Ask Dr. Z

Hi Dr. Z! We have a question regarding online Q&A 1768 from 2008. Our office recently went through an external audit and our auditor marked one of our charges incorrect for not billing the additional endarterectomy of the iliac/femoral along with the bypass. In the procedures performed the provider listed them as 1. Right iliac and right femoral endarterectomy with patch angioplasty and 2. Right above-knee femoral to popliteal bypass with 6 mm Gore-Tex graft. As we know some coding rules change, we are wondering if something has been updated from the date this Q&A was published or if you have any other advice. I know it’s long, but I have pasted the report data below. We coded only 35656. What is your opinion about the use of 35355 as well? Thanks, TN Subscriber 9.1.10 DESCRIPTION OF PROCEDURE: A right groin incision was made. The dissection was carried out through the subcutaneous tissue down below the femoral sheath. The femoral sheath was then opened. There was a modest amount of scarring around the area of the previous puncture site where the closure device had been inserted. The common femoral artery was then dissected free along the entire length for clamping. Next, dissection was then carried up underneath the inguinal ligament as adequate retraction was obtained with a Martin Arm. The distal external iliac artery was then dissected free with the crossing vein across the external iliac artery was ligated and divided with multiple hemoclips. Next, once I had obtained adequate exposure for iliofemoral endarterectomy a skin incision was then made on the above—knee medial aspect of the leg. Next, dissection was carried down through the subcutaneous tissue down to the level of the sheath. The sheath was then opened. The popliteal space was then entered. Dissection was then carried down to the level of the popliteal artery, it was then dissected free circumferentially. Potts tie, silk ties were placed around multiple side branches of the vessel. The vessel was small in caliber, probably 4 mm. Next, a 6 mm ringed Gore-Tex graft was then obtained and tunneled subsartorially between the 2 incisions. Next, the patient was then heparinized and following an appropriate time the external iliac artery was then clamped with a Satinsky clamp. Then, the common femoral artery was then clamped with a profunda clamp distally. Next, an arteriotomy was made and extended with the Potts scissors. Next, the endarterectomy was then performed with the common femoral artery and external iliac artery. Next, the remaining debris was then removed and the distal plaque within the common femoral artery was tacked down with 6-0 Prolene sutures. Next, a Vascu-Guard patch was obtained and soaked appropriately and then subsequently used and sewn in place with a running 5-0 Prolene stitch. Prior to completion of the patch angioplasty the lumen was flushed and heparinized with saline solution. The artery was allowed to back-bleed proximally and distally by virtue of removing the clamps. Next, the anastomosis then completed. Three interrupted repair stitches were used to control some suture line bleeding. Next, the vessel was once again clamped proximally and distally. A patchotomy was made standard with the Potts scissors. Next, the graft was then cut to fit and sewn to the patch repair in an end—to-side fashion with a running 5-0 Prolene stitch. Following completion of anastomosis the proximal and distal clamps were removed. A distal graft clamp was placed. Next, there were no repair sutures needed. Next, a graft clamp was then placed proximally. Next, the popliteal artery was then clamped proximally and distally. An arteriotomy was made and extended with Potts scissors. Next, the graft was then cut to fit and sewn in place in an end-to-side fashion to the popliteal artery with a running 6-0 Prolene stitch. Just prior to completion of the anastomosis, the lumen was flushed with heparinized saline solution. The artery was allowed to back-bleed proximally and distally as well as the graft by briefly removing the clamps. Next, the lumen was once again, flushed with heparinized with a saline solution. Next, the anastomosis was then completed. Next, the proximal and distal clamps are removed. The graft clamp was then removed. There was a palpable pulse in the foot upon completion of the anastomosis. Next, protamine was given. Adequate hemostasis was obtained with Surgicel and thrombin spray. Next, all wounds were then irrigated and closed with 2 running 3-0 sutures in the above-knee popliteal incision and in 4 layers in the groin with Vicryl sutures. Skin clips were used in the skin. Sterile dressings were applied. The patient was awakened, extubated, returned to the recovery area in satisfactory condition. All instrument, needle and sponge counts were reported as correct on 3 occasions.