Vol. 16 •Issue 22 • Page 10
Coding Corner
Coding Cardiovascular Procedures
Case Study 1
Preoperative and Postoperative Diagnoses: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy; for chemotherapy.
Procedure Performed: Insertion of subcutaneous Hickman port.
Operative Technique: The 76-year-old patient was taken to the operating room. In supine position, the patient’s whole right anterior chest, including the supraclavicular area and a portion of the neck, were prepped with Betadine solution and then draped in the usual sterile manner. Lidocaine 1% 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. 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 3 inches below the wire’s entry site, the skin was infiltrated with 1% 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 heparin-coated 7 mm internal diameter Hickman catheter was then passed through the catheter assembly into the superior vena cava. The catheter assembly was peeled off the skin, leaving the Hickman catheter, which 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 and Postoperative ICD-9-CM Diagnoses: Ovarian cancer, status post hysterectomy and bilateral salpingo-oophorectomy; for chemotherapy.
183.0 Malignant neoplasm of ovary
CPT Code Assignments, Rationale
In this procedure the physician made an incision over the subclavian vein, the guidewire was inserted and an incision was made over and down through the subcutaneous tissues. A pocket was then created, and the catheter was pulled down and into the pocket.
To assign a code to this procedure, check the CPT manual index under the term Device followed by Venous Access. Under Venous Access, look for the term Insertion. Two indented entries are shown: central and peripheral. In the report you will see that the catheter was placed through the subclavian vein and came to rest in the vena cave. This documentation is key in identifying that this is a central venous catheter.
You will need to read the descriptions for each code in the 36560Ð36566 range. The description for code 36561 describes the procedure performed and should be assigned for both the facility and professional components.
36561 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older
Case Study 2
Preoperative and Postoperative Diagnoses: Implanted permanent pacemaker with pacemaker site erosion.
Procedure Performed: Revision of pacemaker site with re-implantation of the pulse generator into the pectoralis muscle.
Operative Technique: This patient was brought to the cardiac catheterization lab in the fasting state. She was sterilely prepped and draped for a left infraclavicular approach. Lidocaine anesthesia was administered.
A skin incision was performed. Using meticulous dissection, multiple indwelling leads were dissected away, and the pulse generator was extracted. The pulse generator was an Intermedic Nova, model 282-04, serial #35332, bipolar ventricular pacer. Deep dissection was performed, and the pulse generator was placed in a pocket in the pectoralis muscle below the current pocket. The lead and pacemaker were carefully sutured down. Interrupted 3-0 Dexon was utilized to close the area to achieve maximum tissue coverage of the multiple leads. There were no complications. The patient was returned to her room in good condition.
ICD-9-CM Code Assignments
Preoperative and Postoperative ICD-9-CM Diagnoses: Implanted permanent pacemaker with pacemaker site erosion.
996.72 Other complication due to other cardiac device, implant and graft
CPT Code Assignments, Rationale
Documentation indicates that there is erosion at the pacemaker site. This procedure is performed to revise the pacemaker site; if the current pocket cannot be reused, a new pocket is formed. Documentation states that an incision was made, and the generator removed. A new pocket was created below the current pocket, and the leads and the pacemaker were inserted into this pocket and sutured in place.
In the CPT index, refer to the term Pacemaker, Heart followed by Revise Pocket then Chest É 33222. After reading the description you will see this is the correct code. It may be assigned for both the facility and professional components.
33222 Revision or relocation of skin pocket for pacemaker
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.
