HELP Please!!! Aortobifemoral Bypass Using End to End Anastomosis...


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I'm completely stuck onthis one. The codes that I have came up with so far are 35646-50-GC and 35331-59-GC. Any help would be gretaly appreciated. Thanks in advance!!


The patient was correctly identified in the preoperative holding area.
He was brought to the operating room in stable condition, attached to
cardiac monitors and placed under general anesthesia. An arterial line
was placed in the right radial artery. A Foley catheter was placed and
the patient was placed in a supine position with an underbody Bair
Hugger as well as a chest Bair Hugger. The preoperative signals were
marked on the bilateral feet and the patient's abdomen and bilateral
groins were prepped and draped in the usual sterile fashion. A surgical
timeout was performed. No concerns were raised at that time.

Care was first taken to perform the femoral dissection. A vertical incision was created in each groin using the #10 blade. This was carried down through skin
and subcutaneous tissue down to the level of the femoral sheath using
electrocautery. Any intervening lymphatics were tied off using 3-0 silk
suture ties and on entrance into the femoral sheath, the common femoral
artery was easily identified. Sharp dissection was created around the
common femoral artery down to the level of the femoral bifurcation using
the Metzenbaum scissors. Any small arterial branches on the medial and
lateral aspect were controlled using blue Vessel-loops and then, the
common femoral artery and the profunda femoris as well as the
superficial femoral artery were all controlled using white Vessel-loops on
both sides. After getting circumferential control of each of the
vessels on bilaterally, care was then taken to mobilize the inguinal
ligament proximally using electrocautery and then inspecting for any
crossing veins overlying the external iliac artery that would prove
difficult during tunneling. These were controlled using a right angle
clamp as well as 2-0 suture ties and then cutting them using Metzenbaum

After completing the groin dissection, care was taken to perform the
abdominal portion of the procedure. A standard laparotomy was performed
using a #10 blade from the pubic symphysis all the way up to the xiphoid
process. The subcutaneous tissue was then further dissected down using
the electrocautery and down to the level of the fascia. The fascia was
first incised using the electrocautery and then carried out through its
entire length to enter the preperitoneal space. First, the transverse
colon was reflected upwards and the bowel was laterally reflected
towards the patient's right side. Care was taken to perform lysis of
adhesions in several areas around the bowel that were densely connected
to the colon using the Metzenbaum scissors. After completely mobilizing
the small bowel, the duodenum was visualized near the retroperitoneum
and the duodenum was completely kocherized to reveal the retroperitoneum
as well as the aorta. There were dense adhesions around the aorta.
These were sharply dissected using the Metzenbaum scissors. The aorta
was skeletonized from the level of the bifurcation all the way up to the
renal arteries. The renal arteries when identified were isolated out
using right angles and controlled using white Vessel-loops. During
dissection, the left renal vein was easily identified, circumferentially
dissected and controlled using a white Vesi-loop as well. Once gaining
complete control of the aorta, a small window was created in the
infrarenal portion of the aorta for which we would eventually perform
the aortic transection and thrombectomy. Retroperitoneal tunnels were then performed from the groin into the abdominal cavity using manual dissection and the aortic cross clamp.

The patient was then given 12.5 grams of mannitol and systemic heparin prior to
clamping and ACT was checked to confirm therapeutic heparinization (ACT >240).
The Vessel-loops were then pulled up on the renal arteries and the
suprarenal aorta was clamped. The aorta was then transected at the
previously described area and a thromboendarterectomy was performed in
the aorta to remove the chronic thrombosis using the saret clamp. The
aorta was allowed to forward bleed to remove any remaining thrombus.
After that, the clamp was moved from a suprarenal position to below the
renals and the renal arteries were allowed to perfuse leading to a renal
ischemia time of about eight minutes. At that point, a standard end-to-end anastomosis was performed proximally on the aorta using 3-0 Prolene
suture to a 14 mm x 7.7 mm bifurcated graft that had been previously soaked in
rifampin. On completion of the anastomosis, there was noted to be no
bleeding at the anastomotic site on release of the clamp. Both of these
limbs were allowed to bleed forward. The limbs of the graft were then
allowed to be brought through the retroperitoneal tunnels to the groins,
which were previously created and the grafts were beveled to size at the
distal anastomotic sites. The common femoral arteries bilaterally were
prepared by clamping each of the vessels using the Vessel-loops previously
placed and standard arteriotomies were created on the common femoral
arteries using an #11 blade. Standard end-to-side graft to arterial anastomosis was
performed using 5-0 Prolene double-armed suture. Before completing each
of these anastomoses, they were allowed to back bleed and flush to
remove any air or clot.

On completion of the anastomoses, the sites were hemostatic after using
topical agents as well as several repair stitches and there was graft
dependent signal in the bilateral dorsalis pedis and posterior tibial
arteries. Hemostasis was achieved in all three wound beds using
Surgicel, thrombin, Gelfoam, and Surgiflo. The wound beds were then all
copiously irrigated. The bilateral groins were first closed in four
layers; the femoral sheath using 2-0 Vicryl in a running fashion. The
Scarpa's fascia was closed with 3-0 Vicryl in a running fashion. The
deep dermal layer was closed using 3-0 Vicryl in a running fashion and
the subcuticular layer was closed using 4-0 Monocryl in a running
fashion. Care was then taken to copiously irrigate the abdomen and
close it in several layers. The retroperitoneum was first closed over
the graft using 2-0 Vicryl in a running fashion. The abdominal wall
fascia was then closed after removing all instruments from the abdominal
cavity and wanding to make sure that there were no retained foreign
bodies using #1 looped PDS and the umbilicus was reapproximated using
3-0 Vicryl in an interrupted fashion. The skin was then closed with
staples. Sterile dressings were placed on each groin using the Prevena
wound VAC and an air strip dressing was placed over the abdominal wall.
The patient tolerated the procedure well, was aroused from anesthesia
without difficulty, in stable condition. Surgical sponge and sharp
counts were correct at the end of the case. At the end of the case, the
patient had palpable dorsalis pedis and posterior tibial artery pulses.


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We code only 35646.
(If using GC Modifier make sure this patient is a Medicare patient and also that a resident physician under the supervision of a teaching (Fellow) Physician) Payment is not affected by GC it's strictly for Medicare reporting purposes thus the reason no other carrier recognizes GC.

No modifier 50 needed where it was an Aorto-Bifemoral bypass as the graft is from from the aorta has is already create with bilateral limbs to accommodate the femorals. Bilaterally.
35646. Is correct.
The Thromboendarterectomy 35331 is inherent to the Aortobifemoral Bypass Graftf procedure. That area of the aorta had to be transacted and thrombus removed to,accommodate the aortic portion of the Graft, so would not be medically necessary to report 35331.