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Kidney Transplant extension graft 50327

Dawn C Posted Tue 19th of April, 2016 09:40:24 AM
My provider is telling me that I should be billing 50327 for back bench extension graft. I don't believe the note supports the billing of 50327. I believe more information is needed to support the billing of 50327. They also believe they can bill 50327 for sewing each side of the vein. I say 50327 is billed per vein, not per anastamosis. Please see my note example and let me know if you believe billing 50327 is supported. If it is supported can it be billed X's 2 for each side of the vein or only per vein? As the anesthesia service was preparing the patient, I prepared the RIGHT renal allograft on the back table by removing all extraneous connective tissue.  There were 2 arteries on a common carrel patch, single vein and ureter of sufficient length.  The kidney was stored in sterile ice with preservative solution and covered with sterile towel. The patient had a foley catheter placed sterilely, and the abdomen was prepped and draped in the usual sterile fashion.  We then did our standard surgical time out, reviewing the patient, allergies, antibiotics, operation to be performed, immunosuppression medications and ABO of the donor and recipient.  All agreed and we proceeded.  The anesthesia service acknowledged the administration of the IV Solumedrol 250 mg and Campath or Simulect or Thymoglobulin. We then made the right  lower quadrant oblique incision from an area about two centimeters medial to the anterior iliac spine to the pubic symphysis.  We were able to go through the skin, subcutaneous tissue, fascia, and into the right retroperitoneal space.  We were able to stay out of the peritoneum throughout the entire operation.  We kept the cord structures mobilized out of harm's way.  We spared the epigastric vessels. We had excellent exposure of the left external iliac artery and vein and carefully dissected these free of the nerve, keeping this lateral and out of harm's way.  The vessels felt of very good caliber, and there were no obvious abnormality in the vein or the artery. We gave the patient 2,000 units of intravenous heparin, allowed this to circulate for three minutes.  We used a Kay-Lambert clamp on the iliac vein and opened the vein with the 11-blade, Potts scissors, and Hepflush.  We anastomosed the donor renal vein to the recipient left external iliac vein using 5-0 Prolene in our four-quadrant standard technique.  When this venous anastomosis was completed, we went ahead and placed fogarty clamps on the proximal and distal left external iliac artery, opened into the iliac artery with the 11-blade.  The 4.0 arterial punch times 5 was used, so we had a nice opening of the anterior artery wall to accept the renal artery.  Then we used 6-0 Prolene, placing a cephalad and caudal stitch, and then we were able to anastomose each side easily under direct visualization.  When the arterial anastomosis was complete and tied, we went ahead and placed gentle vascular bull-dog clamps on the renal artery and renal vein proper, where we removed first the iliac vein clamps and allowed for flow across the venous anastomosis, and there was with excellent hemostasis.  We then allowed for the distal artery to open.  The anastomotic area opened nicely, signifying no technical issues.  We then allowed for forward flow from the artery down the leg.  There was excellent flow, again with no need for any suture repair across the anastomosis.  We then removed the clamps from the renal artery and vein proper, allowed for flow into and out of the kidney, placed warm irrigation all around the kidney to allow it to go ahead and vasodilate nicely, and there was no need for any suture repairs.  Hemostasis was obtained by the use of clips or ties as necessary.  Electrocautery was used on the capsule as necessary.  The kidney pinked up nicely.  The patient was given our standard mannitol 12.5 gm as well as Lasix 100 mg IV.  We then went ahead and placed the kidney into the left iliac fossa.  It laid nicely and had good color. We then repositioned our Bookwalter retractor and had good exposure of the bladder.  The antibiotic irrigant was flushed into the bladder.  The bladder distended very nicely into our field.  We were able to safely enter into the bladder, place our stay sutures of 3-0 silk, and then went ahead and allowed for the fluid to empty out of the bladder.  We then made sure the ureter laid in its correct position.  We opened opposite its blood supply with the tenotomy scissors.  We shortened it to the appropriate length and then we did our standard neo-ureterocystotomy using 5-0 PDS suture in a running technique. We did place a ureteral stent into the transplant ureter into the collecting system and it laid nicely and then into the bladder.  When this was completed we placed two Lembert type sutures of 6-0 PDS.  We tied these over a right angle so as not to obstruct.  We had good hemostasis.  We irrigated again with antibiotic solution.  Again the kidney laid nicely in the left iliac fossa.  The vessels were laying nicely, with no signs of any obstruction either inflow or outflow.  We went ahead and did the count as we prepared to close the fascia.  The count was correct.  We went ahead and closed the fascia with running #1 PDS suture starting from each end of the wound and tying in the middle.  We used some 2-0 Vicryl to reapproximate Scarpa's in an interrupted fashion.  We then used surgical staples to approximate the skin. We had final instrument and sponge counts correct times two.  Our warm ischemia time was about 56 minutes.  The cold time was about 18 hours and 16 minutes.  
SuperCoder Answered Wed 20th of April, 2016 08:50:51 AM
Hi, The procedure performed indicates that anastomosis was performed on single vein. As per the CPT code 50327 (Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each) it is appropriate to bill the code for per anastomosis rather than per vein. Therefore, the CPT code 50327 is appropriate for the above scenario.
Dawn C Posted Wed 20th of April, 2016 10:19:03 AM
Can you help me understand where the anastomosis was done? I see these connections were made, but it looks to me to be a component of 50360. You have to connect a vein and artery to have a functioning kidney so that anastomosis would not count as and extension graft? My understanding is an extension graft is an additional vein or artery that is used to because the vein or artery is not long enough? Here a the connections I see as part of the transplant. We anastomosed the donor renal vein to the recipient left external iliac vein using 5-0 Prolene in our four-quadrant standard technique. When this venous anastomosis was completed, we went ahead and placed fogarty clamps on the proximal and distal left external iliac artery, opened into the iliac artery with the 11-blade. The 4.0 arterial punch times 5 was used, so we had a nice opening of the anterior artery wall to accept the renal artery. Then we used 6-0 Prolene, placing a cephalad and caudal stitch, and then we were able to anastomose each side easily under direct visualization. Coding description of 50360 says: The physician surgically connects the renal vein and artery of the donor kidney to the recipient's clamped and dissected internal iliac vein and hypogastric artery. After removing the clamps, the physician checks for leakage, bleeding, and insufficient blood supply. To implant the donor ureter, the physician makes an incision into the bladder and passes the ureter through the bladder. The physician sutures the ureter as well as the opening in the bladder (cystotomy). The physician performs a layered closure. The drain tube may be left in. I'm sorry I have always understood 50327 to be additional work that I just don't see. Your guidance is much appreciated.
SuperCoder Answered Thu 21st of April, 2016 08:04:52 AM
Hi, In the above stated report the it mentioned that : ''We anastomosed the donor renal vein to the recipient left external iliac vein using 5-0 Prolene in our four-quadrant standard technique. When this venous anastomosis was completed, we went ahead and placed fogarty clamps on the proximal and distal left external iliac artery, opened into the iliac artery with the 11-blade.'' this supports that anastomosis was performed. Hence, CPT code 50327 was provided. Also, 50360 (Renal allotransplantation, implantation of graft; without recipient nephrectomy) can also be billed as surgically connecting the renal vein and artery of the donor kidney to the recipient's clamped and dissected internal iliac vein and hypogastric artery. After removing the clamps, the physician checks for leakage, bleeding, and insufficient blood supply is performed in the above scenario.

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