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Tag Archives: axillary

Right axillary artery cut down with impella placement

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Procedure:
#1 right axillary cutdown with insertion of percutaneous left ventricular assist device ( Impella CP)
#2 Placement of in to side 6 mm Dacron graft to the right axillary artery
#3 TEE with visualization and interpretation
#4 Fluoroscopy with intraoperative visualization and interpretation

Intraoperative findings:
TEE showed severe left ventricular dysfunction with global hypokinesis. Aortic valve was a trileaflet valve with no insufficiency or stenosis. Limited TEE was performed for the purposes of placement of the ventricular assist device. After placement of the device, the device was positioned appropriately across the aortic valve.
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On fluoroscopy, the final resting position of the percutaneous left ventricular assist device had the elbow of the device positioned at the level of the aortic valve. Device was functioning appropriately.
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Procedure in detail:
The patient had his history and physical updated prior to the procedure. He was transferred to the operating suite and placed on the operating table where he underwent general anesthesia. The patient was already endotracheally intubated.the right shoulder and chest were prepped and draped in usual sterile fashion using DuraPrep solution after TEE probe was inserted by anesthesia. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision. Next

The right axillary artery cutdown was performed by Dr. X. Once this was completed, the right actually artery was exposed and proximal distal vessel loops were placed. I then took over the operation. The patient was anticoagulated with ACT greater than 250 seconds after giving heparin. Proximal distal control of the axillary artery was performed. A longitudinal arteriotomy was then made and extended with angled scissors. A 6 mm Dacron graft was then beveled and anastomosed using 6-0 Prolene. Once this was completed, the graft was de-aired.
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The introducer sheath was then placed within the 6 mm graft and secured. The dilator was removed. The graft was de-aired and then carefully flushed with hep saline. J-wire was then introduced and advanced into the Aortic arch under fluoroscopic guidance. The pigtail catheter was inserted over the wire and positioned within the aortic arch, then used to manipulate the wire into the aortic root. The pigtail catheter was then positioned within the aortic root and the wire was carefully advanced across the aortic valve under fluoroscopic and TEE guidance. Pigtail catheter was advanced into the left ventricle. The J-wire was removed and the 018 guidewire was then placed within the left ventricle. Next
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The ventricular assist device then placed over wire and advanced in position within the left ventricle using fluoroscopic and TEE guidance. The wire was removed. The device was started, with excellent flows, improvement in the mean arterial pressure,as well as good motor current. The 6 mm graft was then trimmed to just above the level of the skin. The peel-away sheath was removed. The positioning sheath was then inserted and secured with 0 Ethibond and 0 silk. The Impala device was then secured with final fluoroscopic Evaluation used to pull the Impala back slightly as it had advanced during these maneuvers. Once this was completed, the soft tissues reapproximated with 0 Vicryl. The skin was closed with 4-0 Monocryl in running subcuticular manner. Dermabond was placed over the wound. The patient tolerated procedure well was transferred to CVRU in critical condition.

IMPELLA 33990
axillary cutdown by DR X?
axillary graft?
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Medical Billing and Coding Forum

axillary artery ligation for post op hemorrhage

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I have a tricky one i could really use help with. Pt came in thru the ED with 2 massively infected axillofemoral dacron grafts. My surgeon removed both and performed a direct repair of a ruptured axillary artery. A week later the patient started bleeding again, so he did this:

Via a new incision at the base of the neck, he located, mobilized, and controlled the subclavian artery with a vessel loop in order to eliminate a lot of the blood flow to the damaged axillary artery.
He then reopened the previous infraclavicular surgery site, ballooned and/or applied digital pressure to control the remaining bleeding vessels, and ligated the disrupted axillary artery, because he didn’t think it could be repaired.
He then returned to the first incision and released the subclavian artery, verified hemostasis, then closed both incisions.

The MD wants to bill CPT 35860 and 35761 because there are 2 incisions. I’m leaning more toward 35860 alone. Would someone who is more familiar with vascular surgery please tell me if a separate code or maybe a modifier 22 is warranted here?

The axillary artery still codes to a limb vessel even though the inicisions were in the neck and chest, right? Maybe? I don’t think 35761 is the right code under any circumstances.

Medical Billing and Coding Forum

Spinal accessory nerve to suprascapular and partial radial to axillary nerve transfer

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Hello,

I am new to ortho coding. I am trying to find the cpt codes for nerve transfers.

I came up with:

Spinal accessory nerve to suprascapular transfer 64713

Right partial radial to axillary nerve transfer 64999

I cannot find a code to compare the unlisted code to.

I would appreciate all the help. Here is the op-report. Thank you

The patient was identified in the preoperative holding area. We reviewed the operative indications, operative plan and recovery. The right shoulder was marked as the operative site and confirmed with the patient. He was then brought to the operating room. He was placed in the prone position. All bony prominences were well padded. Preoperative antibiotics were given per standard protocol. The right shoulder girdle and upper extremity was then prepped and draped in the normal sterile fashion.
A timeout was performed per standard protocol, identifying the patient, the procedure and the operative site. All personnel were in agreement and there were no discrepancies identified.
A transverse incision was made over the superior aspect of the scapula, beginning medial to the superior angle and eventually extending over the acromion. The incision was taken through skin, subcutaneous tissue and fascia down to the trapezius muscle. The fibers of the trapezius were split transversely to identify the spinal accessory nerve. Once we identified the nerve, we used a nerve stimulator to confirm its identity and its function. We carried our dissection laterally to identify the suprascapular nerve. We had difficulty identifying the suprascapular nerve. Proximally, we identified a section of the nerve, proximal to the notch, that appeared damaged. We carried our dissection distally to the acromion and the spinoglenoid notch. Unfortunately, the nerve was not identified in the notch despite wide exposure, suggesting that perhaps the nerve was avulsed distally, with the spinoglenoid notch serving as a second tethering point.
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We decided at this point to revisit the suprascapular nerve at a later time and instead to continue with the partial radial nerve to axillary transfer. The incision was extended longitudinally over the posterior aspect of the arm. The incision was taken through the skin, subcutaneous tissue and fascia down to the triceps. The radial nerve was identified in the triangular space. We identified its branches, and used a nerve stimulator to evaluate the function of each branch. We selected the branch that provided only elbow extension as our donor nerve; another branch that provided wrist extension was preserved. We then carried our dissection proximally to the quadrangular space to identify the axillary nerve. We isolated the anterior motor branch. The donor radial nerve was divided as distal as possible, and the axillary nerve was divided as proximal as possible. The microscope was then brought into the operating field. The nerve ends were prepared and coapted under the microscope using 8-0 Nylon sutures. The repair was reinforced with fibrin glue (Eviseal).
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We turned our attention back to the suprascapular nerve. Again, we found that the proximal portion of the nerve appeared unhealthy, and distally it was absent from the spinoglenoid notch. As such, a spinal accessory to suprascapular nerve transfer would be nonfunctional, and we abandoned this second nerve transfer, deciding it was best to preserve trapezius function as it was one of the few stabilizing muscles remaining around his shoulder.

Medical Billing and Coding Forum

Masectomy with axillary node dissection

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Need Help!!

Postoperative Dx: Left Breast cancer

Op Note: General anesthetic was given. She was prepped and draped in the usual sterile fashion. An incision was made encompassing the nipple-areolar complex extending medial collateral. Dissection was undertaken to make skin flaps. The flaps were raised to the clavicle, the sternum, and the infra mammary fold and then the breast was elevated off the pectorals muscle including as much as the fascia is possible.
The patient has a previous stroke and her pectoralis muscle was markedly atrophied and dissection was difficult. Continued from medial to lateral in and out to the axilla where axillary contents were dissected free, clips were placed on larger vessels and the contents were swept from the axillary vein down preserving a few intercoastal branchial nerves as well as the long thoracic and thoracodorsal. The specimen sent to pathology and the wound was irrigated with sterile water. 3 drains were placed, 1 in the axilla and 1 under each of the flaps as the patient is on blood thinners. The wound was closed……

Can I use CPT 19302 or 19307. Our NP is suggesting 19307.

Would appreciate help.

Rupa

Medical Billing and Coding Forum

Axillary Lymph Node Dissection Levels 1-3

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Good afternoon,

My provider performed an axillary lymph node dissection of levels 1-3 NOT in conjunction with mastectomy.
Does code 38745 include the level 3 nodes? Coding Companion lists only levels 1 & 2. NCCI edits allow the use
of 38525-59 for the level 3 nodes but with it being all on one side with one incision is it appropriate to do this??
If not would it be appropriate to append -22?

Medical Billing and Coding Forum

Coding a Partial Mastectomy with SNB and axillary lymph node dissection.

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Can I code this 19302,LT, 38745,59 with 38525,59 ?????

PREOPERATIVE DIAGNOSIS: Left breast carcinoma.

POSTOPERATIVE DIAGNOSIS: Left breast carcinoma.

PROCEDURES PERFORMED:
1.Left partial mastectomy with ultrasound localization.
2.Left axillary sentinel lymph node biopsy.
3.Left completion axillary lymph node dissection.

ANESTHESIA: MAC.

ANESTHESIOLOGIST: XXXX

SURGEON: XXXX
ASSISTANT: XXX

INDICATIONS FOR PROCEDURE: 53-year-old female with a newly diagnosed left breast carcinoma. She has a clinically normal axilla. She is undergoing a partial mastectomy with axillary sentinel node sampling at this time. Risks and benefits were explained including bleeding, infection, tumor recurrence, need for additional margin resection, arm edema, nerve injury, and indications for completion axillary lymph node dissection. All questions were answered. She desires to proceed. A surgical assistant is standard, necessary, and customary for the safe performance of this procedure.

DESCRIPTION OF PROCEDURE: Monitored anesthesia care was started upon returning from lymphoscintigraphy. Intraoperative ultrasound was utilized to identify the 3 o’clock tumor. The breast and axilla were infiltrated with 1% lidocaine and 0.5% Marcaine. The axilla was initially opened. Multiple hot lymph nodes were present. The highest activity was noted to be 20,000 units on the gamma counter. Subsequent nodes measured 2000 units with background activity all being negligible less than 200 units. The identified hot lymph nodes were all dissected using electrocautery and sent for frozen sectioning. A total of five hot lymph nodes were present, two of which were grossly positive for metastatic breast carcinoma. The axilla was subsequently extended allowing for completion dissection to be performed. The axillary vein was identified and skeletonized inferiorly. The long thoracic nerve and thoracodorsal nerves were both identified and preserved. The intercostal brachial nerve was diminutive in size and difficult to separate from the surrounding fibrofatty tissue. This was intentionally divided during the dissection. The axillary contents were peeled inferiorly and sent for permanent sectioning. Upon completion, the long thoracic and thoracodorsal nerves were confirmed intact and functional. The axillary vein was noted to be hemostatic. The axilla was closed in layer over a #10 flat Jackson-Pratt drain followed by Dermabond.

The breast was incised through a 3 o’clock periareolar incision. Ultrasound was used to guide the dissection. Using electrocautery, a large core of tissue was taken enveloping the entire mass. This was excised ex vivo. Subsequent Ultrasound confirmed the mass centrally located with multiple centimeters of normal surrounding breast parenchyma with the clip easily identified centrally. Satisfactory hemostasis was assured throughout the breast cavity. Additional portions of all six margins were obtained and sent for permanent sampling. The breast had been completely skeletonized from beneath the skin leaving no additional breast tissue to be had at this location. Portions of the pectoralis major fascia were also included. Hemostasis was assured. The defect was closed in layers with absorbable suture followed by Dermabond. Multiple clips had been placed circumferentially around the cavity to allow consideration for postoperative partial breast radiation. The patient was taken to Recovery awake and uneventfully.

Medical Billing and Coding Forum