Coding Cardiovascular System Procedures, Part 1


Vol. 15 •Issue 16 • Page 10
Coding Corner

Coding Cardiovascular System Procedures, Part 1

(Editor’s note: A second case study on coding cardiovascular system procedures will be published in the Aug. 29 issue.)

Case Study 1

Preoperative Diagnosis: Thrombosis of right forearm in the loop Gore-Tex hemo-dialysis fistula with no mechanical problem identified.

Postoperative Diagnosis: Thrombosis of right forearm in the loop Gore-Tex hemo-dialysis fistula with no mechanical problem identified.

Procedure Performed: Thrombectomy of right forearm graft.

Anesthesia: Right axillary block.

Extremities: Symmetrical without edema. In the right forearm, there is a looped Gore-Tex subcutaneous graft 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. This is the outer most of the three fistulas, and it is the only one of these currently functioning. The other two are 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 and sheets. 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 5,000 units of Heparin intravenous. 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. 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. The patient was given 30 mg Protamine to reverse the 5,000 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.

Code Assignments and Rationale

Preoperative ICD-9-CM Diagnosis: Thrombosis of right forearm in the loop Gore-Tex hemodialysis fistula with no mechanical problem identified.

Postoperative ICD-9-CM Diagnosis: Thrombosis of right forearm in the loop Gore-Tex hemodialysis fistula with no mechanical problem identified.

ICD-9-CM Diagnosis Codes:

Preoperative:

996.73 Other complication due to renal dialysis device, implant and graft

Postoperative:

996.73 Other complication due to renal dialysis device, implant and graft

CPT Codes

The surgeon states that an incision was made in both limbs of the graft and that the clot was removed using Fogarty catheters until brisk flow was returned in both ends of the graft. The hemodialysis fistula is the graft that was created in order for the patient to receive dialysis. The incisions were then closed.

Refer to the 2005 CPT manual index and look up the term Thrombectomy under which you will see the term Dialysis Graft. Indented under this is the phrase without Revision and the following code.

36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or non-autogenous dialysis graft

This code should be assigned for both the facility and professional components.

Peggy Hapner is the manager of the health information management consulting division at Medical Learning Inc. (MedLearn®), St. Paul, MN.