, how were the arteries accessed? Cutdown or percutaneously? 36245-50 is bundled and cannot bill separately. Also, may bill for either the cutdown (34812) or 12 French sheath (34713) placement and closure but not both.

34713 lay description:
The femoral artery may be accessed percutaneously or by open incision. For percutaneous access the femoral artery is identified using ultrasound guidance and the guide catheter is percutaneously inserted with subsequent insertion of a large arterial sheath (i.e., 12 French or larger). Closure may involve the use of an arterial closure device (ACD). Several types of ACDs may be used for closure including a small balloon that ensures sealant coverage of the arteriotomy, four needles that anchor and close suture material upon removal, or a collagen sponge with polymer that forms a self-tightening suture seal. Alternately, the femoral artery may be examined via an open technique. With the patient in the supine position, the physician exposes the femoral artery through an incision in the groin area revealing the femoral artery on one side while underlying subcutaneous layers and muscles incised to reach the artery are placed out of the way as hemostasis is achieved in preparation for delivery of the endograft, endovascular prosthesis, or creation of a conduit. Closure may be by direct suture. Report 34713 for percutaneous access and closure of a femoral arteriotomy for delivery of an endovascular prosthesis. Ultrasound guidance is included. Report 34812 for open femoral artery exposure with delivery of an endovascular prosthesis and repair and closure of the femoral artery. Report 34714 for open femoral artery exposure with endovascular device delivery or establishment of cardiopulmonary bypass that requires creation of a prosthetic conduit utilizing a femoral artery.
 
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