sumrgirl
New
Good morning!
I'm an ortho coder that is in desperate need of some vascular coding help! My hand doc went into a case to perform a median nerve decompression in the forearm (normally this would be coded with CPT 64708), however this was a dialysis patient and it turns out the compression on the median nerve was being caused by a non-functioning infected dialysis shunt. (Pt already has a new functioning AV graft proximal to the elbow.) As he dissected into the forearm and discovered the problem, he ultimately ended up excising the entire graft. I'm not 100% sure what type of graft, or if that even matters, but he refers to it as a Gore-Tex shunt that was sutured directly to the brachial artery, then later refers to it as a vascular loop graft. Once removed it measures approximately 12-14 inches long. I have searched high and low and cannot find a CPT code that seems appropriate for removal of a dialysis graft. The closest I've found is 35903 (excision of infected graft; extremity). Is that code appropriate for dialysis graft removal? He did say it was infected, contained whitish/brownish thick fluid. It seems like a pretty generic code, but I'm not sure if it applies to this type of graft. In the MS section we have 25248 (exploration with removal of deep foreign body, forearm or wrist). However, I feel like I should be using a vascular code for this. Any input would be greatly appreciated!!
Thanks in advance for the help!
Kristi
Below is the portion of the op note that describes the graft removal
attention was then turned towards the proximal forearm. Initially about a 10 cm longitudinal incision was made in the proximal palmar aspect forearm distal to the elbow flexion crease incision was made only through the skin subcutaneous tissue was carefully bluntly dissected down to the fascia. The graft discussed and the findings portion of this procedure was a loop that was just ulnar to the midline of the proximal forearm and was able to be clearly visualized and subcutaneous tissue this incision was in the midline of the loop. Some subcutaneous tissue was dissected laterally, that is radially to inspect the graft and was noted to be quite adherent and scarred into the subcutaneous tissue and thus this point my incision was not to remove the graft to reduce the risk of hematoma and to reduce the dissection. Thus the fascia was identified and the lacertus fibrosis was divided longitudinally dissection was then accomplished identifying the brachial artery and that the associated median nerve which is expected was deep and ulnar to the brachial artery proximal to the was for wrist fibrosis there was considerable scarring this I initially dissected distally and freed up the median nerve as it coursed through the forearm the proximal fibers arch of the flexor digitorum superficialis was divided and this did not really appear to be compressing the median nerve.
Then attention was turned proximally where there is considerable scarring there is considerable vascular clips so careful dissection was accomplished to the proximal direction through this scarring and ultimately the median nerve was directly in contact with the very proximal ulnar portion of the vascular graft loop. At this point the incision had been extended proximally with a transverse incision at the antecubital fossa and then extended proximally in the distal brachium careful dissection was accomplished freeing up the median nerve from the graft the graft was profoundly thickened and hard material and in order to decompress the nerve a segment of this graft needed to be removed. Thus at this point I tried to cut the graft about 3 cm distal to the anastomosis it appeared to be connected to a branch off of the main brachial artery. This graft was not able to be divided with a 15 blade and ultimately had to use very large Mayo scissors with considerable force to cut the graft when it was cut there was whitish-brownish thickish fluid seen within the graft very small amount of which did drip into the wound. This was removed from the wound as soon as possible and ultimately as noted below irrigation with Irrisept was used. At this point the ends of the graft were clamped with a large hemostat to prevent further leakage of infectious material and I then dissected more proximally and found that there is a very small segment that I could tie off proximal to the graft allowing the graft to be removed on this proximal ulnar aspect. Thus right for the graft to connect to the vascular structure this was tied off with 2-0 Prolene. This was just adjacent, several millimeters from the obvious brachial artery which was pulsating nicely and after I tied this structure off there is no change in the pulsation of the brachial artery. Thus this proximal 3 cm the graft was removed.
Attention was then turned towards removing the remainder of the graft as there was no apparent way I could Reliably prevent leakage of purulent material into the patient's arm otherwise thus dissection was accomplished and the subcutaneous tissue the incision had to be extended distally and the graft was removed this ultimately was about 12 inches perhaps 14 inches. Proximally on the radial side the graft tied directly to the brachial artery but interestingly the proximal 2 to 3 cm appeared to be softer more like the appropriate texture of the Gortex. I snipped the graft in the radial side approximately 1 cm from the attachment to the brachial artery there is no fluid that leaks from this there is a little bit of clotted off material that was removed from the little segment remaining proximally the graft was obviously at this point removed from the operating field at this point the wound was thoroughly irrigated with Irrisept. The median nerve was once again evaluated and was noted to be freed up proximally within the arm and then the subcutaneous layer was closed with 4-0 Vicryl. Skin was closed with 5-0 nylon mattress fashion sterile bulky soft dressing was applied to the hand as well as the forearm. Patient tolerated the procedure well was taken back to the PACU in stable condition
I'm an ortho coder that is in desperate need of some vascular coding help! My hand doc went into a case to perform a median nerve decompression in the forearm (normally this would be coded with CPT 64708), however this was a dialysis patient and it turns out the compression on the median nerve was being caused by a non-functioning infected dialysis shunt. (Pt already has a new functioning AV graft proximal to the elbow.) As he dissected into the forearm and discovered the problem, he ultimately ended up excising the entire graft. I'm not 100% sure what type of graft, or if that even matters, but he refers to it as a Gore-Tex shunt that was sutured directly to the brachial artery, then later refers to it as a vascular loop graft. Once removed it measures approximately 12-14 inches long. I have searched high and low and cannot find a CPT code that seems appropriate for removal of a dialysis graft. The closest I've found is 35903 (excision of infected graft; extremity). Is that code appropriate for dialysis graft removal? He did say it was infected, contained whitish/brownish thick fluid. It seems like a pretty generic code, but I'm not sure if it applies to this type of graft. In the MS section we have 25248 (exploration with removal of deep foreign body, forearm or wrist). However, I feel like I should be using a vascular code for this. Any input would be greatly appreciated!!
Thanks in advance for the help!
Kristi
Below is the portion of the op note that describes the graft removal
attention was then turned towards the proximal forearm. Initially about a 10 cm longitudinal incision was made in the proximal palmar aspect forearm distal to the elbow flexion crease incision was made only through the skin subcutaneous tissue was carefully bluntly dissected down to the fascia. The graft discussed and the findings portion of this procedure was a loop that was just ulnar to the midline of the proximal forearm and was able to be clearly visualized and subcutaneous tissue this incision was in the midline of the loop. Some subcutaneous tissue was dissected laterally, that is radially to inspect the graft and was noted to be quite adherent and scarred into the subcutaneous tissue and thus this point my incision was not to remove the graft to reduce the risk of hematoma and to reduce the dissection. Thus the fascia was identified and the lacertus fibrosis was divided longitudinally dissection was then accomplished identifying the brachial artery and that the associated median nerve which is expected was deep and ulnar to the brachial artery proximal to the was for wrist fibrosis there was considerable scarring this I initially dissected distally and freed up the median nerve as it coursed through the forearm the proximal fibers arch of the flexor digitorum superficialis was divided and this did not really appear to be compressing the median nerve.
Then attention was turned proximally where there is considerable scarring there is considerable vascular clips so careful dissection was accomplished to the proximal direction through this scarring and ultimately the median nerve was directly in contact with the very proximal ulnar portion of the vascular graft loop. At this point the incision had been extended proximally with a transverse incision at the antecubital fossa and then extended proximally in the distal brachium careful dissection was accomplished freeing up the median nerve from the graft the graft was profoundly thickened and hard material and in order to decompress the nerve a segment of this graft needed to be removed. Thus at this point I tried to cut the graft about 3 cm distal to the anastomosis it appeared to be connected to a branch off of the main brachial artery. This graft was not able to be divided with a 15 blade and ultimately had to use very large Mayo scissors with considerable force to cut the graft when it was cut there was whitish-brownish thickish fluid seen within the graft very small amount of which did drip into the wound. This was removed from the wound as soon as possible and ultimately as noted below irrigation with Irrisept was used. At this point the ends of the graft were clamped with a large hemostat to prevent further leakage of infectious material and I then dissected more proximally and found that there is a very small segment that I could tie off proximal to the graft allowing the graft to be removed on this proximal ulnar aspect. Thus right for the graft to connect to the vascular structure this was tied off with 2-0 Prolene. This was just adjacent, several millimeters from the obvious brachial artery which was pulsating nicely and after I tied this structure off there is no change in the pulsation of the brachial artery. Thus this proximal 3 cm the graft was removed.
Attention was then turned towards removing the remainder of the graft as there was no apparent way I could Reliably prevent leakage of purulent material into the patient's arm otherwise thus dissection was accomplished and the subcutaneous tissue the incision had to be extended distally and the graft was removed this ultimately was about 12 inches perhaps 14 inches. Proximally on the radial side the graft tied directly to the brachial artery but interestingly the proximal 2 to 3 cm appeared to be softer more like the appropriate texture of the Gortex. I snipped the graft in the radial side approximately 1 cm from the attachment to the brachial artery there is no fluid that leaks from this there is a little bit of clotted off material that was removed from the little segment remaining proximally the graft was obviously at this point removed from the operating field at this point the wound was thoroughly irrigated with Irrisept. The median nerve was once again evaluated and was noted to be freed up proximally within the arm and then the subcutaneous layer was closed with 4-0 Vicryl. Skin was closed with 5-0 nylon mattress fashion sterile bulky soft dressing was applied to the hand as well as the forearm. Patient tolerated the procedure well was taken back to the PACU in stable condition