Wiki PLEASE help!! Needs to be coded today

iamlou

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Hi all,

This is so complicated and the Dr. wants it coded today. I'm at a loss, so hoped someone can help me with codes. Please take a look at the op report (sorry, it's pretty long) and see what you come up with. Thank you so much!

PREOPERATIVE DIAGNOSIS: Ischemic right leg and foot.

PROCEDURE:
1. Redo right femoral (profunda to distal third posterior tibial artery
bypass with ipsilateral greater saphenous vein) in situ.
2. Resection and grafting of right common femoral artery aneurysm (7 mm
PTFE interposition graft).
3. Thrombectomy of the right external iliac artery.
4. Thrombectomy of the right profunda femoral artery.

ANESTHESIA: General anesthesia.

I made an incision in the distal third of the leg medially between the
saphenous vein and the posterior tibial artery. I noted the saphenous vein
at this position was of good caliber. I opened the fascia and exposed a
small pulseless posterior tibial artery that I sprayed with papaverine. I
then made a long incision from the calf to the groin unroofing the greater
saphenous vein. It was a dual system in the upper calf and in the thigh.
I then extended the incision over the inguinal ligament, divided down to
the inguinal ligament, elevated that with the Martin Arm retractor with a
pediatric Deaver. This patient had had a previous femoropopliteal bypass
of synthetic material years prior. I dissected that out. It was
all scarred in. I transected that graft and that enabled me to identify
the femoral bifurcation. The SFA was occluded. I noted that the entire
common was aneurysmal and pulseless. I dissected out the external iliac
artery under the inguinal ligament and had a water-hammer pulse in it. I
encircled it with an umbilical tape. I then occluded the profunda with a
vessel tape. I encircled the profunda's 2 major branches. Both were
pulseless. A total of 12,000 units of heparin were given during the case.
After the heparin was given, I occluded the profunda and external iliac
artery and filleted open the common. It was filled with thrombus. I
resected the common that included the hood of the thrombosed graft. I then
used the Fogarty catheter and thrombectomized the external iliac and had
pulsatile inflow. I re-occluded it with a gooseneck. I then took a 7 mm
PTFE graft, sewed it end-to-end to the external iliac artery and then
beveled it and sewed it into the orifice of the profunda from within the
common femoral. I now had in-line flow into the proximal profunda. I then
filleted open the profunda outside the bifurcation of the common, and it
had thrombus in it. I used a 4 Fogarty and carefully thrombectomized his 2
major branches. I had excellent back-bleeding into both. I then
re-occluded them with bulldogs and then I transected the greater saphenous
vein from the saphenofemoral junction, over-sewed the saphenofemoral
junction with 5-0 Prolene, spatulated the saphenous vein and sewed it in
end-to-side to the primary profunda before its bifurcation with 6-0
Prolene. I now had in-line flow into the profunda and then into the
saphenous vein graft. I then carefully clipped all of the side branches of
the greater saphenous vein. I used the LeMaitre valvulotome after I
transected it distally and lysed all the valves. I had pulsatile flow down
the graft. I then reinspected the posterior tibial artery. It was tiny.
I filleted it open longitudinally with an 11 blade knife and Potts
scissors. There was back-bleeding. I re-occluded that with the bulldog. I
carefully sent the 2 Fogarty proximally and distally. There was some
return of thread-like thrombus proximally and there was some gentle natural
inflow after the profunda was restored. I re-occluded this with the
bulldog. I then did the anastomosis end-to-side with 7-0 Prolene. Before
the completion of the suture line, I flushed the vein graft and gently
passed the 2 Fogarty distally. It went to the ankle. I then completed the
suture line. The heparin was not reversed. The wounds were then
inspected. They were hemostatic. They were closed with layers of Vicryl
and the skin with clips and nylons. Blood loss was about 200 mL. He
tolerated the procedure well.
 
procedure

I got 35876 which includes revision/redo of graft and thrombectomies..

I am questioning if excision of aneurysm that included hood of graft would be included in revision... If not I got 35141 for that.

Hopefully someone else will also weigh in.
 
Thank you for your replies. I started out thinking of using 35876 too, but when I looked at the description of the procedure in the Coder's Desk Reference for procedures, it doesn't quite fit. That code is for removing a thrombus from the graft and then closing the graft site. In this case, the Dr. removed the whole graft and then put in a new one, essentially "redoing" it. The codes 35585 and 35700 were mentioned, along with thrombectomy codes of 35351 and 35372. What do you think?
 
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