deeva456
Expert
I need a second opinion for this case. Would you bill both 33858 & 33866?
33858 - Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed; for aortic dissection
33866 - aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isolated cerebral perfusion (List separately in addition to code for primary procedure).
It seems like it is double dipping if both codes are billed.
Thank you for your input
Dolores
CARDIOPULMONARY BYPASS TIME: 1 hour 58 min
CROSS CLAMP TIME: 1 hour 38 min
FINDINGS/TARGETS: Type A aortic dissection
CARDIOPLEGIA: Intermittent cold blood antegrade and retrograde.
ESTIMATED BLOOD LOSS: >500 mL
BLOOD PRODUCTS GIVEN: See OR record
DRAINS: Two chest tubes
SPECIMENS: Aorta
PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed on the table in the supine position. General anesthesia was induced by Haughton, Robert Frederic, MD and appropriate monitoring lines placed. The patient was prepped and draped in the usual sterile fashion. A sternal incision was made with a scalpel and the subcutaneous tissue opened cautery. The sternum was divided in the midline with the saw and bone wax applied to the sternal edges. Next, our attention was paid to the right groin which was opened in a transverse fashion with a scalpel. The subcutaneous tissue was opened cautery. The femoral sheath was opened sharply. The common femoral artery was identified and isolated. After heparinization, we attempted to cannulate the right femoral artery but were unable to pass the wire. We then repeated the above dissection for the left femoral artery and were able to pass the wire without difficulty. The left femoral artery was cannulated with a 19 French arterial cannula and secured with a Prolene pursestring. We then returned our attention to the chest for the pericardium was opened. There was no significant effusion. There was an obvious type A dissection present. A two-stage venous cannula was placed in the right atrial appendage and an angled 24 Fr cannula placed in the superior vena cava. Normothermic bypass was initiated and the patient gently cooled to 24° Celsius. A cross-clamp was placed on the ascending aorta and the heart was arrested with retrograde cold blood cardioplegia. The aorta and divided. We delivered intermittent retrograde cardioplegia throughout the operation to maintain arrest. Once the patient reached 24° he was placed in the Trendelenburg position and the cross-clamp slowly removed. Circulatory arrest was initiated for total of 30 minutes. The aorta was resected up to the level of the innominate artery. Intramural thrombus was removed. The layers were reapproximated with BioGlue and a 28 mm Hemashield single side-branching Graft was sewn on in an with running 4-0 prolene suture. This was reinforced with a layer of felt and then with BioGlue. Flow was then reestablished down the sidebranch with a 20 Fr arterial cannula and the clamp placed on the graft. We delivered another dose of cardioplegia down the coronary ostia. We returned our attention to the aortic root. There was a tricuspid valve which had severe insufficiency on echo. The aorta was resected back to the sinotubular junction. The aortic valve was resuspended with 4-0 Prolene pledgeted sutures. The dissection carried all the way down to the root just above the left coronary ostia. The layers were reapproximated with BioGlue. The graft was sized and sewn on in an with running 4-0 prolene suture. Again this was reinforced with felt and BioGlue. The cross-clamp was then slowly removed and the graft vented. After rewarming the patient was ventilated and slowly weaned from bypass. The postoperative echo showed no residual intracardiac air and a normally functioning aortic valve. Protamine was given the patient decannulated. The vents removed with good hemostasis. Multiple rounds of blood products were given for coagulopathy with good hemostasis. The femoral arterial cannula was removed and the purse string secured with good hemostasis. This wound was closed in layers of absorbable suture, as was the right-sided wound. Two chest tubes and a ventricular pacing wire were placed in the standard fashion. The sternum was then closed with #7 single and double wires and the soft tissue and skin with absorbable suture. Sterile dressings were applied. The patient was taken back to intensive care unit in stable condition
Sponge and needle counts were reported as correct. The patient tolerated the procedure well with no apparent complications.
CONDITION: Stable to CSICU
33858 - Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed; for aortic dissection
33866 - aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isolated cerebral perfusion (List separately in addition to code for primary procedure).
It seems like it is double dipping if both codes are billed.
Thank you for your input
Dolores
CARDIOPULMONARY BYPASS TIME: 1 hour 58 min
CROSS CLAMP TIME: 1 hour 38 min
FINDINGS/TARGETS: Type A aortic dissection
CARDIOPLEGIA: Intermittent cold blood antegrade and retrograde.
ESTIMATED BLOOD LOSS: >500 mL
BLOOD PRODUCTS GIVEN: See OR record
DRAINS: Two chest tubes
SPECIMENS: Aorta
PROCEDURE IN DETAIL: After informed consent, the patient was brought to the operating room and placed on the table in the supine position. General anesthesia was induced by Haughton, Robert Frederic, MD and appropriate monitoring lines placed. The patient was prepped and draped in the usual sterile fashion. A sternal incision was made with a scalpel and the subcutaneous tissue opened cautery. The sternum was divided in the midline with the saw and bone wax applied to the sternal edges. Next, our attention was paid to the right groin which was opened in a transverse fashion with a scalpel. The subcutaneous tissue was opened cautery. The femoral sheath was opened sharply. The common femoral artery was identified and isolated. After heparinization, we attempted to cannulate the right femoral artery but were unable to pass the wire. We then repeated the above dissection for the left femoral artery and were able to pass the wire without difficulty. The left femoral artery was cannulated with a 19 French arterial cannula and secured with a Prolene pursestring. We then returned our attention to the chest for the pericardium was opened. There was no significant effusion. There was an obvious type A dissection present. A two-stage venous cannula was placed in the right atrial appendage and an angled 24 Fr cannula placed in the superior vena cava. Normothermic bypass was initiated and the patient gently cooled to 24° Celsius. A cross-clamp was placed on the ascending aorta and the heart was arrested with retrograde cold blood cardioplegia. The aorta and divided. We delivered intermittent retrograde cardioplegia throughout the operation to maintain arrest. Once the patient reached 24° he was placed in the Trendelenburg position and the cross-clamp slowly removed. Circulatory arrest was initiated for total of 30 minutes. The aorta was resected up to the level of the innominate artery. Intramural thrombus was removed. The layers were reapproximated with BioGlue and a 28 mm Hemashield single side-branching Graft was sewn on in an with running 4-0 prolene suture. This was reinforced with a layer of felt and then with BioGlue. Flow was then reestablished down the sidebranch with a 20 Fr arterial cannula and the clamp placed on the graft. We delivered another dose of cardioplegia down the coronary ostia. We returned our attention to the aortic root. There was a tricuspid valve which had severe insufficiency on echo. The aorta was resected back to the sinotubular junction. The aortic valve was resuspended with 4-0 Prolene pledgeted sutures. The dissection carried all the way down to the root just above the left coronary ostia. The layers were reapproximated with BioGlue. The graft was sized and sewn on in an with running 4-0 prolene suture. Again this was reinforced with felt and BioGlue. The cross-clamp was then slowly removed and the graft vented. After rewarming the patient was ventilated and slowly weaned from bypass. The postoperative echo showed no residual intracardiac air and a normally functioning aortic valve. Protamine was given the patient decannulated. The vents removed with good hemostasis. Multiple rounds of blood products were given for coagulopathy with good hemostasis. The femoral arterial cannula was removed and the purse string secured with good hemostasis. This wound was closed in layers of absorbable suture, as was the right-sided wound. Two chest tubes and a ventricular pacing wire were placed in the standard fashion. The sternum was then closed with #7 single and double wires and the soft tissue and skin with absorbable suture. Sterile dressings were applied. The patient was taken back to intensive care unit in stable condition
Sponge and needle counts were reported as correct. The patient tolerated the procedure well with no apparent complications.
CONDITION: Stable to CSICU