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Composite Bypass Graft Question

  1. #1
    Default Composite Bypass Graft Question
    Exam Training Packages
    I am thinking about using cpts 35656 and 35681 together for a Composite bypass graft using reverse greater saphenous vein and 8-mm ringed gortex graft, femoral below the knee popliteal artery bypass graft. I have ran both these codes through Encoder Pro and found no edits. Curious to see if these codes can be billed together or if there is a better set of codes to use???


    PREOPERATIVE DIAGNOSIS: Ischemic ulcer, left foot with occlusion, left
    superficial femoral and popliteal artery.

    POSTOPERATIVE DIAGNOSIS:

    1. Occlusion, left superficial femoral artery and popliteal artery.
    2. Severe stenosis, origin profunda femoris as well as common femoral
    artery.

    PROCEDURE PERFORMED:

    1. Common femoral artery and profunda femoris endarterectomy.
    2. Composite bypass graft using reverse greater saphenous vein and 8-mm
    ringed Gore-Tex graft, femoral below-the-knee popliteal artery bypass
    graft.

    OPERATIVE NARRATIVE: Patient was brought to the OR and given general
    anesthetic. The left leg was then prepped and draped in the usual sterile
    fashion using Hibiclens scrub and ChloraPrep. An incision made in the
    groin vertically through skin and subcutaneous tissue. The common femoral,
    superficial, and profunda femoris arteries were identified. There was also
    a large posterior branch at the origin of the common femoral artery. There
    was severe disease in the common femoral artery with posterior plaquing as
    well as near complete occlusion of the profunda femoris artery with
    atherosclerotic disease. Vascular loops were placed around these arteries
    and then an incision was made along the medial aspect of the leg
    identifying the greater saphenous vein. This was dissected free using
    multiple incisions along the medial aspect of the leg. At the level of the
    knee, however, it became very small and atrophic and was an inadequate
    conduit for bypass graft. This patient required a below-the-knee bypass.
    Thus, it was elected to proceed with reversing the greater saphenous vein
    and making a composite graft with 8-mm Gore-Tex graft. Thus, the vein was
    then harvested. It was flushed with saline. All branches were identified
    prior to removal. These were clamped and then tied using Vicryl silk ties
    on the vein side. The vein was inspected and found to be a good conduit
    for this length of vein. An 8-mm Gore-Tex graft was then selected and
    tunneled in appropriate position. The patient was then given 8000 units of
    heparin. The common femoral, profunda femoris, and superficial femoral
    arteries were clamped. A longitudinal arteriotomy was made and
    endarterectomy was then done on the common femoral and origin of the
    profunda femoris artery. This allowed excellent backbleeding from the
    profunda femoris artery. The Gore-Tex graft was then transected to
    appropriate length and size and sutured in place using 1 suture of CV5
    suture. With this completed, it was flushed from the profunda and then the
    graft was flushed distally with good control of hemostasis at the level of
    the anastomosis with some needle hole bleeding controlled using thrombin
    and Gelfoam.

    The graft was then tunneled underneath the first incision. It was then
    transected to appropriate length and size and spatulated. The vein graft
    was also spatulated and an end-to-end anastomosis was performed using 1
    suture of CV6 suture. This was then completed and checked for hemostasis.
    A small amount of bleeding from 2 spots was controlled using a CV6 suture
    with good control of hemostasis. Flow was then allowed to continue in this
    vein graft. A tunnel had been developed above the knee for exposure of the
    proximal popliteal artery and a 0 silk tie was placed through this. The
    graft was then tunneled in to appropriate position without any kinking or
    coiling of the tunneled graft. Attention was then directed to the distal popliteal artery.
    This had been dissected through a separate incision
    medially with an adequate area of soft popliteal artery identified, which
    was amenable for anastomosis. This was then cross clamped proximally and
    distally. A longitudinal arteriotomy was made. The vein graft was
    transected to appropriate length and size and then sutured in place using
    running suture of 6-0 Prolene. When this was nearly completed, it was
    flushed proximally and distally and then the anastomosis was completed.
    Forward flow was also turned first to the proximal superficial, popliteal
    artery, and then distally. There was excellent pulsatile flow through the
    graft with Doppler flow initially identified at the level of the ankle and
    with further dilation and warming, there was a strongly palpable posterior
    tibial pulse at the termination of the procedure. When the graft was
    clamped, there was no pulse palpated, thus the procedure was ended. The
    patient was given 15 units of protamine to reverse this heparin. All
    wounds were irrigated out with saline. All wounds were closed using
    running sutures of 3-0 Monocryl for the deep tissue with 2nd layer to close
    the subcu tissue, 4-0 Monocryl with Steri-Strips were used to close the
    skin. Dry sterile dressings were placed on the wound. The patient was
    then brought to recovery room in satisfactory condition with all sponge and
    needle counts correct at the end of the case.




    Thanks,
    Crystal C
    Last edited by crystal52599lhs; 07-26-2011 at 11:09 AM. Reason: needed to add the report

  2. #2
    Location
    Richardson, TX
    Posts
    822
    Default
    Quote Originally Posted by crystal52599lhs View Post
    I am thinking about using cpts 35656 and 35681 together for a Composite bypass graft using reverse greater saphenous vein and 8-mm ringed gortex graft, femoral below the knee popliteal artery bypass graft. I have ran both these codes through Encoder Pro and found no edits. Curious to see if these codes can be billed together or if there is a better set of codes to use???


    PREOPERATIVE DIAGNOSIS: Ischemic ulcer, left foot with occlusion, left
    superficial femoral and popliteal artery.

    POSTOPERATIVE DIAGNOSIS:

    1. Occlusion, left superficial femoral artery and popliteal artery.
    2. Severe stenosis, origin profunda femoris as well as common femoral
    artery.

    PROCEDURE PERFORMED:

    1. Common femoral artery and profunda femoris endarterectomy.
    2. Composite bypass graft using reverse greater saphenous vein and 8-mm
    ringed Gore-Tex graft, femoral below-the-knee popliteal artery bypass
    graft.

    OPERATIVE NARRATIVE: Patient was brought to the OR and given general
    anesthetic. The left leg was then prepped and draped in the usual sterile
    fashion using Hibiclens scrub and ChloraPrep. An incision made in the
    groin vertically through skin and subcutaneous tissue. The common femoral,
    superficial, and profunda femoris arteries were identified. There was also
    a large posterior branch at the origin of the common femoral artery. There
    was severe disease in the common femoral artery with posterior plaquing as
    well as near complete occlusion of the profunda femoris artery with
    atherosclerotic disease. Vascular loops were placed around these arteries
    and then an incision was made along the medial aspect of the leg
    identifying the greater saphenous vein. This was dissected free using
    multiple incisions along the medial aspect of the leg. At the level of the
    knee, however, it became very small and atrophic and was an inadequate
    conduit for bypass graft. This patient required a below-the-knee bypass.
    Thus, it was elected to proceed with reversing the greater saphenous vein
    and making a composite graft with 8-mm Gore-Tex graft. Thus, the vein was
    then harvested. It was flushed with saline. All branches were identified
    prior to removal. These were clamped and then tied using Vicryl silk ties
    on the vein side. The vein was inspected and found to be a good conduit
    for this length of vein. An 8-mm Gore-Tex graft was then selected and
    tunneled in appropriate position. The patient was then given 8000 units of
    heparin. The common femoral, profunda femoris, and superficial femoral
    arteries were clamped. A longitudinal arteriotomy was made and
    endarterectomy was then done on the common femoral and origin of the
    profunda femoris artery. This allowed excellent backbleeding from the
    profunda femoris artery. The Gore-Tex graft was then transected to
    appropriate length and size and sutured in place using 1 suture of CV5
    suture. With this completed, it was flushed from the profunda and then the
    graft was flushed distally with good control of hemostasis at the level of
    the anastomosis with some needle hole bleeding controlled using thrombin
    and Gelfoam.

    The graft was then tunneled underneath the first incision. It was then
    transected to appropriate length and size and spatulated. The vein graft
    was also spatulated and an end-to-end anastomosis was performed using 1
    suture of CV6 suture. This was then completed and checked for hemostasis.
    A small amount of bleeding from 2 spots was controlled using a CV6 suture
    with good control of hemostasis. Flow was then allowed to continue in this
    vein graft. A tunnel had been developed above the knee for exposure of the
    proximal popliteal artery and a 0 silk tie was placed through this. The
    graft was then tunneled in to appropriate position without any kinking or
    coiling of the tunneled graft. Attention was then directed to the distal popliteal artery.
    This had been dissected through a separate incision
    medially with an adequate area of soft popliteal artery identified, which
    was amenable for anastomosis. This was then cross clamped proximally and
    distally. A longitudinal arteriotomy was made. The vein graft was
    transected to appropriate length and size and then sutured in place using
    running suture of 6-0 Prolene. When this was nearly completed, it was
    flushed proximally and distally and then the anastomosis was completed.
    Forward flow was also turned first to the proximal superficial, popliteal
    artery, and then distally. There was excellent pulsatile flow through the
    graft with Doppler flow initially identified at the level of the ankle and
    with further dilation and warming, there was a strongly palpable posterior
    tibial pulse at the termination of the procedure. When the graft was
    clamped, there was no pulse palpated, thus the procedure was ended. The
    patient was given 15 units of protamine to reverse this heparin. All
    wounds were irrigated out with saline. All wounds were closed using
    running sutures of 3-0 Monocryl for the deep tissue with 2nd layer to close
    the subcu tissue, 4-0 Monocryl with Steri-Strips were used to close the
    skin. Dry sterile dressings were placed on the wound. The patient was
    then brought to recovery room in satisfactory condition with all sponge and
    needle counts correct at the end of the case.




    Thanks,
    Crystal C
    Nope, you're correct. These codes can be billed together and he is utilizing one composite from vein and graft.

    Julie Graham, BA, CPC, CCC

  3. #3
    Location
    Columbus, Ohio
    Posts
    77
    Default Add on 35681 billed with 35566 denied for primary CPT missing
    I have coded a note with 35566 and 35681 and Anthem is denying stating I am billing an add on code w/o the primary. I cannot find anything that says these cannot be billed together. If anyone can provide any assistance I would greatly appriciate it.
    Stephanie W., CPC, CPMA

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