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-   -   Mitral Valve Repair (http://www.aapc.com/memberarea/forums/showthread.php?t=9107)

cmblocher 10-15-2008 12:33 PM

Mitral Valve Repair
Could someone please advise me if this scenario warrants being coded differently than a single Mitral repair using one prosthetic ring (33426)

"Mitral valve repair using a double-decker approach with a #36 AnnuloFlex ring along the papillary muscles and a 28-mm MEMO3D ring at the annulus"

Thanks for any adivce.

MLS2 10-22-2008 01:46 PM

I am looking into this...I have actually never seen a case where 2 rings were used. I'll get back to you:)

MLS2 10-22-2008 02:08 PM

I checked with a CT surgeon and he thinks it would be a "complex" repair, but I'm not sure that would mean a 33427 just because they used 2 rings. It could possibly warrant a 22 modifier on the 33426. But without seeing the rest of the report I can't tell for sure.

cmblocher 10-28-2008 09:51 AM

Here is the report, Maybe I read into it wrong. MLS2 thank you for your help.
OPERATION: Coronary artery bypass grafting x3 using the left
internal mammary artery to the left anterior descending, saphenous
vein graft to the diagonal, saphenous vein graft to the obtuse
marginal and mitral valve repair using a double-decker approach with
a #36 AnnuloFlex ring along the papillary muscles and a 28-mm MEMO3D
ring at the annulus.

ANESTHESIA: General endotracheal.

INDICATIONS: Patient is a 49-year-old male who has presented with
complaints of chest pain and severe shortness of breath. He
decompensated over the weekend and was found to have severe mitral
valve regurgitation. He had ruled in for myocardial infarction.
His catheterization shows that he has very complex disease in the
circumflex and left anterior descending distribution and he has an
occluded right coronary artery. He has severe mitral regurgitation
on the basis of restricted leaflet defect and posterior medial
papillary muscle dysfunction. He is for surgical repair.

PROCEDURE: The patient was taken to the operating room. He
underwent a general endotracheal anesthetic. A Swan-Ganz catheter,
radial artery catheter and transesophageal echocardiography probe
were placed prior to beginning his operation. He was brought to the
operating room and scrubbed and draped in the usual sterile fashion.
A median sternotomy was made using our standard technique. The
left internal mammary artery was harvested using electrocautery. It
was a 3-mm vessel of good quality and harvested without any
identifiable injury. A vein was harvested from the right thigh
using the endoscopic vein harvesting system. The patient was
anticoagulated. The ascending aorta was cannulated with a 20-French
aortic cannula. The superior vena cava was cannulated with a
28-French single-stage venous cannula. The inferior vena cava was
cannulated with a 32-French single stage venous cannula. A
retrograde cardioplegic cannula was placed in the coronary sinus.
The antegrade cardioplegic cannula was placed in the ascending
aorta. Cardiopulmonary bypass was instituted. The aorta was
crossclamped and 1 liter of cardioplegia was given. Antegrade ice
was used as a topical hypothermic agent. We then began our grafts.
The proximal descending artery is nongraftable. It is a very small
vessel. We grafted the first obtuse marginal. It is a 2-mm vessel
of good quality. We sewed a vein graft to this using 7-0 Prolene in
running technique and gave an additional 500 mL of cold blood. We
then grafted the diagonal. It is a 1.75-mm vessel of good quality.
We sewed a vein graft to this using 7-0 Prolene and gave an
additional 500 mL of cold blood. We then snared the KV. We opened
the right atrium and extended it through the roof of the left atrium
and then sewed the anteroapical septum. We placed a 36-mm
Carbomedics AnnuloFlex ring, which we weaved around the base of the
papillary muscles and then sewed it back together with 4-0 Gore-Tex
sutures. We then brought one end of the Gore-Tex sutures through
the base of the papillary muscles and sewed it to the other side of
the ring and tied it back down into position. This allowed us to
pull the papillary muscles into a midline position. We had run
retrograde cardioplegia at least every 20 minutes. We then placed a
28-mm MEMO3D ring on our annulus. We brought our sutures through
the annulus, brought them up to the ring and then tied it down into
position. We then insufflated the ventricle copiously with saline
and it appeared that we had a good result. We then closed our
atriotomies with a 3-0 Prolene.
We placed the left ventricular
valve via the right superior pulmonary vein. We then grafted the
left mammary to the left anterior descending. It is a 2-mm vessel
of good quality. We sewed this using 7-0 Prolene. We then tacked
it to the anterior surface of the left ventricle. We gave the hot
shot cardioplegic solution. We released the aortic crossclamp and
placed a side-biting clamp across the ascending aorta. A 4.4-mm
punch was used for the aortotomies and then both vein grafts were
sewn directly to the aorta using 5-0 Prolene. We released the
side-biting clamp, deaired the grafts and allowed them to reperfuse.
We resumed ventilation. We deaired the left ventricle. We weaned
the patient from cardiopulmonary bypass without difficulty. His
postoperative echocardiogram shows good biventricular function with
an ejection fraction of about 50%. We reversed our anticoagulation
with protamine, decannulated the patient and placed a pacer wire in
the inferior surface of the right ventricle and one onto the skin.
We placed a chest tube into each thorax. He had large bilateral
effusions. We drained about 2 liters of the pleural effusions. We
closed the pericardium and placed a chest tube into the mediastinum.
The sternum was closed with #6 stainless steel wire. The
subcutaneous layers were closed with two layers of 0 Polysorb. The
skin was closed with 3-0 Polysorb. The patient was transferred to
the intensive care unit in stable condition.

MLS2 10-29-2008 10:25 AM

I came up with 33533-51, 33518, 33508 and for this one I think I would go with the 33427.

hope this helps!:)

cmblocher 10-30-2008 10:47 AM

Thank you for being so helpful :)

sgochoco 11-06-2008 01:55 PM

My reply may be a bit late, but I wanted to offer my thoughts. After reading the note, I do not feel that this procedure was "complex" or "radical". You can have a complex or radical repair without a "ring". What I would suggest, depending upon the payer, is to bill the 33426 with a 22 modifier. The extra work involved in the repair was an additional ring. He/She did not transfer chords for this pt, or do anything extensive outside the scope of sewing 2 rings in place. It probably took more time and was a bit more tedious, but it does not look radical to me. I would be interested in knowing how you bill this and if the claim was paid or denied.

cmblocher 11-06-2008 04:34 PM

Sgochoco- I was going to bill with 33427. But in the end I felt more comfortable with the 33425-22, and so that was what I billed for.

I tell ya, this coding business can really make you think. In cases like these, I put the report to the side... and re-read the next day.

Thanks for your input!

MLS2 11-10-2008 11:00 AM

Should have went with my gut instinct...that's what I thought at first:)
glad you figured it out.

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