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Coding an Open Thrombectomy

Vol. 18 •Issue 18 • Page 9
Coding Corner

Coding an Open Thrombectomy

The patient had thrombus in the loop Gore-Tex fistula in the right forearm.

Pre- and 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 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 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 back-bleeding 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. Venous and arterial phase fistulograms were done using total of 40 cc of hypaque solution. The arteriograms were read as above. The butterfly was removed and the patient was given 30 mg Protamine to reverse the 5,000 units of Heparin given prior to 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 DIAGNOSES

Pre- and 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

ICD-9-CM PROCEDURE CODES

39.49 Revision of vascular procedure

CPT CODING

Under the heading Operative Technique, 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 incisions were then closed. (The following sentence includes this information: "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 back-bleeding noted. The graftotomy")

As stated under 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." The procedure performed is a Thrombectomy, which is listed in the CPT manual index. A review of the entries under this term reveals that your choice will be Dialysis Graft without Revision 36831.

Facility and Professional Coding:

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

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




     

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