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Need help coding procedure.

  1. Default Need help coding procedure.
    Medical Coding Books

    I need some assistance coding a vascular surgery. The CPT code I found that describes the procedure is 36819 but the physician did not do the arteriovenous anastomosis. here is the report.

    I appreciate any advice, comments.
    Thank you!
    Dolores CPC - CCC

    INDICATION: The patient is a 62-year-old female who had a left
    upper arm fistula created. Then due to ischemia had a DRIL
    procedure, but the vein despite the large size on venogram is too
    deep. The patient is taken to surgery for superficialization and

    OPERATIVE REPORT: The patient was placed on the operating table in
    the supine position. The patient was induced under general
    anesthesia. The left arm was prepped and draped in the standard
    fashion and standard antibiotics were given. He was under monitored
    anesthesia. The patient's left arm was prepped and draped in a
    standard fashion, and Marcaine was used 20 mL to anesthetize over
    the cephalic vein. Using incisions about 3 to 4 cm in length the
    vein was mobilized, superficialized, and then the subcu layer was
    closed underneath to make sure the vein was very superficial, and
    the skin was closed with 3-0 Monocryl followed by skin staples. The
    patient transferred to recovery in stable condition after successful
    transposition of the vein to a more superficial level. Blood loss
    is minimal, maybe 50 mL. The patient received 300 mL of crystalloid
    intraoperatively. Instrument and sponge counts correct.

  2. #2
    Richardson, TX
    Hmmm if it's cephalic I'm thinkn 36818. And maybe use modifier 52 since no anastomosis was done?
    Julie Graham, BA, CPC, CCC

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