Vol. 13 •Issue 8 • Page 9
Coding Corner
Cardiovascular System Coding Exercise
Case Study One
Preoperative Diagnosis: Thrombosis of right forearm loop Gore-Tex hemodialysis fistula with no mechanical problem identified.
Postoperative Diagnosis: Thrombosis of right forearm loop Gore-Tex hemodialysis fistula with no mechanical problem identified.
Procedure Performed: Thrombectomy of right forearm graft
Anesthesia: Right axillary block.
Extremities: Symmetrical without edema. In the right upper extremity, there is a looped Gore-Tex subcutaneous graft in the right forearm with no palpable pulse, thrill or audible bruit. There is no evidence of erythema, edema or tenderness in the arm.
Operative Findings: The patient had thrombus in the loop Gore-Tex fistula in the right forearm. The fistula is actually the third such loop fistula placed in the concentric fashion with this being the outermost of the three fistulas and the only one currently functioning with the other two being disconnected. The patient had calcification in the distal 4-5 cm of the venous limb of the graft; however, there was no narrowing greater than 50 percent noted on the fistulogram. The fistulogram showed adequate arterial end flow with good arterial vessels coming from the brachial artery and through its bifurcation into the forearm. There was a widely patent graft and good venous outflow into the cephalic vein in the arm. There was no evidence of stenosis in the vein in the antecubital fossa with the median cubital vein remaining widely patent as it has always been with no evidence of venous outflow stenosis in the vein.
Operative Technique: After induction of a right axillary block without complications, the right upper extremity was prepped with duraprep solution and draped using sterile towels.
A 4 cm transverse incision was made with an existing transverse scar in the antecubital fossa. The underlying arterial and venous limbs of the graft were dissected free from surrounding structures, and the patient was given 5000 units of Heparin IV. A graftotomy was made transversely in the distal venous limb of the graft and in the first centimeter of the arterial end of the graft and thrombectomy accomplished with 3 and 4 Fogarty catheters with brisk arterial end flow and good venous backbleeding noted. The graftotomy sites were closed using 5-0 Prolene running suture and a 19 gauge butterfly placed in the venous end of the graft and venous and arterial phase fistulograms done using total of 40 cc’s of hypaque solution. The arteriograms were read as above. The butterfly was removed and the patient was given 30 mg Protamine to reverse the 5000 units of Heparin given prior to his thrombectomy. The subcutaneous tissue was approximated using 3-0 Vicryl running suture and the skin edges approximated using 4-0 Prolene running simple skin sutures.
Sponge, needle and instrument counts were reportedly correct. The patient was taken to the recovery room in satisfactory condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Thrombosis of right forearm loop Gore-Tex hemodialysis fistula with no mechanical problem identified.
996.73 Other complication due to renal dialysis device, implant and graft
Postoperative Diagnosis: Thrombosis of right forearm loop Gore-Tex hemodialysis fistula with no mechanical problem identified.
996.73 Other complication due to renal dialysis device, implant and graft
CPT Code Assignments
An incision was made in both limbs of the graft and the clot was removed using Fogarty catheters until brisk flow was returned in both ends of the graft. The incisions were then closed.
Refer to the term Thrombectomy in the index followed by Dialysis Graft and without Revision. Code 36831 is listed, and this is the correct code to assign for both the facility and professional components.
Facility Code Assignment
36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or non-autogenous dialysis graft (this is a separate procedure)
Professional Code Assignment
36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or non-autogenous dialysis graft (separate procedure)
Case Study Two
Preoperative Diagnosis: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy; for chemotherapy.
Postoperative Diagnosis: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy.
Procedure Performed: Insertion of subcutaneous Hickman port.
Operative Technique: The patient was taken to the operating room where, in supine position, the whole right anterior chest was prepped with Betadine solution including the supraclavicular area and a portion of the neck and then draped in the usual sterile manner. Lidocaine 1 percent solution was infiltrated into the skin just below the mid-portion of the right clavicle. The right subclavian was identified with a large bore long needle and syringe. The patient was in the Trendelenberg position.
A J-tipped guide wire was introduced into the subclavian vein, and under fluoroscopy, the guide wire was noted to be going to the superior vena cava into the atrium. A small incision was made at the site of entry of the needle. About three inches below this site of entry of the wire, the skin was infiltrated with 1 percent Lidocaine solution transversely, approximately 2.5 inches long. An incision was made over this and down through the subcutaneous tissue. A subcutaneous pocket was made using sharp and blunt dissection below appropriate position. Hemostasis was obtained with electrocautery. The vein dilator and catheter assembly were introduced into the guide wire and into the subclavian vein.
The dilator was removed and a heparinized 7 mm internal diameter Hickman catheter was then passed through the catheter assembly into the superior vena cava. The catheter assembly was peeled away off the skin, leaving the Hickman catheter. The Hickman catheter was then pulled subcutaneously downward using a tonsil clamp into the subcutaneous pocket. The sleeve guard was placed, and the end of the catheter was connected to the port. The sleeve guard was then slid down into the connection. Under fluoroscopy, the catheter was found to be in good position without any kinking.
The port was then further anchored to the superficial fascia and subcutaneous tissue using 3-0 Vicryl sutures. The subcutaneous tissue and incision were approximated using 3-0 Vicryl sutures and the skin was approximated with 4-0 Nylon vertical mattress sutures. Op-site dressings were applied.
The patient tolerated the procedure quite well and left the operating room in stable condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy.
183.0 Malignant neoplasm of ovary
Postoperative Diagnosis: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy
183.0 Malignant neoplasm of ovary
CPT Code Assignments
The patient is being treated for ovarian cancer and the surgeon is inserting a Hickman port. Refer to the term Device in the index followed by Venous Access and Insertion. This will lead you to the correct code of 36533, and it should be used for both the facility and professional components.
Facility Code Assignment
36533 Insertion of implantable venous access device, with or without subcutaneous reservoir
Professional Code Assignment
36533 Insertion of implantable venous access device, with or without subcutaneous reservoir n
Peggy Hapner is health information management consulting division manager at Medical Learning Inc. (MedLearn®), St. Paul, MN.
