Ask Dr. Z

Good afternoon, Dr. Z and Dr. Dunn. I have a lot of questions about the following op report. I'm debating whether to represent the angioplasty with 35456,LT or 35459,LT, along with 75962,26,LT. I'm leaning towards 35456,LT, because the doctor says it was done in the mid thigh, but 35456,LT is considered bundled with 35566,LT, according to NCCI edits, while 35459,LT isn't. It also seems as if 36140,LT is considered bundled with 35566,LT, but would that be added with a 59 modifier if an angioplasty of the graft is done? On the other hand, does the statement, "Primary vascular procedure listings include establishing, both inflow and outflow, by whatever procedures necessary.", pertain to this situation? How about the repairs due to extravasation, during the angioplasty of the graft? Could 35226,LT be used as an additional code? If so, how many units? I decided against using 35682,LT, because the doctor basically did a resection and anastomosis of the same vein, as opposed to merging two veins from different locations. Was that the correct decision? Is there another code you'd use to describe this procedure? If not, does this warrant billing with modifier 22? The doctor also mentions several angiograms. How many units of 75710,26,LT can I use? On top of that, the doctor mentions that a Doppler was brought onto the field. Does this statement warrant the use of 93922,26,LT? I know the narrative says "noninvasive", so is there another code you'd use, like 37250,LT and/or 75945,26,LT, or is it just included in 35566,LT? I don't see any NCCI edits saying either of those codes are included in the bypass. As you can see, I'm extremely confused. Your assistance would be greatly appreciated. Your answers to this might help point me in the right direction with a lot of future op reports. Thanks, in advance. Here's the op report: DATE OF OPERATION: 03/29/2010 ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. POSTOPERATIVE DIAGNOSIS: Atherosclerosis with rest pain and motor dysfunction, left foot. PROCEDURES: 1. Left lower extremity angiograms. 2. Left superficial femoral artery to anterior tibial artery bypass with composite great saphenous vein graft. 3. Angioplasty of vein graft. 4. Completion angiograms. INDICATION: This is an 88-year-old female who presented with rest pain and ischemia to the left foot with some mild motor dysfunction of her toes. The patient did undergo a cardiac evaluation. She was brought to the operating room for elective femoro-anterior tibial bypass after having undergone aortoiliofemoral and left lower extremity angiograms earlier in the week. The patient had this performed with composite nonreversed great saphenous vein graft from the left leg. Completion angiogram demonstrated areas of stenosis in the vein graft and angioplasty was performed. This was complicated by a linear tear with some extravasation in the mid thigh, which was directly repaired with interrupted stitches of 6-0 Prolene. There also did appear that the vein graft requiring a repair was an interrupted stitch of 6-0 Prolene. Completion angiograms demonstrated very good result with good caliber of the vein graft and run-off onto the dorsalis pedis artery in the foot. PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position on the operating room table. After administration of general anesthesia by the anesthesia department, the patientâ?Ts lower abdomen, groin, entire left lower extremity, and right thigh were prepped and draped in the usual surgical sterile fashion. Attention was turned to the left lower extremity and in the distal third of the leg, a lateral skin incision was made approximately 8 cm in length. This was carried down through the skin, subcutaneous tissue, and fascia. The anterior tibialis muscle was retracted medially and the extensor digitorum longus retracted laterally. Dissection was carried down and the neurovascular bundle was identified as well as the anterior tibial nerve. The anterior tibial artery was dissected out. The Doppler was brought onto the field. The proximal portion was without evidence of flow and dissection was carried more distally to where collateral flow was heard in the artery. For this reason the incision was extended more distally. The artery was harder and calcified more proximally where it was occluded. The artery was softer more distally. A portion of the artery was dissected out where the vessel was soft and suitable caliber being 2 to 2.5 mm in diameter. Attention was turned to the left groin. Incision was carried down through the skin with the scalpel. Dissection was then carried down through the subcutaneous tissue and fascia and femoral sheath. The common femoral artery, profunda femoris, and superficial femoral arteries were identified and dissected out, and vessel loops placed. The great saphenous vein was identified. A bridge incision was made in the thigh and the dissection carried down through the subcutaneous tissue and the saphenous vein exposed. Continuous incision was then made along the medial leg and the saphenous vein was exposed along its length. Below the knee at about the proximal to mid calf, the saphenous vein became of smaller caliber dividing into two tributaries. The larger branch was followed. The vein was smaller and more disadvantaged at this site and in the distal leg, the vein then became larger again and was with good caliber to the medial malleolus. This was dissected out. As there was the disadvantage portion of vein measuring less than 2.5 mm, the plan was to do a venovenostomy to use the portion of the vein greater than 2.5 mm. For this reason, the dissection was carried farther down the superficial femoral artery proximally where it was still with good caliber with minimal disease based on the angiogram through the proximal thigh incision. Dissection was carried down through the subcutaneous tissue and fascia, and several centimeters, approximately 8 cm distalfrom the bifurcation, the superficial femoral artery was dissected out and vessel loops placed. Following this, a subcutaneous tunnel was made traversing to the lateral thigh with a gentle curve and then along the lateral aspect of the leg in a subcutaneous position and down to the distal wound. The saphenous vein was controlled at the saphenofemoral junction. The saphenous vein had been dissected out along its length, ligating and dividing the tributaries between 3-0 and 4-0 silk ties and clips on the tissue side. The dissection was routine, but on distending the vein through a tributary, which controlled the vein proximally, the vein did require repair of multiple small areas with 7-0 Prolene. The vein was clamped at the saphenofemoral junction taking a cuff of the femoral vein excising the saphenous vein and oversewing the femoral vein with 6-0 Prolene. Attention was then turned to performing the proximal anastomosis. The first vein valves were cut under direct vision. with LeMaitre valvulotome with two passes. The blood flow was pulsatile through the vein. The mid-distal third was smaller, disadvantaged as noted. Proximal anastomosis was performed by controlling the superficial femoral artery. About 5000 units of intravenous heparin was given under my direction. An additional dose was given as needed. Vertical arteriotomy was made in the superficial femoral artery and extended with the Potts scissors. The vein was used in nonreversed fashion, spatulated, and anastomosed, end-to-side using a running stitch of 6-0 Prolene. Prior to completing the anastomosis, the femoral artery was back bled and antegrade flushed. There was a good inflow. The anastomosis was then completed. It was then that the valves were cut with a valvulotome. The first two valves had been cut under direct vision. The remainder of the valves was then cut using LeMaitre valvulotome with two passes. Blood flow was pulsatile through the vein, although the smaller disadvantage segment of the vein was as noted in the mi-distal portion of the vein. The vein was then passed through the subcutaneous tunnel and brought out to the anterior tibial wound. The anterior artery was then controlled where the artery appeared of good caliber and was soft. This was opened with the #11-blade and extended with the Potts scissors. There was reasonable backbleeding in the artery as well as some antegrade flow via collaterals. Angiogram was performed, which demonstrated that this was a good site for the anastomosis with flow into the dorsalis pedis artery with the artery being of good caliber without significant stenosis. The vein length was then measured. The vein graft was then cut to remove out portion of the disadvantaged segment of vein. Venovenostomy was then performed over #8 pediatric feeding tube. When this was complete, the end of the vein was then spatulated and anastomosed end-to-side to the anterior tibial artery using a running stitch of 7-0 Prolene. Prior to completing the anastomosis of the vein graft, the artery was back bled and flushed. The artery was flushed with heparinized saline solution. The vein graft was flushed, and the air was released. The anastomosis was then completed. Flow was allowed to propagate down the foot. There was a palpable pulse in the dorsalis pedis artery in the foot and an excellent Doppler signal distal to anastomosis. The vein graft was pulsatile but still did not appear to distend fully, being on the smaller side despite excising the smaller portion. Completion angiogram was performed through a side branch just distal to the proximal anastomosis. This did demonstrate a couple areas of severe narrowing, the first being in the anterior thigh. The area was marked with a glow tape. A #5 French sheath was placed through the side branch, and a glidewire followed by angioplasty balloon was passed through the mid thigh and angioplasty was performed. On the post-completion angiogram, unfortunately there was some evidence of extravasation and cutdown was done in the mid thigh and a linear tear in the vein was directly repaired. It was also noted along the distal lateral incision and again evidence of a frail vein that the guidewire had transversed thru the vein wall. The wire was pulled back and this was repaired with a 3-0 interrupted stitch of Prolene. The wire was negotiated down the vein, and completion angiograms demonstrated also two other areas of narrowing, and the angioplasty balloon was applied lightly in these areas with excellent result on completion angiogram. Due to the presence of the sheath and the angioplasty balloon, intermittently the vein graft was flushed with heparinized saline solution. Intra-arterial papaverine had also been given due to some spasm of the artery distal to the anastomosis after controlling the vessel. The artery here is soft. Completion angiograms demonstrate excellent result of the vein graft and the distal anastomosis to be patent with the anterior tibial artery patent into the dorsalis pedis artery on the foot. The guidewire, the balloon, and the sheath were then removed from the vein and the branch stump was ligated with 3-0 silk. Flow was allowed to propagate down the vein graft into the foot. The patient did have a strong dorsalis pedis pulse as well as a palpable vein graft pulse along the lateral leg. Hemostasis at the anastomoses was obtained with thrombin and Gelfoam. Hemostasis of the subcutaneous tissue was obtained with diathermy. Attention was turned to closing the wounds when hemostasis was satisfactory. The groin wound was closed in two layers using 2-0 and 3-0 Vicryl. The skin was reapproximated with skin clips. Similarly over the SFA and proximal anastomosis, subcutaneous tissue was closed in two layers. The remainder of the saphenectomy site along the medial leg was reapproximated in one or two layers with Vicryl and the skin was reapproximated with skin clips. The lateral leg wound was closed using subdermal stitches proximally. Due to the thin subcutaneous tissue and some leg swelling, the distal portion of the incision was reapproximated using interrupted stitches of 3-0 nylon. The incisions were cleansed and sterile dressings were applied. The patient tolerated the procedure and was taken to the recovery room in stable condition.