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Question on Vascular surgery

  1. #1
    Question Question on Vascular surgery
    Medical Coding Books
    I am very green when it comes to Vascular surgery and I feel so lost on where to begin. They are so complex and from what I remember in school, they could have multiple codes for one surgical case. I have listed one of the operative reports below in hopes that someone could explain to me in laymen terms what it all means. I am actively seeking some sort of course to help me better understand the vascular world but in the meantime I was hoping I could draw off the experts to get me started.

    PROCEDURE PERFORMED: Right suprageniculate popliteal artery to anterior tibial artery bypass using nonreverse saphenous vein in an anatomic tunnel.

    INDICATIONS: Patient is a 60-year-old nursnig home resident who presented with profound ischemic rest pain in the right lower extremity. Angiography demonstrated severe infrspopliteal trifurcation occlusive disease with reconstitution of anterior tibial artery. He had pre-op vein mapping which demonstrated adequate caliber saphenous vein; however, pre-op cardiac stress test suggested reverible defect and he had pre-op cardiac cath which demonstrated adequate coronaries and he presents now for right lower extremity distal bypass.

    PROCEDURE: We began the procedure by making vertical incision midway between the tibial crest and the fibula along the middle third of the right leg and carried the dissection down through the deeper issues with the aid of Bovie electrocautery. The patient had extensive subcutaneous venous varicosities and these were either ligated or clipped as they were encountered. Following this we were fianlly able to identify the anterior tibial vessels through the musculature and the anterior tibial artery was skeletonized from appropriate length distally and proximally and encircled with vessel loops. It appeared to be a soft compliant vessel and would accept an outflow anastomosis. We then turned our attention to the medial aspect of the right lower extremity and via three incisions, two in the medial right leg and one in the distal medial thigh, the entire length of required saphenous vein was dissected free and skeletonized and harvested. Following this the incisions in the proximal medial calf and in the distal medial thigh were deepened and the infrageniculate popliteal fossa and suprageniculate popliteal fossa were entered respectively. The supragenculate popliteal artery was identified and had a palpable pulse and it was skeletonized for an appropriate length and encircled distally and proximally with vessels. Following this an anatomical tunnel was created from the suprageniculate popliteal fossa to the infrageniculate popliteal fossa after which a tunnel was created from infrageniculate popliteal fossa to the anterior tibial exposure through the interosseous. The patient was then systematically heparinized and then we transected the harvest segment of saphenous vein and ligated the remaining stumps with 3-0 Ploysorb ties. We then flushed through the vein ensuring that we had clipped and/or ligated all branches. I decided not to reverse the vein because of the probable size mismatch to the outflow artery. After adequate circulation time of heparin, vascular clamps were applied on the exposure suprageniculate popliteal artery and a longitudinal arteriotomy was created. Examination of the lumen demonstrated atheromatous plaque but I decided not to do an endarterectomy at this level as there appears to be adequate lumen and decent pulse. The proximal end of the nonreversed saphenous vein graft was spatulated and tailored to match the length of the popliteal arteriotomy and we proceed to sew our proximal anastomosis using 6-0 Prolene suture. Following this flow was then reestablished to the vein graft and as expected there was no flow distally because of retained valves. Then a LeMaitre valvulotome was introduced to the distal aspect of the nonreversed saphenous vein graft and passed a total of three times which resulted in excellent pulsatile outflow through the distal end of the graft after which he was flushed with heparinized saline and clamped off for later use. I then marked the saphenous vein graft under arterial tension and passed it though our previously created tunnel in the retropopliteal orientation and also through the interosseous until it was at the level of the anterior tibial exposure and once again checked the flow and it was excellent and pulsatile and I was comfortable that it was not twisted or kinked. Following this I then turned my attention to the exposed anterior tibial artery and vascular control was established and a longitudinal arteriotomy was created. I then spatulated the distal end of the nonreversed saphenous vein graft and proceeded to sew the outflow anastomosis using 7-0 Prolene suture. Just prior to tying down the final suture I flushed in a retrograde antegrade fashion as well as heparinized saline prior to tying down the final suture. Flow was then reestablished and there was excellent palpable pulse in the outflow anterior tibial artery as well as in the dorsalis pedis artery in the foot as well as excellent Doppler signal.

    I appreciate any help you can offer. Thanks!

  2. Default
    What you need to pull out of alll that is that it is a pop-ant tib bypass graft with vein.
    (35566). The harvest of the saph vein is included, and not billable seperate. They took the saph vein and started at the popliteal artery and went around the clot and attached it to the ant. tib. therefore suppling blood to the lower leg and foot.

  3. #3
    Default
    Quote Originally Posted by mindyanna View Post
    I am very green when it comes to Vascular surgery and I feel so lost on where to begin. They are so complex and from what I remember in school, they could have multiple codes for one surgical case. I have listed one of the operative reports below in hopes that someone could explain to me in laymen terms what it all means. I am actively seeking some sort of course to help me better understand the vascular world but in the meantime I was hoping I could draw off the experts to get me started.

    PROCEDURE PERFORMED: Right suprageniculate popliteal artery to anterior tibial artery bypass using nonreverse saphenous vein in an anatomic tunnel.

    INDICATIONS: Patient is a 60-year-old nursnig home resident who presented with profound ischemic rest pain in the right lower extremity. Angiography demonstrated severe infrspopliteal trifurcation occlusive disease with reconstitution of anterior tibial artery. He had pre-op vein mapping which demonstrated adequate caliber saphenous vein; however, pre-op cardiac stress test suggested reverible defect and he had pre-op cardiac cath which demonstrated adequate coronaries and he presents now for right lower extremity distal bypass.

    PROCEDURE: We began the procedure by making vertical incision midway between the tibial crest and the fibula along the middle third of the right leg and carried the dissection down through the deeper issues with the aid of Bovie electrocautery. The patient had extensive subcutaneous venous varicosities and these were either ligated or clipped as they were encountered. Following this we were fianlly able to identify the anterior tibial vessels through the musculature and the anterior tibial artery was skeletonized from appropriate length distally and proximally and encircled with vessel loops. It appeared to be a soft compliant vessel and would accept an outflow anastomosis. We then turned our attention to the medial aspect of the right lower extremity and via three incisions, two in the medial right leg and one in the distal medial thigh, the entire length of required saphenous vein was dissected free and skeletonized and harvested. Following this the incisions in the proximal medial calf and in the distal medial thigh were deepened and the infrageniculate popliteal fossa and suprageniculate popliteal fossa were entered respectively. The supragenculate popliteal artery was identified and had a palpable pulse and it was skeletonized for an appropriate length and encircled distally and proximally with vessels. Following this an anatomical tunnel was created from the suprageniculate popliteal fossa to the infrageniculate popliteal fossa after which a tunnel was created from infrageniculate popliteal fossa to the anterior tibial exposure through the interosseous. The patient was then systematically heparinized and then we transected the harvest segment of saphenous vein and ligated the remaining stumps with 3-0 Ploysorb ties. We then flushed through the vein ensuring that we had clipped and/or ligated all branches. I decided not to reverse the vein because of the probable size mismatch to the outflow artery. After adequate circulation time of heparin, vascular clamps were applied on the exposure suprageniculate popliteal artery and a longitudinal arteriotomy was created. Examination of the lumen demonstrated atheromatous plaque but I decided not to do an endarterectomy at this level as there appears to be adequate lumen and decent pulse. The proximal end of the nonreversed saphenous vein graft was spatulated and tailored to match the length of the popliteal arteriotomy and we proceed to sew our proximal anastomosis using 6-0 Prolene suture. Following this flow was then reestablished to the vein graft and as expected there was no flow distally because of retained valves. Then a LeMaitre valvulotome was introduced to the distal aspect of the nonreversed saphenous vein graft and passed a total of three times which resulted in excellent pulsatile outflow through the distal end of the graft after which he was flushed with heparinized saline and clamped off for later use. I then marked the saphenous vein graft under arterial tension and passed it though our previously created tunnel in the retropopliteal orientation and also through the interosseous until it was at the level of the anterior tibial exposure and once again checked the flow and it was excellent and pulsatile and I was comfortable that it was not twisted or kinked. Following this I then turned my attention to the exposed anterior tibial artery and vascular control was established and a longitudinal arteriotomy was created. I then spatulated the distal end of the nonreversed saphenous vein graft and proceeded to sew the outflow anastomosis using 7-0 Prolene suture. Just prior to tying down the final suture I flushed in a retrograde antegrade fashion as well as heparinized saline prior to tying down the final suture. Flow was then reestablished and there was excellent palpable pulse in the outflow anterior tibial artery as well as in the dorsalis pedis artery in the foot as well as excellent Doppler signal.

    I appreciate any help you can offer. Thanks!
    Thanks Lisammy. I would have thought there would be more than just the one code. Having an answer though might help me better understand how you got there. I have several vascular surgeries I need to code, this might take me forever!

  4. #4
    Location
    Central Indiana
    Posts
    51
    Exclamation 35566 is incorrect code
    I agree with Lisammy in theory, but the code given is wrong. A popliteal-ant tib BPG with vein is actually 35571, not 35566 (this code is for a femoral-distal vein BPG).

    Something to remember about vascular coding is that many of the open procedures bundle. For example, if your doctor had performed an endarterectomy at the site of the anastomosis, it would have bundled into the bypass code and wouldn't have been reimbursed seperately. Under the "Arteries and Veins" subtitle in CPT it states, "Primary vascular procedure listings include establishing both inflow and outflow by whatever procedures necessary." Endovascular procedures are handled differently and those are where you will typically see multiple line items for one surgical procedure. Hope this helps!

  5. Default
    Thanks Keri. My brain must have been ready for the holiday weekend on that one.

  6. #6
    Default
    Keri, thank you very much for the additional information and for explaining the difference. I will try to use this knowledge going forward with the more than 40 surgeries I have to code. I wish I had a vascular coder by my side in the process! It is a comfort to know I do have these forums to turn to as I do NOT have another coder in my company to ask questions.

  7. #7
    Default
    Another tip: Ingenix Coding Companion for Cardiology/Cardiothoracic Surgery/Vascular Surgery is a GREAT tool to have when coding for Vascular!

  8. #8
    Location
    Fayetteville, NC
    Posts
    300
    Default
    @ svevans. How true!! I have one too and it has been a life saver (and reimbursement saver) on many occasions!!

  9. #9
    Default additional question
    I have a similar case in my office, but my physician did a reversal saphenous vein as well as the popliteal to dorsalis pedis bypass. does anyone know if that is included in the bypass graft code?

    thank you
    Kristen Richard, CPC

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