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Thread: Help!! Aortic stent graft coding....

  1. #1
    Join Date
    Apr 2007

    Question Help!! Aortic stent graft coding....

    AAPC: Back to School
    here is another OP note i was given to help with.. i am not familiar with these procedures. Would be greatly appreciative if someone could lead me in the right direction.. thanks!!!

    Distal aortic suture line pseudoaneurysm and two right iliac

    Distal aortic suture line pseudoaneurysm and two right iliac

    1. Abdominal aortic stent graft.
    2. Embolization of right internal iliac artery.

    HISTORY: The patient is a 70-year-old gentleman eight years out
    from a tube graft repair of an abdominal aortic aneurysm. Six
    days ago he began having back pain, which was relatively severe
    over three days. It subsided and he saw Dr. Hoke on the day
    before surgery and a CT scan was done. The CT scan showed
    periaortic fluid collection consistent with an acute bleed
    process versus an enlarging pseudoaneurysm. The patient had been
    totally stable and the pain decreased so he was worked up and
    brought to the operating room at this point in time for hope for
    endovascular repair of distal aortic suture line pseudoaneurysm
    versus a leaking expanding right iliac aneurysm.

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

    Initial step was to place an 8-French sheath in the left groin,
    which was done percutaneously. Once this was in place transverse
    incision was made over the right groin and the common femoral
    artery exposed for adequate length.
    Initial step here was to embolize the right internal iliac
    artery. Initially we tried this by placing a 6-French sheath in
    the right femoral artery and accessing the internal iliac with
    various sorts of hook-type guiding catheters. We were

    unsuccessful in this after an extended period of time. Next we
    went to the left groin, crossed the iliac bifurcation using a
    contra catheter and glidewires. We were able to get a guidewire
    into the internal iliac and extend the guiding cath in but were
    never able to extend the sheath into that area. After an
    extended period of time doing this, Dr. White graciously came in
    and helped us address this problem. He was able to get a guiding
    catheter over to the 8-French x 55 sheath at the left groin over
    the bifurcation and once this was in place then cannulate the
    internal iliac with an 0.014 coronary wire over which we were
    able to eventually advance the sheath and get good purchase into
    the internal iliac artery.

    Once we had done this two Amplatz occluder devices, first an 8 mm
    and then once this was deployed per routine a second 6-mm Amplatz
    occluder device was deployed. Once this was done initial
    angiogram showed continued flow into the internal iliac artery
    but good position of the Amplatz devices.

    Once we had gotten this done, which actually took a number of
    hours, we proceeded on with the aneurysm repair. The short 8-
    French sheath was replaced in the left groin. A 12-French strip-
    away sheath was placed in the right groin. Once these were in
    place a Meier wire was advanced up the right iliac into the
    thoracic aorta. The Endologix device was then advanced up over
    the wire into the thoracic aorta loaded with a 28 x 16 __________
    bifurcator device. Just prior to placing this, the SurePass
    guidewire to the contra lateral limb was advanced up the sheath
    grabbed with a snare and brought out the left 8-French sheath.
    Once we had done this we were able to strip away the strip-away
    sheath in the right groin advancing the entire device up into the
    thoracic aorta as noted above. Once this was in position the
    wires were in the sheath and the device was appropriately
    oriented and wires under nice control, we were able to retract
    the stent graft integrating sheath below the iliac bifurcation.
    Once we had done this we were able to pull the entire system down

    to the aortic bifurcation seating it nicely by the aortic
    bifurcation. An 0.014 Endologix wire was then advanced up the
    SurePass contra limb precannulating gate before deployed. Once
    we had done this we deployed the main body of the graft by
    pulling the device control cord. Having done this we were able
    to retract the integrated sheath deploy the ipsilateral limb.

    Having successfully deployed both limbs a pigtail catheter was
    advanced up the 0.014 left groin 0.014 wire and aortogram
    performed. Note the location of the renal arteries were noted at
    this point in time. Having done this we placed the infrarenal 34-
    34-100 aortic extension using the pin and pull technique and
    placed it just at the top of the previously placed graft
    specifically below the area of about 50% narrowing in the main
    aorta. Once this was successfully deployed the main body overlap
    and proximal areas were dilated with a Reliant balloon and the
    right limb of the graft dilated as well.

    At this point in time we advanced an 0.014 guidewire back up the
    pigtail catheter, pulled it back to the aortic bifurcation then
    carefully advancing it up using a little twirl as went. We

    advanced the pigtail back up to the aorta just above the upper
    limits of the graft. Having done this we were able to go ahead
    over the right limb guidewire advance a 20 x 13 x 70 right limb
    extension. We positioned this and successfully deployed this.
    Having done this, Coda balloon was used to dilate this as well.

    Following this a completion arteriogram was shot. We showed no
    evidence of any endoleak. The proximal location was perfect. By
    this time the right internal iliac was totally occluded as per
    our plans with good flow into the right iliac artery. We felt at
    this point we did not need to dilate the left limb as there was
    good apposition and good flow.

    Having done all this we were able to go ahead and remove all the
    devices from the right femoral artery. Clamps were applied and
    the artery carefully reapproximated using 6-0 Prolene. This was
    a heavily diseased artery and actually we noted we did have
    virtually no back flow. However once we got the artery repaired,
    released the clamp to good pulse and good Doppler pulse from the
    left ankle and so we felt we were okay.

    Having done this ACT was done and was found to be adequate. The
    right groin was closed using running 3-0 Vicryl deep and running
    subcuticular 4-0 Vicryl on the skin. The left 8-French sheath
    was removed and we used a Mynx closure device for this procedure.
    This worked well and successfully.

    At this point the patient was allowed to wake up, was extubated,
    and was taken to the recovery room having tolerated the procedure
    well. Sponge and needle count correct x2.

  2. #2
    Join Date
    Apr 2007
    Richardson, TX


    34804 for the graft deployment; 75952-26

    34812 - 50 for bilateral femoral artery exposure

    36200 - 50 introduction of cath into aorta rt/lt

    For extentions or 'cuffs' bill 34825/34826; 75953-26

    You can also bill for IVUS 37250/75945-26 if performed.
    Julie Graham, BA, CPC, CCC

  3. #3

    Thumbs down Julie could you help me please with this OP note


    1. Aortoiliac occlusive disease with focal moderately severe mid-infrarenal

    abdominal aortic stenosis.

    2. Disabling bilateral lower extremities intermittent claudication (Rutherford


    3. Left lower extremity atheroembolic events (probably related to aortic


    4. Diabetes mellitus.

    5. Chronic obstructive pulmonary disease.

    6. Chronic tobacco abuse.

    7. Morbid obesity.


    1. Aortogram.

    2. Aortic catheterization.

    3. Primary stenting of infrarenal aorta with iCast 9 mm x 58 mm stents dilated

    to a final diameter of 12 mm.

    ANESTHESIA: General endotracheal.



    1. Moderately severe calcific and ulcerative mid infrarenal aortic stenosis

    associated with moderate bilateral ostial common iliac artery occlusive


    2. No significant resting transaortic pressure gradient following stent


    3. Palpable pedal pulses at case conclusion.


    COUNTS: Correct.

    DRAINS: None.

    SPECIMENS: None.

    DISPOSITION: To recovery unit in stable condition.

    STATEMENT OF MEDICAL NECESSITY: Mrs. Blank is a 50-year-old Caucasian

    female with diabetes mellitus and a history of extensive tobacco use who

    recently presented with an episode of ischemic sigmoid colitis coincident with

    left lower extremity atheroembolism. She further described disabling bilateral

    and symmetrical lower extremity exertional discomfort consistent with

    intermittent claudication. Lower extremity arterial duplex identified a severe

    distal infrarenal aortic stenosis and a CT arteriogram revealed a complex and

    partially calcified moderately severe distal infrarenal aortic stenosis

    associated with iliac occlusive disease. She desired treatment. I recommended

    endovascular aortic treatment on the basis of the focality and location of the

    stenosis (in the aorta) and her moderate surgical risk profile. The risks,

    benefits, and alternatives to treatment were described to the patient in detail.

    She expressed understanding of these, provided informed consent, and wished to


    DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed

    in the supine position. General anesthesia was induced. The left arm was

    tucked and padded. The right arm was extended on an arm board and padded. A

    right internal jugular central venous catheter and radial arterial line were

    placed by the anesthesia service. A Foley catheter was sterilely inserted.

    Preoperative antibiotics were administered. The abdomen and groins were then

    prepared and draped sterilely. An Ioban drape was applied.

    The right common femoral artery was percutaneously cannulated under fluoroscopic

    and ultrasonographic guidance with a standard Seldinger technique. A 5-French

    sheath was inserted in a retrograde fashion. The left common femoral artery was

    similarly percutaneously cannulated under fluoroscopic and ultrasonographic

    guidance with a micropuncture needle. A 5-French sheath was inserted in a

    retrograde fashion.

    A 0.035-inch magic torque guidewire was advanced through the left iliac system

    and positioned in the thoracic aorta. An 8-French x 35 cm Brite Tip sheath was

    advanced through the left iliac system and positioned in the caudad aspect of

    the infrarenal aorta. A 0.035 inch floppy Glidewire was advanced through the

    right iliac system in conjunction with a marker pigtail catheter and positioned

    in the proximal infrarenal aorta proximal to the proximal location of the known

    mid aortic stenosis. A standard aortogram was then performed utilizing dilute

    Visipaque contrast and digital subtraction arteriography under magnification.

    The aortogram again demonstrated a moderately severe ulcerative and calcified

    mid aortic stenosis. The ostia of the common iliac arteries possessed moderate

    calcific occlusive disease. The common iliac artery stenoses, however,

    possessed no significant velocity acceleration according to recent duplex

    interrogation. I elected to proceed with primary aortic stenting on the basis

    of these arteriographic results. The indication for primary aortic stenting was

    to exclude the mid aortic stenosis because of its probable involvement with the

    prior lower extremity atheroembolic events and to relieve her intermittent

    claudication symptoms.

    A systemic anticoagulation was induced by the administration of 5000 units of

    heparin intravenously. An iCast 9 mm x 58 mm stent was advanced through the

    left iliac system and centered over the aortic stenosis. The stent was deployed

    to a nominal pressure. The stent was then dilated proximally and distally

    sequentially with 10 mm x 20 mm and 12 mm x 20 mm semi-compliant balloons. The

    central portion of the stent at the stenosis site was then gently dilated with a

    12-mm balloon. A subsequent aortogram demonstrated a satisfactory result with

    exclusion of the stenosis and no significant residual stenosis. A minor amount

    of contrast was noted to track around the stent edge proximally and supplied a

    patent lumbar artery. No evidence of extravasation nor dissection was noted. I

    elected to conclude the procedure on the basis of these arteriographic results.

    The diagnostic catheter was removed under direct visualization. The 8-French

    sheath was withdrawn and replaced with a short 8-French sheath. She tolerated

    the operation well, was extubated, and was transported to the recovery unit in

    stable condition. The sheaths were removed per protocol. She possessed

    palpable pedal pulses at the conclusion of the procedure.

    I have never requesting coding help. Not sure if this is the correct protocal.
    I was very confused on this one?
    DX 440.21 + 444.22
    36200-50 + 34812-50 75625-26 ???
    Thank you

  4. #4


    37205 for aortic stent
    36200-50 for cath placement in aorta
    75630-26 for S&I of aorta with runoff
    75960-26,59 for S&I stent placement
    no cutdown was performed so 34812 would not be correct.
    for dx I would use 440.0 for aortci stenosis, 440.21 for claudication, 444.22 for lower ext emboli.

  5. #5
    Join Date
    Apr 2007

    Default Aortic Stent Graft for AAA

    These still have me so confused. Could you look at this one too and tell me what you think? I have these codes but i'm second guessing myself. I'm just still not comfortable with these.. Thanks again!!!!

    75952 26
    and then i get lost...?????

    Aortic stent graft for treatment of aortic aneurysm

    An 8-French sheath was placed in the right femoral artery
    percutaneously for access. The left groin cutdown was made using
    a transverse suprainguinal crease incision. Common femoral
    artery was dissected out and looped for vascular control. A
    guidewire was passed up the right femoral artery into the aortic
    arch area. An 18-gauge needle was used to access the exposed
    left femoral artery and a guidewire likewise positioned up the
    thoracic aorta.

    Next a snare was placed up the right femoral sheath. Following
    this the 17-French AFX sheath was placed up the left femoral
    artery replacing it for the previously placed 6-French sheath.
    This was done and the contralateral limb wire was passed up the
    17-French sheath, snared with a snare, and brought out the right

    femoral sheath. Once we had these under control. The AFX
    bifurcated device was transferred to the AFX sheath and advanced
    under fluoroscopy to the distal end to well above the aortic
    bifurcation releasing the limb to the graft. We then pulled the

    entire system down the aortic bifurcation. At that point we then
    advanced the 0.014 Endologix guidewire up the contralateral limb
    wire hypotube. Once this was done the main body of the graft was
    deployed by pulling the control cord handle.

    At this point retracted the AFX sheet deploying the ipsilateral
    limb. We then removed the inner core assembly and advanced the
    dilator into the AFX sheet. We then advanced the dilator and
    sheath assembly to just above the level of the lowest renal

    At this point we released the contralateral limb by retracting
    the SurePass wire and pulling the limb cover from the limb. We
    then passed up a pigtail catheter up over the 0.014 wire and
    placed at just above the renal arteries.

    At this point arteriogram was done to visualize the areas of the
    renals. These were marked and a C-arm fixed.

    Once this was done we advanced the infra- and suprarenal aortic
    cuff above the renal arteries. We then removed the safety clip
    and began deployment deploying two segments. We then pulled the
    whole assembly back to place the highest point of the aortic cuff
    graft just at the lower edge of the left renal artery, which was
    about a centimeter distal from the right renal artery. Once we
    had this in place deployment was completed. We then pulled back
    the pigtail catheter and advanced up the center of the graft
    through the aortic cuff. Arteriogram was done at this point
    showing no visible endoleaks and good placement of the graft.
    Because the deployment was made complete the decision was made to
    forego any balloon dilatation.

    Once we had accomplished this the device was removed from the
    left femoral artery and clamps applied. The artery was repaired
    using interrupted 6-0 Prolene sutures. Clamps released and good
    pulse felt beyond repair. The right 8-French sheath was removed

    using a Mynx closure device. This worked well without any

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