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Atrial baffle procedure (non-Mustard, non-Senning)

  1. Default Atrial baffle procedure (non-Mustard, non-Senning)
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    Help!! I am crossing every single finger and toe that someone here has had to code this
    procedure. It's a rare birth defect, so the procedure isn't one that performed frequently.

    From the op report:

    PROCEDURE:
    1. Left superior vena cava baffling towards the right atrium.
    2. ASD closure with a fresh pericardial patch.

    Description of Procedure:
    ... the TEE was done that confirmed the diagnosis of a very large ASD with absent
    of the IVC drain and also confirmed the diagnosis of left superior vena cava arising
    to the dome of the left atrium without bridging innominate vein. After opening
    the chest, the thymus was fully dissected. Then a large piece of pericardium was
    harvested and the rest of the pericardium was marsupialized. The pursestring was
    done in the ascending aorta and right superior vena cava, left superior vena cava
    and inferior vena cava. A pursestring was done in the right upper pulmonary veins.
    Then the patient was heparinized and was cannulated in the usual fashion and
    cardiopulmonary bypass was initiated at 32 degrees Celsius. A plegia needle was
    placed in the ascending aorta and LA vent was placed in the right superior pulmonary vein.
    Right and left SVC snuggers were placed and tied down. Next, the aorta was
    crossclamped and needle cardioplegia was antegrade infused and the patient had
    good cardiac arrest. The IVC snuggers was tied down and the right atrium was
    opened and stay sutures were placed on the edges of the atrium for better
    visualization. Inside the heart, a large ostium secundum ASD was visualized
    with a complete absence of the IVC rim Then the left superior vena cava was
    visualized that was arising to the dome of the left atrium. In order to repair
    this kind of congenital malformation, a large piece of autologous pericardium
    was harvested and it was used to baffle the left superior vena cava with a 5-0
    C1 Prolene running suture line. The first stitch was placed in the tissue
    between the left superior vena cava and the left atrial appendage and that
    suture line was carried out toward the anterior close to the mitral annulus on
    the left side and then anterior, close to the right superior vena cava on the
    right side. Then this pericardial patch was turned and baffled inferior,
    posterior toward the direction of the IVC. In that way, both arterial rims
    were taken with this pericardial patch. Once finalized, the LSVC was baffling
    with a single pericardial patch toward the right atrium and with the same
    single pericardial patch the ASD was closed. After closing the ASD and
    baffling the LSVC. The LA vent was stopped and the heart was de-aired and the
    aortic crossclamp was removed, recovering the patient with normal sinus rhythm.

    I was able to find a more straight-forward description of this procedure in an old
    issue of The Annals of Thoracic Surgery (circa 1986!!):
    Repair of Left Superior Vena Cava Entering the Left Atrium

    ABSTRACT Connection of an anomalous left superior
    vena cava to the left atrium is an uncommon lesion that is
    usually associated with other complex intracardiac malformations.
    A technique for diverting the anomalous caval
    return along the left atrial roof and into the right atrium is
    presented. This simple tunnel method avoids potential obstruction
    to systemic and pulmonary venous return and
    leaves viable atrial tissue comprising the majority of the
    new pathway... We present an alternative method of
    repair that consists of constructing a tunnel along the roof
    of the left atrium, thereby diverting the anomalous caval
    return into the right atrium. This simple method leaves
    viable atrial wall comprising the majority of the new
    pathway.


    SO... my provider is suggesting we use 33774 (Repair of transposition of the great arteries,
    atrial baffle procedure (eg, Mustard or Senning type) stating that it was a modified
    Mustard procedure. I want to agree, but the only similarities between the CPT code and his op rpt
    is the baffle/tunnel that was created. Other options I have suggested include 33999 (unlisted cardiac)
    or 34502 (repair of vena cava, any method). The ASD repair will be billed in addition to this code.

    Am I missing a more obvious choice for this procedure? (it feels like I am...)

    If you've made it to this point, bless you...

    Andrea T Williams, CPC

  2. #2
    Default Atrial baffle procedure (non-Mustard, non-Senning)
    Hi Andrea,

    I would suggest looking at 33645, as this seems to resemble a Warden procedure performed for anomalous vein drainage. Although there do seem to be a few components of the Mustard technique I agree that it doesn't match that completely. Also, I would not bill separately for the ASD closure since the body of the op note indicates it was closed using the same patch.

    "Once finalized, the LSVC was baffling with a single pericardial patch toward the right atrium and with the same single pericardial patch the ASD was closed"

    Hope this helps!
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

  3. Smile
    Quote Originally Posted by dimmitta View Post
    Hi Andrea,

    I would suggest looking at 33645, as this seems to resemble a Warden procedure performed for anomalous vein drainage. Although there do seem to be a few components of the Mustard technique I agree that it doesn't match that completely. Also, I would not bill separately for the ASD closure since the body of the op note indicates it was closed using the same patch.

    "Once finalized, the LSVC was baffling with a single pericardial patch toward the right atrium and with the same single pericardial patch the ASD was closed"

    Hope this helps!
    {this is very delayed} Thank You, dimmitta, so much for your response!!

    I reached out to the STS Coding Help Desk and received this response:

    "...33774 would not be appropriate. There's not an exact code for this anomaly. Suggested codes are 34502, Reconstruction of vena cava, or 35211, Repair blood vessel, intrathoracic, with bypass, or as you suggested, the unlisted code 33999. If the physician feels 34502 or 35211 are representative of the work involved in the procedure, use one of those codes. If not, go to the unlisted code. You would report the 33641 for the ASD repair in addition."

    thank you, again, for responding... this was definitely a real head scratcher!!

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