Results 1 to 3 of 3

AAA repair surgery/stenting

  1. #1
    Default AAA repair surgery/stenting
    Medical Coding Books
    I was given this Op note to code and am not very familiar with these procedures... could someone look at this and help?? thanks!!!

    i know the Iliac ptca and stenting are in the new vascular codes, just not sure about the abd aortic stent graft.. thanks again!!

    PREOPERATIVE DIAGNOSES:
    1. Abdominal aortic aneurysm.
    2. Left iliac artery stenosis.

    POSTOPERATIVE DIAGNOSES:
    1. Abdominal aortic aneurysm.
    2. Left iliac artery stenosis.

    OPERATIVE PROCEDURES:
    1. Abdominal aortic stent graft.
    2. Angioplasty, left iliac artery.
    3. Angioplasty and stenting, right external iliac artery.

    HISTORY: The patient is a 49-year-old gentleman known to have
    abdominal aortic aneurysm. He has been increasing in size over
    the last several years. He is also known to have some vascular
    disease based on his CTA workup. In light of this he was worked
    up for a potential endovascular procedure and was felt to be a
    reasonable candidate for it. He is brought to the OR at this
    time.

    PROCEDURE: The patient was brought in the operating room, placed
    in the supine position, and underwent induction of general
    endotracheal anesthesia. The patient was then positioned,
    prepped, and draped in the routine sterile fashion.

    Initial step was to place an 8-French left femoral catheter
    percutaneously. This was placed. C-arm showed good tracking of
    the device; although, we did have a little problem negotiating
    the guidewire past the stenosis at the proximal iliac artery.

    Once this was done the right groin incision was made in a
    transverse fashion just above the inguinal ligament. The femoral
    artery was exposed for an adequate length of two clips proximally
    and distally. Note was made of heavy calcification in the right
    femoral artery.

    At this point the decision was made to do an additional
    dilatation of the left iliac artery stenosis. A 7 x 40 mm Rival
    balloon was then passed up a guidewire in the left iliac artery
    up to the area of stenosis right at the bifurcation. This area
    was successfully dilated. Once we did this, a guidewire was
    passed up the right femoral artery sticking it first in an 18-
    gauge needle, advancing a glidewire up into the proximal thoracic
    aorta. Over this we placed a 6-French sheath. A 6-French sheath
    was passed initially so we could pass a pigtail catheter up the
    right femoral artery into the proximal abdominal aorta where an
    aortogram was done. This was done specifically to assess the
    length of the right iliac artery. It was found that the common
    iliac artery on the right was about a 3.5 cm vessel so we decided
    to go with a 70-30 28 main body device. Once we had done the
    arteriogram the 6-French sheath was removed and a 9-French peel-
    away sheath placed up the right femoral artery. Through this
    sheath we passed the contra-limb guidewire from the Endologix
    device. Snare was placed up the left groin. Its wire was
    grabbed and pulled back through the left 8-French sheath. Once
    we had gotten this in order pressure was applied to the right
    femoral artery and the 9-French peel-away sheath was removed. The
    main body was then passed over the Meier wire and advanced up
    into the femoral artery. We did have some problems doing this
    and the initial pass was unsuccessful. The main body of the
    device was removed and a dilator was used to advance up over the
    wire to open up the artery some. Once we had done this we were
    able then to get the main body over the Meier wire. As we
    advanced the main body the contralateral wire was advanced,
    pulled back up through the left groin sheath as it advanced. Once
    we got in position care was taken to ensure that the guidewire
    was in the right orientation.

    At this point the main body device was unsheathed using a pin and
    pull technique on the main body introducer device. Once this was
    done the device was pulled back and anchored at the bifurcation
    pulling back on the device and the contralateral limb wire. At
    this point then a 0.014 guidewire was passed up the left limb
    guidewire into the proximal thoracic aorta alongside the Meier
    wire. Just before anchoring the device on the bifurcation the
    device was unsheathed so that we could pull it down the
    bifurcation and anchor it. Having done this the integrated
    sheath deploying the ellipse out of the limb was retracted and
    the entire limb opened up nicely. At this point a pigtail
    catheter was passed up the left guidewire up to above the renal
    arteries and another aortogram done. This was done to identify
    the origin of the renal arteries. Once they were ascertained and
    marked the aortic extension was brought up and advanced up the
    right Meier wire introducer. The device here used was a 34-34-
    120 suprarenal proximal device. Locating it just at the renal
    arteries pin pull technique was slowly but deliberately done to
    anchor the proximal extension just at the renal arteries. The
    end result actually looked quite good.

    At this point a Reliant balloon was used to first dilate the
    overlapped area of the grafts and then the second application
    done at the renal arteries to anchor this device there. A 12 x 4
    balloon then went up past the contra side to dilate the graft up
    to the area of the iliac stenosis. This worked out quite nicely.

    At this point a completion arteriogram was done. When this was
    done we identified a fairly tight-looking 89% lesion about a
    centimeter distal to the right limb. This was not seen on
    previous arteriogram and was likely produced as we advanced the
    device up this very diseased aorta. Once we identified this as a
    problem a 7 mm x 4 balloon was then used to pre-dilate this area.
    This was done successfully and because of the degree of disease
    in the aorta and iliac artery a decision was made to place a
    stent in this area. A self-expanding 9 x 40 stent was chosen.
    This was placed. This was then post-dilated with a 9 x 40
    balloon. Completion angiogram showed excellent result in this
    area. Note was made at this point on the arteriogram that there
    was some concern about the internal iliac arteries bilaterally.
    We could see some vessel feeding the pelvis but on the
    arteriogram there was some concern that potentially the internal
    iliacs on both sides had become occluded. There was nothing at

    this point to do but again we did see flow into the pelvis via
    what appeared like more distal vessels. The right internal iliac
    artery seemed to opacify very lightly but there was some concern
    this probably was compromised.

    At this point the sheath was removed from the right femoral
    artery and attempts were made at closing this using interrupted 6-
    0 Prolene sutures. Angiogram was done by pulling the pigtail
    down to the aortic bifurcation and doing a run. The area of the
    closure appeared to be fairly stenotic in the range of at least
    75-80%. Accordingly the decision was made to go ahead and take
    this down. A long endarterectomy was done and carried up under
    the inguinal ligament proximally and distally down to an area
    just above the profunda takeoff, which was quite distal on the
    right groin. We were able to tack up a fairly pronounced intimal
    edge distally using interrupted 6-0 Prolene sutures. Having done
    this the arteriotomy closure itself was done using a patch onlay
    technique using Bovine pericardial patch. This was placed using
    running 5-0 Prolene. Once this was completed the clamps were
    released. Actually had good pulse distal to the graft. The
    completion arteriogram was again done and a good result was noted.

    At this point we had giving Heparin at the dose of about 2500
    every hour. We partially reversed the Heparin at this point
    around the ACT. The right groin once it was dry was irrigated
    and closed using 3-0 Vicryl deep and a running subcuticular 4-0
    Vicryl on the skin. A Mynx device was used to close the left
    femoral artery percutaneously.

    At the termination of the procedure pulses were present by
    Doppler bilaterally. The patient was then extubated and taken to
    the recovery room having tolerated the procedure well. Sponge
    and needle count correct x2.

  2. #2
    Default
    Hopefully this helps you out.

    diagnosis:
    441.4 AAA
    447.1 iliac stenosis

    Operation:
    37220-LT left iliac angioplasty
    37221-RT right iliac plasty/stenting
    34800 AA stent graft

    Don't forget the modifiers LT and RT, otherwise one might assume that they were performed on the same leg, inwhich case both codes would be dismissed and not paid on. Incisions and catheter placement for 34800 are already included in the previous operations. As is all imaging.

  3. #3
    Default
    Quote Originally Posted by eaglecloudnebula@yahoo.com View Post
    Hopefully this helps you out.

    diagnosis:
    441.4 AAA
    447.1 iliac stenosis

    Operation:
    37220-LT left iliac angioplasty
    37221-RT right iliac plasty/stenting
    34800 AA stent graft

    Don't forget the modifiers LT and RT, otherwise one might assume that they were performed on the same leg, inwhich case both codes would be dismissed and not paid on. Incisions and catheter placement for 34800 are already included in the previous operations. As is all imaging.
    Great!! Thank you so much!!!

Similar Threads

  1. Help with AAA Repair
    By hopeslove in forum Cardiovascular Thoracic
    Replies: 0
    Last Post: 03-06-2014, 11:56 AM
  2. Help with AAA repair
    By JayRitten in forum Cardiovascular Thoracic
    Replies: 2
    Last Post: 02-05-2014, 04:07 PM
  3. AAA repair
    By Jennarw in forum Cardiovascular Thoracic
    Replies: 2
    Last Post: 06-13-2013, 08:59 AM
  4. AAA repair
    By churst21 in forum Cardiovascular Thoracic
    Replies: 2
    Last Post: 06-12-2013, 09:21 AM
  5. AAA Endograft repair billed as co-surgery
    By mgord in forum General Surgery
    Replies: 0
    Last Post: 04-19-2011, 10:22 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.