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Code selection depends on your understanding of simple, intermediate, and complex closures. Lesion excisions, as with any open wound, often require a level of repair or closure. Simple repairs are included in the excision codes (CPT® 11400-11646), but intermediate and complex closures are separately billable when medically necessary. Per CPT® guidelines, “The excision of benign […]
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Part 3: Scour the documentation for three key details to correctly code for wound repair. Accurately coding dermatological procedures can be tricky. It is imperative that medical coders understand the anatomy of the skin and can extract specific information from the clinical documentation. We’ve spent the last two months reviewing the codes and guidelines for […]
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Differentiate hernia repairs and surgical approaches for improved medical coding. A hernia occurs when an internal part of the body pushes or squeezes through a weak spot in a surrounding muscle or connective tissue (fascia). Although most hernias are harmless and pain-free, some may be painful and dangerous. Surgery is the only cure for a […]
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After adequate anesthesia, legs were prepped with betadine, draped in a sterile fashion. The left thigh laceration was measured 27 cm in length and it arched over from the distal anterior thigh lateral across the knee joint and then inferior. There was a stated degloving and undermining of the skin over the knee. There was no fascial injury. This area was copiously irrigated with a liter of saline and then the skin was closed with running 2-0 nylon sutures over a 19-French Jackson-Pratt drain. Drain was brought out and sewn in place with a 2-0 silk. The laceration measured 27 cm. The right anterior tibial laceration measured 3 cm and then there was a puncture wound, which was controlled with interrupted 3-0 nylon stitches. This was irrigated out initially and the two areas connected just anterior to the tibia.
The right thigh laceration was extensive and included a laceration of the lateral aspect of the quadriceps fascia with bulging muscle. This are was copiously irrigated with a liter of warm saline. The fascia was reapproximated with a running 9 Vicryl stitch, returning the muscle belly underneath the fascia. This measured 20 cm. The skin laceration was then repaired, measured 24 cm and again there was some undermining of the skin. A drain was placed, brought out inferiorly, and sewn in place with a 2-0 silk. the skin was then closed with running 3-0 nylon. Mepliex dressings were applied and Ace bandages were applied, and drains were placed to suction. The patient tolerated the procedure well and was taken to recovery room in stable condition.
I choose codes 12002, 13121, and 13122 x 9. Can someone tell me if this is correct and if it’s not what would be the correct choice.
Thank you
PREOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.
PROCEDURE:
Endovascular stent repair of abdominal aortic aneurysm.
OPERATIVE PROCEDURE:
The patient was brought to the operating room, placed on the operating table.
After adequate general anesthesia, the patient’s groin area was shaved and both
legs were prepped from the toes all the way up to the umbilicus. The patient
was then draped in the usual sterile manner. Bilateral curvilinear groin
incisions were then made and dissection was carried down to the femoral
vessels. On the right side, the common femoral artery was identified and it
was dissected free circumferentially and encircled with a vessel loop. The
patient had enough common femoral artery here that a second vessel loop could
be placed distally such that a segment measuring about 2.5 cm exposed. On the
right side, the common femoral, superficial femoral, profunda vessels were all
dissected free circumferentially and encircled with vessel loops. On each side
using a Cook needle, guidewire was inserted into the femoral vessels followed
by a 5-French sheath. This was all done under fluoroscopic guidance. Once
this was done, we went ahead and placed our Glidewire up further proximally
through the iliacs, through the aneurysm up into the proximal descending
abdominal aorta. Again, all under fluoroscopic guidance. On the left side, a
Kumpe sheath was inserted into the artery. The Glidewire was replaced with a
stiff Bentson wire and over this, we went ahead and passed our main body
device, which was an Endurant II 25 x 14 x 103. The device was positioned into
place, but not deployed. On the right side, we went ahead and placed a pigtail
catheter and an on-table angiogram was then performed. The left renal artery
was identified. The patient had a nephrectomy on the right side. The graft
was then gradually deployed angling the gate more anterolaterally to the left.
The main body was deployed until the gate opened. At this point, the pigtail
catheter on the right side was then removed over a guidewire and replaced with
a Kumpe sheath. Attempt was made to cannulate the gate without success, an
angling sheath had to be then used to cannulate the gate successfully. The
guidewire was then passed up through the gate. Angling sheath was then
removed, and a sheath was then placed over the guidewire as well as a pigtail
catheter and an on-table angiogram was then performed. The distance from our
bifurcation to the iliac takeoff was measured, it appeared that a 16 x 16 x 124
length catheter would be appropriate here and the pigtail catheter and sheath
was then removed over wire and the right limb extension device was then
inserted and then, deployed successfully down to the level of the internal
iliac takeoff on the right. Similarly on the right side, a similar procedure
was performed. It should be noted that our suprarenal anchoring device had
already been deployed and the remaining portion of our graft on the left side
was deployed. The device was then removed and replaced with a sheath. Once
again, a pigtail catheter was also inserted and once again an on-table
angiogram was performed on the left side, distance to our internal iliac
takeoff was measured and it appeared that a 16 x 16 x 93 limb would be the
appropriate size. The pigtail catheter removed and our device was then
threaded over the wire and through our sheath up to our main body graft. The
device was then deployed successfully down to the internal iliac takeoff. At
this point, 2 Reliant balloons were inserted up each limb and inflated
sequentially down the entire length of the aortic graft and the limbs. Once
this was done, a completion aortogram was then performed. This showed good
seal without any endoleaks or no kinks within the graft. At this point, the
sheaths and wires were all removed and the arteriotomies in our femoral vessels
were closed using interrupted 6-0 Prolene sutures. The wounds were irrigated
and aspirated. The wounds were closed in layers with deep layers of 2-0
Vicryl. The skin was closed using 4-0 Monocryl using a subcuticular stitch and
dressed with Steri-Strips, 4×4 gauze, and tape. The patient tolerated the
procedure well without any complications. Anesthesia was reversed. The
patient returned to the recovery room in satisfactory condition. In the
recovery room, the patient was noted to have palpable pedal pulses as he did
preoperatively. Total contrast used was 70 cc and our fluoro time was 34
minutes and 51 seconds.
Are the fistula repairs included in the revision? or Do I just need to add a 22 to the 57295 and move on? 
Any suggestions greatly appreciated – thank you!
The fistulous tract from where the mesh was protruding was evaluated. The edges of this fistula were freshened with Metzenbaum scissors. The fresh mucosal edges were then sutured together primarily with 2-0 Vicryl suture. Good closure of the fistulous tract was identified. The two midline fistulous from where the mesh previously extruded were identified. These fistulous tracts were mucosalized. The mucosa of the fistulous tract was removed and the new mucosal raw edges were sutured together using running 2-0 Vicryl sutures. This was performed for each of the identified midline fistulous tracts. Good coaptation of the vaginal mucosa was achieved. A good closure of the fistula tracts were identified.
Operation
1. Bilateral open femoral artery exposure.
2. Endovascular aneurysm repair with placement of aortic-uni-iliac endogradt, non rupture.
3. Right common iliac artery embolization
4. Left to right femoral to femoral bypass
Technique
1. Bilateral open femoral artery exposure
2.Placement of catheter in abdominal aorta with aortogram.
3.Introduction of the main body device Medtronic Endurant II AUI 28 mm x 14mm x 102 mm from the left common femoral artery
4. Left limb 16 mm x 93 mm
5. Left limb extension 20 mm x 156 mm
6. Left to right femoral to femoral bypass with 8 mm Dacron graft
Procedure:
Bilateral oblique groin incises were created with a scalpel two finer breaths below the inguinal ligament. Electrocautery was utilized to dissect through the subcutaneous tissues to expose the inguinal ligament. The femoral sheath was identified and divided longitudinally to expose the common femoral artery. The proximal and distal common femoral arteries were then circumferentially encircled with silastic vessel loops.The left common fem artery was accessed with an 18g needle, Benton wire, and 9 french sheath. The bentson wire and KMP catheter was advanced into the suprarenal aorta to perform an aortogram.
The 14 french main body Medtronic Endurant II AUI device was placed on the left side. On the contralateral side, a pigtail catheter was inserted to the level of the renal arteries and an aortogram was performed. The main body device was then positioned just below the right renal artery and the endo graft was fully deployed. An aortogram was performed to confirm adequate position of the graft and patent right renal artery.
The left iliac limb was measured with the marked pigtail catheter and the location of the hypoastric artery was confirmed with a retrograde sheath arteriogram.The left iliac limb grafts were deployed just proximal to the left hypogastric artery wiht a 3xm uverlapof the previous left iliac limb. All overlap zones were confirmed wiht a Reliant balloon. Next, the previous placed right iliac limb was embolized with a 22 mm Amplatzer Ii plug thru a 12 French long sheath.
A complete aortogram was performed which confirmed excellent endograft position and patent right renal artery and hypogastric arteries bilaterally. No endoleak was detected. Bilateral common femoral arteries were then controlled proximally and distally with vascular clamps. A tunnel was created over both inguinal ligaments, anterior to fascia along the subcutanouse space, superior to pubis using blunt dissection. An 8,=mm Dacron graft passed thru the tunnel ensuring no kinking or twisting. A longitudinal arteriotomy was made on the left common femoral artery. No endarterectomy was required. ..then closure
34703
34812
34709??
34813
??????
thanks for your help!!
After being placed supine on the operating room table, anesthesia was induced and the patient intubated
without difficulty. The area of the entire abdominal wall was then prepped and draped in a sterile fashion and
a final time out then performed confirming right site and right patient.
A ten blade scalpel was used to make an upper midline celiotomy incision. Electrocautery was used for
hemostasis and to continue the dissection through all subcutaneous layers until the anterior fascia of the
rectus musculature could be identified. Electrocautery dissection was used to dissect subcutaneous tissues off
of the anterior abdominal wall fascia along the entire length of the midline incision until the rectus muscle
separation was completely exposed. The midline of the diastasis recti was then opened exposing the
abdominal cavity completely. At this point, a moderate sized diastasis recti with a small supra-umbilical
ventral hernia could be identified.
Using electrocautery, excess subcutaneous tissues and midline fascia was excised and discarded into order to
restore the normal boundaries of the medial aspect of the rectus musculature bilaterally. All layers of the
anterior abdominal wall were then re-approximated in the midline using running looped 0 PDS sutures. This
included completely re-approximating the inferior hernia defect primarily. The entire surgical field was then
copiously irrigated using diluted Betadine solution. The midline abdominal wall soft tissues were then reapproximated
in the midline in a layered and centrally mattressed fashion using interrupted 3-0 Vicryl
sutures. The midline incision was then closed using skin staples.
The primary hernia repair and plication of the diastasis recti complete, attention was now turned to the
laparoscopic portion of the hernia repairs with mesh implantation. After placing a left upper quadrant
abdominal port under direct visualization, pneumoperitoneum was achieved to a pressure of 15 mm Hg.
Three additional trocars were placed in the other anterior abdominal wall quadrants sequentially using a 15
blade scalpel to make separate transverse incisions and the laparoscope for direct visualization. Harmonic
scalpel dissection was then used to separate the Falciform ligament from the superior aspect of the primarily
re-approximated abdominal wall defect as well as adhesive disease inferior to the umbilicus to allow for a
smooth posterior abdominal wall surface for mesh attachment. Once cleared, the defect was measured and a
20 x 7 cm piece of Proceed composite mesh fashioned for fixation. Two corner 2-0 PDS sutures were placed
along the textured surface of this graft which was then irrigated using diluted Betadine solution, rolled,
passed into the abdominal cavity, and unrolled without difficulty. A suture passer was then used to
exteriorize each fixation suture through a small stab incision made in the anterior abdominal wall using an 11
blade scalpel. These sutures then allowed the mesh to lie smoothly across the midline ventral defects in an
underlay fashion. The patch was further secured in place using a 5 mm SecureStrap device at approximately
1.5 cm intervals circumferentially.
At this point, all ports were removed under direct visualization and pneumoperitoneum released in full. All
remaining skin incisions were then irrigated using diluted Betadine solution and re-approximated using
staples. The port site incisions were cleaned, dried and dressed sterilely using Bacitracin, Telfa gauze, and
Tegaderm. The suture passer incisions were closed using staples and the entire abdominal wall midline then
dressed using Bacitracin and an Aquacel Ag surgical coverlet. Sponge and instrument counts were confirmed
Can 29999 be used for the capsular repair or would that be integral to repair of the CAM lesion?
Any assistance would be greatly appreciated.