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Patient had an open thrombectomy performed earlier that day and was brought back for hemorrhaging. Would the AVF wound exploration be reported with code 35860-78?

ACCESS:

Side: Left

Site: Upper

Type: Radial Cephalic Fistula

Anatomy: Tortuous and Ectatic AV fistula wound exploration.

Patient was laid in the supine position and placed under general anesthesia. Left arm was extended prepped and draped sterile on armboard.

Staples removed from open thrombectomy incision. No surgical bleeding noted from venous suture line. Pt found to be coagulopathic. TXA given by anesthesia. Bovie electric coagulation and was used to provide hemostasis.

Lateral soft tissue flaps were created to allow tension-free closure which was achieved in 2 layers with stratafix suture. Skin was reinforced with skin clips.