Wiki Multiple surgery help

ksbrickey

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Having issues figuring out the coding for the following procedures...the CABG and AVR are not a problem, but the surgeon did a TAA repair, Right innominate to subclavian bypass grafting w/ORIF of sternoclavicular joint with fusion. Not something typical with our practice.

PREOPERATIVE DIAGNOSES: Aortic stenosis, ascending aortic aneurysm,
intermittent atrial fibrillation, coronary artery disease, right arm
subclavian stenosis, peripheral vascular disease, diabetes, hypertension,
hyperlipidemia, obesity, COPD.

POSTOPERATIVE DIAGNOSES: Aortic stenosis, ascending aortic aneurysm,
intermittent atrial fibrillation, coronary artery disease, right arm
subclavian stenosis, peripheral vascular disease, diabetes, hypertension,
hyperlipidemia, obesity, COPD.

PROCEDURE:
1. Coronary artery bypass graft x3, LIMA to LAD, reverse saphenous vein
graft to obtuse marginal 2 and posterior descending artery.
2. Aortic valve replacement with 25 mm Edwards Magna Ease pericardial
tissue valve.
3. Left atrial appendage clipping.
4. Thoracic aortic aneurysm repair.
5. Right innominate to subclavian bypass grafting.
6. ORIF of sternoclavicular joint with fusion.
7. Greater saphenous vein endoscopic venous harvesting.
8. Right femoral central venous catheter placement.

FINDINGS:
1. Heavily calcified bicuspid aortic valve.
2. Heavily calcified ascending aorta with need for removal of individual
plaques.
3. Mildly depressed ejection fraction pre and postop approximately 40%.
4. Posterior descending artery approximately 1.75 mm vessel, LAD 2 mm
vessel, obtuse marginal 1.25, greater saphenous vein from the left leg with
poor quality of the distal leg.
5. Mammary severely adhesed with an area requiring repair in its proximal third innominate artery clear, heavy calcifications at a bifurcation takeoff
of the subclavian artery with a dilated subclavian artery proximally, a good
quality subclavian artery distally at the mid third of the clavicle.
Triphasic subclavian signal post-bypass, complication injury to the superior
vena cava during tunneling of the graft requiring increased exposure and
disarticulation of the sternoclavicular joint on the right.

PROCEDURE: The patient was taken to the operating room, placed under
anesthesia with Swan-Ganz catheter, endotracheal tube and transesophageal
echo, the right shoulder, entire chest, abdomen, lower extremities were
sterilely prepped and draped in the usual manner. Greater saphenous vein is
harvested from the left leg by endoscopic venous harvesting technique.
Proximal and distal vein were ligated. All side branches were clipped and
divided. The vein was closed in a layered fashion with absorbable suture.
Simultaneously, the sternum was opened via median sternotomy. Left internal
mammary artery was harvested as a pedicle graft. All side branches were
clipped and divided distally, it was clipped and divided after the patient
was given systemic heparinization. The innominate vein was dissected out as
was the innominate artery which is very tortuous, this was dissected out in
the midline and dissected out to its bifurcation of the right carotid and
subclavian bifurcation, which was noted to have heavy calcifications. At
this point, a counter incision was made in the mid third of the clavicle on
the right with an incision inferior to the clavicle. Vessels were dissected
out and isolated. At this point, tunneling was being created between the 2
points. There was noted bleeding behind the sternoclavicular joint area.
This was unable to be exposed requiring disarticulation of the sternum from
the clavicle. At this point, the inferior vena cava and a few branches were
noted to be bleeding. These were suture ligated with pledgeted Prolene for
reinforcement. At this point, the patient was placed on cardiopulmonary
bypass with aortic arterial and right arteriovenous line. An aortic root
vent was placed as was a right superior pulmonary vein, a left ventricular
vent and a right atrial retrograde cardioplegic cannula. While on bypass,
the aorta was cross clamped noting the aneurysm approximately 5 cm just
distal to the aortic valve and tapered proximal to the innominate artery
takeoff. The aorta was crossclamped, heart was arrested with antegrade and
retrograde cardioplegia. Retrograde cardioplegia was continued for the
remainder of the case for cardioprotection. Distal was performed with the
vein graft end-to-side manner to the posterior descending artery. This was
sequenced in a side-to-side manner to the second obtuse marginal. Final
distal was LIMA to LAD in its distal third performed with running 7-0
Prolene suture. Left atrial appendage was evaluated inspected and a leftpoint,
an aortotomy was performed superior to the aortic valve. The valve
was bicuspid heavily calcified and stenotic. Upon entering the aorta as
well, there were large plaques along the walls of the ascending aorta. Some
of these were removed to prevent distal embolization. The valve leaflets
were excised and decalcified. Due to the heavy nature of plaquing and the
bicuspid nature and some of the plaques extended onto the anterior leaflet
of the mitral valve, it was decided to place surgical valve with pledgeted
Prolene sutures on the ventricular side. The valve was sized to 25 and an
Edwards Magna Ease valve pericardial tissue was placed. Once this was
seated, after decalcification of the annulus and irrigation and removal of
all debris, the valve was then placed. At this point, the aneurysm was
measured, portion of the aorta was excised removing the aneurysm and the
remainder of the aorta was reapproximated in a double layer fashion as an
aneurysmorrhaphy. With this in place, the proximal anastomosis was placed
on the remaining ascending aorta end-to-side fashion with running 6-0
Prolene suture. Heart was rewarmed, cardiac activity resumed and aortic
crossclamp was removed. Next, the subclavian artery was isolated, clamped
proximally and distally arthrotomy performed, end-to-side anastomosis
created and using a 6 mm Gore-Tex ringed graft and running 5-0 Prolene
suture. This was next anastomosed to be tortuous innominate artery with a
side-biting clamp, again using a running 5-0 Prolene suture. Once prior to
completing the anastomosis, all vessels were allowed to backbleed for
removal of air or debris. There had been some plaquing noted within the
innominate artery at the proximal portion of the subclavian takeoff. A
small portion of this was removed. Next, with cardiac activity resumed, the
patient was weaned from cardiopulmonary bypass. The aortic valve was
inspected intraoperatively by cardiology review. Heparinization was
reversed using protamine sulfate. All cannulas were removed and reinforced
with pledgeted Prolene suture. Atrial and ventricular pacing wires were
placed as well as bilateral pleural chest tubes. A mediastinal chest tube
and a mediastinal JP drain. Once hemostasis had been verified, the
pericardium was loosely reapproximated in the midline without complete
coverage of the right ventricle and the sternum was Pulsavac with antibiotic
irrigation and closed with #6 sternal wire. Prolene suture was used for
closure of the upper abdominal fascia. The clavicle and manubrium were
reapproximated with a #6 sternal wire and then to seat both bones and fuse
the joint, a plate was placed using screws spanning from the upper end of
the manubrium over onto the clavicle. The bypass of the innominate
subclavian bypass was inspected. Hemostasis verified. Once all wounds were
verified with to be hemostatic. The thoracic fascia was reapproximated in the midline
and the pec muscle reapproximated over the subclavian exposure.
The remainder of the wounds were closed in layered fashion with absorbable
suture and a Prevena wound VAC was placed and due to the need for inotropic
support and large volume resuscitation and prolonged procedure, a right
femoral venous catheter was placed by modified Seldinger technique for
additional venous access. The patient was subsequently transported to
intensive. A chest x-ray was taken in the operating room as Ray-Tec count
was not correct. Lap and instrument count was correct. X-ray showed no
evidence of retained foreign body and once the patient was draped and moved
the missing Ray-Tec was identified in the drape. The patient tolerated the
procedure. We will continue with supportive care.

The surgeon provided 33405, 33533,51, 33518, 33860,51...I feel he missed the ORIF and the subclavian bypass grafting, but I could be wrong!

Any help is appreciated!
 
I was going to look at this tomorrow but is there a reason the surgeon doesn't have 33508 also?

Margaret, CPC
 
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