Nope, you're correct. These codes can be billed together and he is utilizing one composite from vein and graft.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.
1. Occlusion, left superficial femoral artery and popliteal artery.
2. Severe stenosis, origin profunda femoris as well as common femoral
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
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
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.
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