Wiki HELP with TAVR coding please!

debbyallen

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Someone HELP!! I coded the report below the following way and it was rejected by Medicare:

ICD10 - 171.2

37242 62
33880 62
37242 62
36200 59
37253 62
34713 62:50:59
75956 26:62


PREOP DIAGNOSIS: Thoracic aortic aneurysm, arch and descending aorta, enlarging
POSTOP DIAGNOSIS: Thoracic aortic aneurysm, arch and descending aorta, enlarging

OPERATION 1: Endovascular repair of thoracic aortic dissection (TEVAR)
Percutaneous right and left feIIDral access
Cannulation of right and left femoral ai1eries
Placement of multiple guidewires and sheaths into aorta and iliac a1tery
Placement and deployment of Navion Thoracic Stem graft 43 x 37 x 200
IVUS ascending aorta with interpretation
JVUS arch and descending aorta with interpretation
Radiologic supervision and interpretation aortic graft placement
Multiple aortograms with fluoroscopy

Deployment Perclose fe1mral closw-e bilaterally
Left sub-clavian occlusion with Amplatz plug by Dr. G.

FINDINGS: There was a normal ascending aorta and and a patent ascending aorta bifurcated graft to
brachiocephalic and left carotid arteries. The arch aneurysm originated at the left subcla'v1an,
including the origin of the vessel.

Following successful deployment of the endograft in the proximal ascending aorta, the origin of the
graft partially retracted cephalad along the outer curvature. Attempts to retract the graft towards
the arch were not successful. IVUS evaluation resealed a fold in the origin of the graft but good
flow into the graft. Following occlusion of the subclavian with coils no endoleak was noted by
angiography. Aortogram of the distal descending thoracic aorta revealed good flow distally.
Upon completion of the femoral repair, a good femoral pulse was noted. The patient tolerated the
procedure well and was transferred to the PAR, extubated.


DESCRIPTION OF PROCEDURE: After the patient had been adequately induced with general
endotracheal anesthetic, the patient was prepped and draped in the usual fashion.
Femoral pulsations were identified and localized. Using a Seldinger technique, a 5-French introducer
sheaths were placed over a guidewire and the Perclose de'v1ces applied bilaterally. The patient
was systemically heparinized. Left radial arterial access was acquired by Dr. Lin, and a pigtail
catheter passed into the ascending aorta. A Benson J-wire was then introduced and advanced
under fluoroscopic control into the iliac artery. A Glidecath was advanced over the guidewire and
both were advanced into the left ventricle. The Benson was exchanged for a Safari stiff wire and
the free end of the wire was marked on the operating table to identify its position. The catheter
was exchanged for the IVUS and the ascending, arch and descending aorta examined. The
aortic anatomy including the aneurysm were clearly 1.1sualized and the landing zones identified
and marked on the screen. Measurements were taken to determine the endograft size to be
used. The abo-..e mentioned graft was selected.
The IVUS catheter was removed leaving the Safari wire in place. Care was taken not to retract the wire
during this procedure. Control of bleeding was obtained with digital pressure at the entry site.
The delivery system for the Valiant Thoracic Endograft was passed bare over the guidewire, and
manipulated fluoroscopically until the proximal markers were at the level of the ascending bypass
graft.

An aortogram was performed at 20 ml/sec for a total of 20 ml lsovue dye via the brachial pigtail
catheter visualizing all the landmarks and verifying appropriate position of the delivery system.
With forward pressure on the sheath, keeping the markers aligned with the distal edge of the
bypass origin, deployment of the de1.1ce was accomplished by slowly pulling the covering sheath
off of the de'v1ce under fluoroscopic control. The fabric of the graft landed perfectly at the level of
the distal border of the left carotid artery. The graft was uncovered down to its midpoint. The
cone of the graft was now released, fixing the graft proximally lo the ascending aorta at the distal
border of the origin of the bypass graft.

Following completion of this deployment, the aortic endograft was now fully deployed and allowed to
open in the proximal descending aorta. The delivery system was now carefully retracted out of
the aorta and endograft, leaving the guidewire in place, however it caught the fabric of the graft
along the greater curvature and retracted the leading edge towards the arch. This tilted the origin
of the graft towards the greater curvature. Through the right femoral sheath, a 10 mm balloon
was advanced over a Benson wire and inserted between the graft and the delivery system.
Inflating the balloon pushed the delivery system away from the greater curvature of the graft,
allowing safe retraction of the system, lea1.1ng the wire in place. A 16 sheath was placed,
occluding the femoral arteriotomy. IVUS evaluation identified the tilted origin of the graft and
good expansion of the body. An aortogram was now performed with 15 ml/sec for a total of 20 ml
lsowe dye, identifying the graft anatomy and noted excellent flow into the arch and distal aorta.
At this point Dr. Lin proceeded with occlusion of the left subcla1.1an at its origin by inserting an
embolizing coil via the brachial approach. This procedure is reported separately by Dr. Lin.
The Safari wire was removed and replaced with a Glidewire over which a Reliant balloon was passed.
This was inflated near the origin of the graft and an attempt was made to retract the origin
cephalad to straighten out the tilt, however the graft could not be moved. The balloon was
removed and the pigtail catheter placed in the ascending aorta. An aortogram was now
performed with 20 ml/sec for a total of 20 ml lsovue dye, which revealed immediate flow into the
body of the graft with excellent seal of the endograft, and no e1.1dence of endoleak. The pigtail
was straightened with the Glidewire and removed.

With satisfactory aortography, the femoral sheaths were removed and the Perclose de1.1ces deployed.
Good pulses were noted in the femoral artery with good distal perfusion. After satisfactory
hemostasis was accomplished, dressing was applied, and the patient was extubated and
transferred to the PAR in satisfactory condition. Examination of the lower extremities revealed
good perfusion and palpable pulses in the dorsalis pedis arteries bilaterally, left greater than right.
SPECIMEN: None
EBL: 150 ml
 
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