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Arabelis Posted Wed 09th of January, 2019 18:57:05 PM
The CPT for the procedure is 35572. This is an add code. I need to add addition code for primary procedure, but He only performed an (Open harvest of right/Left femoral vein and above-knee popliteal vein) one day and next day continue with the procedure. What other code can i use for the first surgery. ???? First Procedure I coded 35572 and for the next day 35540, 35907. I need add the additional code or change 35572 but I don't know for which one? DATE OF OPERATION(S)/PROCEDURE(S): 12/12/2018 PROCEDURE PERFORMED: 1. Open harvest of right femoral vein and above-knee popliteal vein. 2. Open harvest of left femoral vein and above-knee popliteal vein. PREOPERATIVE DIAGNOSIS: Infected abdominal aortic graft. POSTOPERATIVE DIAGNOSIS: Infected abdominal aortic graft. INDICATION FOR PROCEDURE: The patient is a gentleman who presented with history of abdominal pain and knee pain at the outside hospital. The patient received a CT scan within the outside hospital. On the CT scan, the patient was found to have some retroperitoneal stranding. The patient has known aortobifemoral bypass graft and at the level of the anastomosis, there was aneurysm with stranding concerning for infection. Within the next 2 to 3 days, the CT scan was reported and there was rapidly increasing aneurysm at the level of the anastomosis and increasing stranding. Of note, the patient also has a knee infection with Haemophilus influenzae growing out of that. The patient had a colonoscopy prior to this procedure and since then, the patient had symptoms of systemic infection. Given all of these findings, it is extremely concerning that the patient has infected aortobifemoral bypass graft with rapidly enlarging pseudoaneurysm at the anastomotic area. If not intervened upon rapidly, I expect this to rupture in the near future. I discussed at great length with the patient and the family and explained that this is a uniformly fatal problem unless it is surgically repaired. The surgical repair would require complete explantation of this graft and revascularization of his lower extremities which is best done with his deep veins. I explained that potential risks of the vein harvest which includes extensive leg swelling, compartment syndrome with possible loss of the limb. I explained to him that we would be harvesting these 2 veins on the first day and will be coming the next day where we will use this vein to reconstruct his aorta. I have explained both the patient and the family that this procedure is associated with high-risk of limb loss, bowel ischemia, spinal ischemia and potential extensive blood loss during surgery. The patient verbalized understanding and decided to proceed. On today's procedure, we intend to mobilize both femoral and popliteal veins and conclude our portion, to come another day to take these veins out and reconstruct the aorta. DESCRIPTION OF PROCEDURE: The patient was taken back to the operating room and placed in supine position. General anesthesia was induced. Invasive lines and monitors were placed. The lower abdomen including both legs were circumferentially prepped and draped. We began the procedure by making an incision on the right thigh. We made an incision lateral to the sartorius muscle. It was carried down using Bovie. Underlying fascia was sharply divided with Bovie electrocautery. The sartorius muscle was retracted medially. We were able to identify superficial femoral vein which had a palpable pulse. The femoral vein was underneath the artery. We retracted the artery medially and exposed the femoral vein. We continued to dissect off the femoral vein circumferentially and continued distally. The branches that came out of the vein were doubly ligated with a 3-0 silk stitch and divided in-between the ligators. We continued to mobilize the femoral vein from the midthigh down toward the popliteal fossa. All the branches were meticulously tied. We divided Hunter's canal and the adductor hiatus again entering into the popliteal fossa. All the branches of the popliteal vein were doubly ligated and divided in-between the ligator in this fashion from midthigh all the way to behind the popliteal space. We completely circumferentially mobilized the femoral vein. We continued to mobilize further proximally until we encountered the takeoff of the profunda vein. Once the entire portion of the vein was mobilized, we placed moist sponge and turned our attention towards the left side. Similarly, on the left side, a longitudinal incision was made on the thigh on the lateral side of the sartorius muscle. The fascia was sharply divided with the Bovie electrocautery. The sartorius was retracted laterally. The superficial femoral artery here did not have a palpable pulse. We dissected off the artery medially and were able to visualize the femoral vein on the midthigh area. We continued to mobilize the femoral vein down to the level of the popliteal vein. All the branches were doubly ligated with the 3-0 ligators and divided between the ligator. We then mobilized the popliteal vein after dividing the adductor hiatus. The popliteal vein branches were also doubly ligated and divided between the ligators. In this way, we freed the popliteal vein circumferentially. Following this, we turned our attention to the proximal femoral vein. We continued dissection up until the level of the profunda vein. All the branches were ligated and the vein was completely mobilized right after the takeoff of the profunda vein proximally all the way to the popliteal fossa distally. At this point, hemostasis was secured with the Bovie and a topical hemostatic agent. We decided to conclude our procedure at this point. We deliberately did not remove these veins as we planned to do this the next day. At this point, on the right side, we brought the fasciocutaneous flap together with some interrupted 2-0 Vicryl stitches. The skin was closed with staples. This procedure was repeated on the left side in this fashion. We closed the skin on both sides. Sterile dressings were applied. We decided to leave the patient intubated as he is coming back for surgery tomorrow. The patient was subsequently transferred to ICU under stable condition. No complications were encountered. I was present and scrubbed throughout the procedure. DATE OF OPERATION(S)/PROCEDURE(S): 12/13/2018 PROCEDURE PERFORMED: 1. Excision of infected aortobifemoral bypass graft. 2. Reconstruction of the aorta utilizing deep vein in the aortobifemoral bypass fashion. 3. Retroperitoneal debridement of the infected tissue. PREOPERATIVE DIAGNOSIS: Infected aortobifemoral bypass graft. POSTOPERATIVE DIAGNOSIS: Infected aortobifemoral bypass graft. INDICATION FOR PROCEDURE: The patient has an infected aortobifemoral bypass graft. Decision has been made to excise the graft and reconstruct the aorta with femoropopliteal vein. The vein had been harvested a day prior and left behind in situ. The patient is being brought back for explant of the graft and reconstruction of the aorta with recently mobilized and harvest deep vein graft. PROCEDURE: The patient was taken back to the operating room, placed in the supine position. General anesthesia was induced. Abdomen, pelvis, and both lower extremities were circumferentially prepped and draped. We began the procedure by opening the thigh incision, which was carried out on both sides for femoropopliteal vein harvest. First, we turned our attention to the left side. We carried out dissection further proximally on the thigh in order to expose the common femoral artery at the site of the anastomosis. At this point, we circumferentially dissected around the common femoral artery, and profunda and superficial femoral arteries as well. Of note, there were dense adhesions from prior surgery, which we meticulously took down. There was no evidence of infection at the limb of the graft in that area. It appeared that the graft had very well incorporated. After exposing the femoral artery there, we turned our attention to the right groin area. Again, we carried out dissection in the right femoral area to expose the right common femoral, superficial femoral artery, and profunda femoris artery. We took down the adhesions there. Again, the aortobifemoral graft there was very well incorporated. We were able to circumferentially dissect that common femoral, superficial femoral, profunda, including the graft, individually. At this point, second team carried out laparotomy. Dr. Dwivedi performed this portion of the surgery while other team continued to work on the femoropopliteal area. The incision was extended from epigastric to suprapubic area. It was carried down using a Bovie. The fascia was sharply opened by utilizing Metzenbaum and Bovie electrocautery. Of note, there were extensive adhesions from prior surgery. All the adhesions were meticulously taken down. The small bowel was completely retracted toward the right side. In this way, we were able to expose the portion of the aorta. We then carried out dissection of the retroperitoneal structures. Of note, there was a big aneurysmal pulsatile mass that we could see on the lower portion of the aorta. We carried out dissection more proximally toward the aortic neck at the uninvolved portion of the aorta. The duodenum was completely mobilized and retracted toward the right side. We then placed Omni-Tract retractors. We carried out dissection around the aorta, where there was no evidence of any infection. We were able to identify the left renal vein, which was retracted superiorly. It appeared that in order to get to the healthy aorta we had to take down the renal vein. The renal vein was doubly ligated and divided. In this way, we exposed the aortic neck. We carried out circumferential dissection of the aorta right below the renal arteries. An umbilical tape was passed around it. In this way, we got complete proximal control of the aorta. At this point, we continued dissection distally to get complete control of segment of the infrarenal aorta. After we did that, the aorta was clamped at the infrarenal position and sharply divided. The distal end of the aorta was ligated doubly with a 5-0 Prolene stitch. Prior to division of the aorta, we had harvested right as well as left femoropopliteal veins and backbench preparation had been carried out. At this point, the femoral vein was reversed. The end was spatulated. We then carried out anastomosis with the femoropopliteal vein and the stump of the aorta, after debriding all the unhealthy portion of the aorta. Utilizing 3-0 Prolene stitch, we carried out proximal anastomosis between the aorta and the femoropopliteal vein. Anastomosis was completed. Clamps were released. Any bleeding sites were reinforced with interrupted 3-0 Prolene stitch. At this point, the distal end of the graft had good flow upon releasing the clamp on the aorta and anastomosis appeared to be hemostatic. The distal end of the vein graft was clamped. We then carried out further dissection in the retroperitoneal area. We were able to continue dissecting distally until the site where the aortobifemoral graft took off. That is where we found some infection, though there was no gross purulence, but there was a large amount of devitalized tissues. We continued to dissect distally down to the limb of the aortobifemoral graft until where we found it very well incorporated in the pelvis. Both the right and left limbs were sharply divided and ligated at that point. We then dissected the mid body and limb of old aortobifemoral infected graft and completely removed it. We then exposed the native aorta. The native aorta had a thick rind of inflamed and infected tissue around there. We continued dissection to both common iliac arteries. We clamped the common iliac arteries and divided on both sides. A stump of the common iliac artery was ligated utilizing a 5-0 Prolene stitch. Again, the portions of the aorta along with the iliac which were involved with the infection were sharply excised and debrided. The retroperitoneum was then thoroughly lavaged. At this point, a tunnel was created from the inguinal area up into the retroperitoneum on the left side. The vein graft was then tunneled through that. On the left groin, the common femoral, profunda, and superficial femoral arteries were clamped. Arteriotomy was made approximately 1 cm long. The vein graft was spatulated. We then carried out arterial anastomosis utilizing 5-0 Prolene stitch. Clamps were released. There was excellent blood flow on that groin. Following this, we tunneled another femoropopliteal vein through the right groin through the retroperitoneum. At this point, the recently anastomosed left-sided vein graft was clamped at 2 places, a lateral venotomy was made approximately 12 mm long. We then carried out anastomosis between the right limb of the graft and the left limb of the graft utilizing a running 5-0 Prolene stitch. Anastomosis was completed. Clamps were released. There was good flow. On the right groin, the distal end of the vein was spatulated. We clamped common femoral, superficial femoral, and profunda femoris arteries. On the proximal superficial femoral artery, we made about a 10 mm long arteriotomy. The right femoral anastomosis was then carried out again with a running 5-0 Prolene stitch. Anastomosis was flushed, clamps were released, and pulsatile flow was reestablished on that area as well. In this way, we carried out the reconstruction of the aorta with the deep vein in the aortobifemoral fashion. Following this, we turned our attention to the abdomen. Thorough lavage of the abdominal cavity was carried out. Further debridement of the retroperitoneal infected tissues was carried out. Once we were satisfied, we made sure that the proximal anastomosis was hemostatic. We placed some hemostatic agents to get reasonable hemostasis. At this point, both the groins were also washed out and we carried out hemostasis. Following this we closed both femoral areas with interrupted 2-0 Vicryl stitch, followed by a 3-0 subdermal Vicryl stitch. The thigh incision was closed with running 3-0 subdermal Vicryl stitch. The skin in the thigh and groin was closed with staples. In the abdomen, we were not able to close the abdomen after returning the bowel into the abdominal cavity. We decided to temporarily close with the custom VAC. All the bowel was returned to the abdominal cavity and we placed wet towels and 32-French chest tubes, and Ioban was placed on top of that to create a custom VAC. At this point, concluded our portion of the surgery. The patient had dopplerable signals on both feet. Of note, 19-French Blake drains were placed on both thigh incisions. The patient was then transferred to ICU in intubated condition. The patient remained stable throughout the procedure. No immediate complications were encountered. I was present and scrubbed throughout the procedure.
Arabelis Posted Wed 09th of January, 2019 19:06:25 PM
What code can I use when the Doctor performed only Open harvest of right femoral vein and above-knee (35572) without addition primary procedure???
SuperCoder Answered Thu 10th of January, 2019 03:11:22 AM

Hi Arabelis,

 

AAE does not provide coding for operative reports and chart notes.

 

SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information.

 

Regards!

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