Help - Pediatric Code

conleyclan

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I am not finding a code for the surgery in the report that is below. I am trying to decide what CPT code the report might mirror to when I have an unlisted code set up. Thank you for your help.


PREOPERATIVE DIAGNOSIS
PROTEIN-LOSING ENTEROPATHY
STATUS POST FONTAN PROCEDURE
HYPOPLASTIC LEFT HEART SYNDROME

POSTOPERATIVE DIAGNOSIS
PROTEIN-LOSING ENTEROPATHY
STATUS POST FONTAN PROCEDURE
HYPOPLASTIC LEFT HEART SYNDROME

OPERATION
REDO STERNOTOMY WITH LYSIS OF ADHESIONS AND REMOVAL OF DEEP-SEATED STERNAL
WIRES
TAKEDOWN OF EXTRACARDIAC FONTAN PROCEDURE

OPERATIVE FINDINGS
The patient had very thickened and dense adhesions from the previous surgeries
making the dissection extremely difficult. He had very watery adhesions
throughout.

DESCRIPTION OF PROCEDURE
With the patient in the supine position under excellent general anesthesia,
the chest and abdomen were prepped and draped in the standard fashion. The
chest was entered through the previous median sternotomy incision. The
previous sternal wires were deeply embedded in the sternum. The wires were cut
and removed. The sternum was then divided using the oscillating saw. The
undersurface of each hemisternum were then carefully dissected from the
underlying mediastinal structures. The chest retractor was then placed and
opened. The epicardium of the heart was then carefully dissected from the
pericardium circumferentially. There were very dense adhesions within the
pericardium and the epicardium of the heart making the dissection extremely
difficult. The extracardiac Fontan was carefully dissected. Pursestring
sutures were placed in the distal ascending aorta, proximal SVC, and in the
IVC. Intravenous heparin was given. The heart was then cannulated in the
standard fashion. Cardiopulmonary bypass was instituted. An antegrade
cardioplegic catheter was placed in the proximal ascending aorta. Tourniquet
was placed around the inferior vena cava cannula. I proceeded to staple shut
the superior aspect of the extracardiac Fontan. The Fontan tube was then
transected between staple lines. The small stop of the extracardiac Fontan was
left attached to the right pulmonary artery. The aorta was then crossclamped
and the heart arrested using cold antegrade blood cardioplegia. I then entered
the right atrium at the level of the previous fenestration. I then made a much
larger atriotomy extending inferiorly and I also opened the inferior aspect of
the extracardiac Fontan. A large segment of the medial wall was excised. I
then created a very large side-to-side communication between the extracardiac
conduit and the right atrium. A vent was placed inside the right atrium for
deairing purposes. A 4-0 Prolene was used for the anastomosis between the
Gore-Tex conduit and the right atrium. The patient was placed in the
Trendelenburg position. The antegrade cardioplegic catheter was used as an
aortic root vent. The aortic cross-clamp was then removed. The heart resumed
normal sinus rhythm. Temporary atrial and ventricular pacing wires were
placed. Once fully warmed the patient was weaned from cardiopulmonary bypass
without any difficulty. The heart was then decannulated. The pursestring
sutures were tied and the cannulation sites reinforced using 4-0 Prolene
suture. Careful hemostasis was obtained. The patient had excellent
hemodynamics. A mediastinal chest tube was placed. The incision was then
closed in layers. A sterile dressing was applied. The patient tolerated the
procedure well.
 

jewlz0879

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20680 for the sternal wire removal and take a look at either 33615 or 33617 for your Fontan procedure. They can both be billed as there are no CCI edits for 20680/33615&33617.

Can't bill for re-do sternotomy (33530) as it is not billable with any of the selected codes.

HTH
 

conleyclan

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Thank you Julie. Just want to be sure I am understanding this. You feel like they did a redo of a fontan? Are you thinking that they removed the extracardiac Fontan and created a completely new one?

Diane
 

jewlz0879

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Well the patient has hypoplastic left heart syndrome so he/she only has one ventricle to pump to the lungs and body; normally your right ventricle pumps to your lungs while the left pumps to the body. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic right ventricle.

Reading what the physician did, looking at the codes and Ingenix CT Surgery book, I would go with 33617 as it doesn't seem closure of the ASD was done. Now, CPT does say that normally 33615 is performed first, so you may want to check with your physician and make sure this is correct.

I've actually never coded one of these (I do code Cardio/CT/Vascualar surgery, however) so I may be missing something or interpreting something incorrectly. That's why I say, if you can, see what your doc says. I 'd hate to give you a wrong answer.

HTH
 
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