Hello all! I have seen some great advice given on the forums and wanted to throw this challenge out there. The coders at our facility are all scratching their heads at the best way to approach this one. We are an acute care hospital and this patient was seen as an outpatient surgery case. There are several op notes, so I’m just going to summarize to avoid a several page long query. Any help would be greatly appreciated and thanks in advance!
Diagnosis: Non- small cell lung cancer needing vascular access due to peripheral venous insufficiency for startup of chemotherapy
First surgery
1. Left subclavian single lumen PowerPort placement
Surgeon accessed left subclavian with guidewire, followed by peel-away sheath and internal dilator along appropriate course. Guidewire and dilator were removed and substantial bleeding occurred which prompted surgeon to perform an ABG for possible arterial access instead of venous. ABG came back with elevated pO2 so a co-surgeon was brought in for consult which both evaluated flouro images and decided to proceed as a venous cannulization. Case was finished with insertion of tunneled central venous catheter to superior vena cava. Pocket was created on the chest and port was inserted. Catheter was mated to the port and closure of sites occurred. Patient was taken to PACU for postoperative imaging to determine if arterial cannulization had occurred.
Second surgery
1. Removal of left-sided arterial port.
2. Repair of subclavian artery
3. Right internal jugular vein single lumen PowerPort placement
Patient brought back to OR after subclavian artery identified as the cannulization point. Surgeon cut-down to level of pectoralis muscle, divided muscle and identified catheter access into subclavian artery. Vascular co-surgeon placed a pursestring suture in the subclavian artery and the catheter was slowly withdrawn. Pursestring suture was pulled tight after catheter was removed and hemostasis was maintained. Muscle and fascia were reapproximated. Original port and remaining catheter were also removed and sites were closed. Surgeon moved to right side of body, accessed the internal jugular vein and performed catheter insertion down into the vena cava. Pocket was created on right side of chest and port was placed. Catheter was tunneled and mated to port. Incision sites were closed.
So I am trying to figure out diagnoses and CPT for this one. Since the patient left the OR and was in recovery after the original surgery, we would assign a complication code for the arterial access right? Would it be considered an intraoperative complication since it happened during the procedure instead of a postoperative? Would a misadventure code need to be assigned since the surgeon messed up? Below is what we have.
Diagnoses
C34.91, I87.2, I97.88, Y65.51? (would it be a wrong operation on correct patient), Y92.530
CPT
36561 (Initial VAD insertion), 35201-78-XP (Subclavian artery repair with unplanned return to OR performed by vascular surgeon, or should this not be coded as vascular repair is included in the insertion/removal of VAD), 36590-78 (Removal of initial VAD with unplanned return to OR), 36561-76 (Insertion of second VAD with same procedure repeated by same physician)
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