CPC Chapter 10- Cardiovascular System Practical Review Flashcards
CASE 1
Preoperative diagnosis: Sinus of Valsalva aneurysm on the left coronary sinus. (This is the working diagnosis unless report gives a different diagnosis or more defining information.)
Postoperative diagnosis: Same
Operation: Repair sinus of Valsalva aneurysm with pericardial patch. (This is the procedure performed, but coders must confirm the procedure was performed in the body of the notes.)
Procedure: The patient was taken to the operating room and placed supine on the table. After general endotracheal anesthesia was induced, rectal temperature probe, a Foley catheter and TEE probe were placed. The extremities were padded in the appropriate fashion. Her neck, chest, abdomen, and legs were prepared and draped in standard surgical fashion.
The chest was opened through a standard median sternotomy. The patient was fully heparinized and placed on cardiopulmonary bypass. At this point, we started to open the pericardium. We were met with a large amount of dense adhesions and some fluid that was blood-tinged, salmon colored, and it was cultured. Tonsil clamps were placed on the inferior portion of the pericardial sac, and we used Bovie cautery and Metzenbaum scissors to take down all the adhesions laterally, exposing the right atrium first and then the aorta. There were some lighter adhesions over the left ventricle, which were broken with finger dissection. There was a moderate amount of fluid in different pockets that were suctioned free. There was no evidence of frank blood.
After dissecting out the right atrium, we dissected out the aorta circumferentially using Bovie cautery and Metzenbaum scissors. We then freed up the entire LV and the apex, as well as the inferior and lateral borders of the heart. After this, we then checked the activated clotting time (ACT), which was greater than 550. The ascending aorta was cannulated without difficulty. A dual stage venous cannula was placed in the right atrium. Retrograde cardioplegia was placed in the right atrium through the coronary sinus, and antegrade cardioplegia was placed in the ascending aorta. After the patient was on bypass, we completed dissection. We looked through the superior pulmonary vein. It appeared to be densely adhesed, so we opted to vent through the apex of the LV. We proceeded to flush our lines, cooled to 32 degrees. Once we had a nice arrest, we opened the aorta. An aortotomy was created in standard fashion, the area was tacked back, and we were able to identify the aneurysm in question. There was a large amount of thrombus, and it was removed. There was also some mural thrombus which was laminar and stuck to the aneurysm, and I elected not to debride this area.
This defect apparently took up the entire left of the sinus of Valsalva.(This tells you exactly where the aneurysm is located.) The coronary was probed and there was approximately a 2-3mm rim of tissue beneath the coronary to sew to, and the valve was intact. The aortic valve was intact, and there was a rim of tissue just lateral to the annulus for us to sew to. After debriding and irrigating, we sized a bovine pericardial patch and sutured it in place with 4-0 Prolene suture.(This documentation describes the patch procedure.) This was done in a running fashion, working from the annulus up towards the coronary artery underneath the coronary, and then around laterally and superiorly, sewing through the aortic tissue.
We now successfully excluded the aneurysm and packed the entire sinus.(This documents that the entire aneurysm was repaired.) We gave cardioplegia in a retrograde fashion, with nice flow back from the left main. We inspected the repair and it was competent. We irrigated one more time and closed the aorta, de-aired the heart with standard maneuvers, and removed the cross-clamp. We then weaned the patient off of bypass and re-warmed the patient. There was no aortic insufficiency, good function of the aortic valve, and no flow into the aneurysm anymore, with a nice patch repair. We closed the chest with stainless steel wires, the fascia was closed with Vicryl sutures, and subcutaneous tissue and skin were closed in similar fashion.(The rest of the note explains that the patient was removed from the bypass machinery and closure. Note there is no indication of chest tube placement. Any time you open the chest the negative pressure required for respiration is lost and a chest tube is placed to re-establish this negative pressure. This is never a separately coded item because it is an integral part of the surgery.)
What CPT® and ICD-10-CM codes are reported?
33720
Q25.43
CASE 2
Preoperative diagnosis: Acute renal failure.(This is the diagnosis.)
Postoperative diagnosis: Same.
Indication: Patient is a 23 year-old critically ill woman who went to the operating room for a lung transplant. A Vas-Catheter(Catheter.) was indicated to proceed with CVVHD upon arrival in the ICU.
Procedure: Left subclavian Vas-Cath placement (insertion).(This is the working description of the procedure.)
The left chest was draped and prepped in the usual sterile fashion and the patient was placed in the Trendelenburg position. The subclavian vein was readily located with a needle,(Entry directly into the subclavian vein indicates a non-tunneled catheter.) and the Seldinger technique was used to place a Vas-Cath for dialysis.(This is the description of the placement.) Excellent flow was returned through both lumens. The catheter was secured in place and a sterile dressing was applied. The patient is to be transported to the ICU where a post-procedural x-ray will be taken.
What CPT® and ICD-10-CM codes are reported?
36556
N17.9
CASE 3
Preoperative diagnosis: 6.7cm descending thoracic aortic aneurysm. Type B aortic dissection, chronic.(This is the working diagnosis, until report is reviewed.)
Postoperative diagnosis: Same
Operation: Left thoracotomy.(This is the surgical approach.) Repair of a descending thoracic aortic aneurysm with a 34 mm Gelweave graft.(This is the surgical procedure.)
Bypass time: 1 hour, 15 minutes(Our first indication that cardiopulmonary bypass was used.)
Procedure: The patient was brought to the operating room, placed on the table in the supine position. A blocker was placed on the left main stem bronchus, and we isolated the left lung. We proceeded to place the patient in the right lateral decubitus position. He was padded and secured with all pressure points relieved, and at this point, we prepared and draped the patient in the usual sterile fashion.
We performed a left posterolateral thoracotomy;(This is our approach to this surgery.) dividing the muscles, the fourth intercostal space was entered. The lung was completely deflated. At the same time, we exposed the left common femoral vein as well as the left common femoral artery, and heparinized the patient. These vessels were isolated and prepared for cannulation.
A venous line was placed into the right atrium through the common femoral vein, and this was secured. The patient was placed on partial bypass maintaining a blood pressure in the lower extremities of around 50 mmHg. We continued at this point with our dissection. The esophagus was plastered against the aorta. It was peeled off. Intercostals were controlled and divided. We placed an aortic cross-clamp proximally and distally, and we entered the aneurysm.(Here, we note the aneurysm.) We identified two lumens and these were resected, and proximally we identified the true lumen and resected the false lumen after obtaining control of the subclavian artery. Distally we fenestrated the wall between the true and false lumen to prevent any mal-perfusion.
At this point, we sized the aorta to a 34 mm aortic graft, |7| and we fashioned the proximal anastomosis using 3-0 Prolene with a large needle in a running fashion. We nerve hooked this suture line and tied this down. The posterior suture line of the proximal anastomosis was reinforced with 4-0 Prolene pledgeted stitches. At this point, we removed the cross-clamp and pressurized the anastomoses. Areas of leak were controlled with 4-0 Prolene. The graft was cut to length and after examining our distal aorta and, making sure an appropriate fenestration had been performed, we fashioned an anastomosis again using 3-0 Prolene with a large needle. Before removing the proximal cross-clamp we de-aired the graft with a 25-gauge needle. We very slowly removed the proximal cross-clamp as well as the distal cross-clamp, and flow was reinstituted down the aorta. We weaned the patient off bypass and examined our distal and proximal anastomoses. All incisions were closed, and the patient tolerated the procedure well.
What CPT® and ICD-10-CM codes are reported?
33875
I71.23, I71.012
CASE 4
Preoperative diagnosis: Cardiac tamponade secondary to malignant effusion due to the pericardial metastasis from the lung. (This is the diagnosis as the pre and post-operative diagnoses are the same.)
Postoperative diagnosis: Same
Procedure: Pericardial Window via subxiphoid approach. (This is the working procedure description, but it must be verified in the report.)
Details: The patient was positioned supine on the table and prepped and draped. A low midline incision approximately 5cm in length was made over the sternum and xiphoid. (This is the approach used to gain access to the pericardium.) This was carried down to the linea alba, which was opened. The xiphoid was divided. We then found the pericardium and opened the pericardium again with electrocautery. We enlarged the site so it was easily 1cm across. (The pericardium is cut open for drainage.) At this time, there was a gush of fluid under pressure. It was serosanguinous fluid. It was not turbid, nor was there any odor. We suctioned this fluid for approximately 500ml in the suction container. There was probably an additional 100ml of spill on the drapes. Approximately 100ml was also sent for cytology and culture. (A sample of body fluids retrieved during the procedure is sent to the lab for pathological workup.)
After we felt we had fully drained the pericardium and had had a significant hemodynamic improvement, we then made a small transverse incision; to the right of her lower sternal incision and through this and across the fascia, we passed a #20-French Blake drain. (A tube is placed and left in the chest to allow for continued drainage.) This was placed on the diaphragmatic surface of the heart and was tied in place using 2-0 Ethibond sutures. We then closed the fascia with 0 Vicryl and the subcutaneous tissue with 0 Vicryl. These were all interrupted, and the skin was stapled. At the end of the procedure, the patient’s condition remained stable.
What CPT® and ICD-10-CM codes are reported?
33025
C79.89, C34.90, I31.4
CASE 5
Preoperative diagnosis: Prosthetic valve endocarditis.(This is the working diagnosis, coming into the surgery.)
Postoperative diagnosis: Same
Operation: Re-replacement of a 10-year-old tricuspid valve using a 31 mm Carpentier-Edwards pericardial bioprosthesis. (This is the planned procedure statement, replacement of the tricuspid valve.)
Procedure: The patient was brought to the operating room, and after having the appropriate monitoring devices placed, he was intubated and general endotracheal anesthesia was achieved. The patient was prepared and draped in the usual sterile fashion.
The chest was entered via a median sternotomy incision. (This is the approach used.) Simultaneous to this, the right common femoral vein was dissected. The pericardium was opened, the patient was given systemic heparin, and the ascending aorta and superior vena cava were cannulated. Similarly, the right common femoral vein was cannulated. The patient was started on bypass. (This documents the use of cardiopulmonary bypass.)
Caval snares were placed, and the right atrium was opened. An intra-atrial thrombus excised and cultured. The prosthetic valve was excised, the annulus was debrided and irrigated. The valve was sized and a 31mm valve was selected. (This was the removal of the old valve and the placement of the new one. Note just the leaflets were removed and the annulus stayed.)
Pledgeted 2-0 Ethibond sutures were passed circumferentially around the annulus in a ventriculoatrial fashion. These sutures were tied and the valve was inspected. The valve was found to be well-seated,(This documents that the valve is in the correct place and fits well.) and the atrium was closed with running 4-0 Prolene sutures.
The patient was rewarmed, deaired, and then weaned from bypass with low-dose inotropic support. Temporary drains were placed and the mediastinum was policed for hemostasis and the sternum re-approximated with stainless steel wire. The femoral vein and groin wounds were closed with layered Vicryl sutures. The patient was taken back to the Cardiac Surgical Unit in stable condition after tolerating the procedure well.
What CPT® and ICD-10-CM codes are reported?
33465, 33530
T82.6XXA, I07.9
CASE 6
Preoperative Diagnosis: Multiple varicose veins with severe leg pain.
Postoperative Diagnosis: Same.
Procedure: Removal of multiple varicose veins, right lower leg, involving both the greater and lesser saphenous systems.
Anesthesia: General.
Procedure: With the patient prepped and draped in the usual sterile manner, multiple small incisions were made over the patient’s varicose veins in the right leg. Through these incisions multiple clusters and branches from the greater saphenous vein and lesser saphenous veins were removed. Starting at the saphenofemoral junction, dilated tortuous segments of the greater saphenous vein and lesser saphenous vein were also removed. Most of the greater saphenous vein was removed to well below the knee. Meticulous hemostasis was achieved. All perforators associated with these clusters were ligated with 3-0 Vicryl suture. The patient’s leg was wrapped in sterile Webril and Ace wrap. There were no complications.
What CPT® and ICD-10-CM codes are reported?
37722-RT, 37718-51-RT
I83.811
CASE 7
Preoperative diagnosis: Coronary artery disease. Hypercholesterolemia
Postoperative diagnosis: Same
Operation: Coronary artery bypass graft x 4. Left internal mammary artery to obtuse marginal artery, right internal mammary artery to the left anterior descending artery, reverse saphenous vein to the first diagonal artery and reverse saphenous vein graft to the right posterior descending artery.
Indications: The patient is a 39 year-old gentleman with a history of hypercholesterolemia and hypertension, who presents with a positive stress test. Catheterization revealed left main, circumflex disease, as well as total right coronary artery disease.
Procedure: The patient was brought to the operating room and placed supine on the operating table. After the induction of general endotracheal anesthesia, the patient was prepared and draped in the usual sterile fashion. We proceeded to harvest a saphenous vein endoscopically from the left lower extremity. At the same time, the LIMA and then RIMA were harvested by open technique.
The pericardium was opened and tacked up to form a cradle. The patient was heparinized. The conduits were prepared for bypass. We opened the cardiac cradle, cannulated the ascending aorta and right atrium. Antegrade and retrograde cardioplegia catheters were placed. At this time, we placed the patient on cardiopulmonary bypass. The targets were examined, and they seemed to be graftable. At this point, we placed a cross-clamp on the ascending aorta and arrested the heart with antegrade and retrograde cardioplegia, topical ice, and the patient was cooled down to 32 C.
At this point, we exposed the territory of the RPDA. It was found to be a modest target. A reverse saphenous vein graft to right posterior descending artery was fashioned using 7-0 Prolene. Flow was measured at 50 ml/min. Next, we directed our attention to the first diagonal artery. It was also a modest target. It was opened. The anastomosis was fashioned using the reverse saphenous vein graft with 7-0 Prolene. Flow was measured at 60 ml/min. At this point, we exposed the territory of the obtuse marginal. The left internal mammary was prepared. A LIMA to obtuse marginal graft was performed with 7-0 Prolene. There was excellent hemostasis. We tacked down the wings of the mammary. The bull-dog was placed on the mammary.
At this point, we performed two proximal aortotomies with the4.0mm aortic punch. Two proximal anastomoses were fashioned after the veins were cut to length with 6-0 Prolene. Bull-dogs were placed on each of these veins.
We rewarmed the patient. The territory of the left anterior descending artery was exposed. The RIMA was prepared. The RIMA to left anterior descending coronary artery (LAD) anastomoses was fashioned using the 7-0 Prolene. Once this was completed, the wings of the mammary were tacked.
At this point, warm cardioplegia was given in retrograde fashion. The bull-dogs were removed from both the LIMA and the RIMA. We resumed perfusion of the heart. We de-aired the root of the aorta and removed the cross-clamp. The patient resumed a normal sinus rhythm. The sites were oversewn; the vein grafts were de-aired in the usual fashion.
We examined the proximal and distal anastomoses, and there was excellent hemostasis. Three Blake drains were placed, two into the mediastinum and one into the right pleura, as we did not enter the left pleural space. The patient was weaned off cardiopulmonary bypass without any difficulty. The sternum was reapproximated with heavy stainless-steel wire in a mattress fashion. The pectoralis fascia and subcutaneous tissue were approximated with 1-Vicryl skin with 4-0 Vicryl as well as Dermabond. The lower extremities were closed in similar fashion. The instrument counts were correct. The patient was transferred to the SICU in stable condition.
What CPT® and ICD-10-CM codes are reported?
33534, 33518, 33508
I25.10, E78.00
CASE 8
Preoperative diagnosis: Ischemic cardiomyopathy. Intraventricular block delay. Congestive heart failure. The patient has a dual-system pacemaker in place.
Postoperative diagnosis: Same
Operation: Insertion of left ventricular epicardial pacemaker lead with generator change
Indications: Ischemic cardiomyopathy with intraventricular conduction delay in a patient experiencing congestive heart failure; status post failed attempt at placement of transvenous coronary sinus lead.
Procedure: The patient was brought to the operating room and, after having the appropriate monitoring devices placed, was intubated and general endotracheal anesthesia was achieved. The patient was prepared and draped in the usual sterile fashion.
The chest was entered via a small left posterior thoracotomy. The left anterior chest generator pocket was opened, and the generator explanted. The left lung was collapsed. The pericardium was opened, and two unipolar epicardial leads were placed in the posterolateral left ventricle. Thresholds were checked and found to be adequate. The leads were tunneled subcutaneously to the generator pocket.
A new St. Jude biventricular pacemaker generator was then reconnected to the transvenous atrial and ventricular leads as well as to the epicardial lead. The generator was again interrogated, and the thresholds and impedances of all leads were found to be adequate. The generator was replaced in the pocket. The pocket was irrigated with antibiotic saline and closed in layers with Vicryl suture.
A single left pleural drain was placed, and a single pericostal suture was utilized to reapproximate the ribs. The fascia and subcutaneous tissue were closed with layered Vicryl suture, and the skin was closed with a subcuticular stitch.
The patient was transferred to the coronary care unit in stable condition, having tolerated the procedure well.
What CPT® and ICD-10-CM codes are reported?
33202, 33224-51
I25.5, I45.4, I50.9
CASE 9
Preoperative diagnoses: Critical aortic valve stenosis, coronary artery disease, hypertension, diabetes mellitus
Postoperative diagnoses: Same
Operation: Aortic valve replacement with a 19mm St. Jude bioprosthesis. Coronary artery bypass graft x 2 – reverse saphenous vein graft to left anterior descending artery and reverse saphenous vein graft to obtuse marginal artery.
Anesthesia: General
Indications: This is an 80-year-old female with a history of hypertension, diabetes mellitus, and coronary artery disease, who presented to the emergency department with a syncopal episode. An echo revealed severe to critical aortic valve stenosis. Cath confirmed this diagnosis as well as two-vessel coronary artery disease with a tight proximal left anterior descending artery lesion, a tight circumflex lesion, and a 40% right coronary artery lesion.
Procedure: The patient was brought to the operating room and placed supine on the table. After induction of general anesthesia, the patient was prepped and draped in the usual sterile fashion.
We to harvested the saphenous vein endoscopically from the left lower extremity. Once we were ready to divide the conduit, the patient was heparinized. The conduit was divided and prepared for bypass. A median sternotomy was performed; there was a pericardial cradle.
We cannulated the ascending aorta. Antegrade and retrograde cardioplegia catheters were placed. The patient was placed on cardiopulmonary bypass with an ACT greater than 400. We examined the targets, and they were deemed to be graftable.
At this point, the pulmonary artery was dissected off the aorta. We placed a vent through the right superior pulmonary vein, and then we cross-clamped the ascending aorta and gave cardioplegia in antegrade and retrograde fashion, as well as topical ice. We cooled the patient to 32 C.
With an excellent arrest, we exposed the territory of the obtuse marginal. It was opened, found to be a graftable vessel. A reverse saphenous vein graft to the obtuse marginal was fashioned using 7-0 Prolene. The flow was measured at 90 ml/min.
At this point, the territory of the LAD was exposed. It was opened, and a reverse saphenous vein graft to left anterior descending artery anastomosis was fashioned using 7-0 Prolene. Flow was measured at 110 ml/min. Cardioplegia was given down these grafts as well as in a retrograde fashion throughout the case, every 20 minutes.
We performed a hockey-stick incision of the aorta approximately 1.5cm above the right coronary artery. We used silk sutures to expose the aortic valve. It was a severely calcified, trileaflet aortic valve. The leaflets were cut out. The annulus was debrided. We irrigated the ventricle, then we proceeded to size the valve to a 19mm valve. Sutures of 2-0 Ethibond were placed in ventriculoaortic fashion circumferentially. They were then passed through the valve. The valve was seated and tied down without difficulty. The right and left coronary ostia appeared to be intact and free of obstruction. There appeared to be no evidence of weakness around the annulus.
We rewarmed the patient. The aorta was closed using two layers of 4-0 Prolene with two felt strips. We proceeded to perform two proximal aortotomies once the veins were cut to length. The veins had bull-dogs on them. At this point, we removed the cross-clamp, and normal sinus rhythm was reinstituted.
Ventricular pacing wires were placed, and after de-airing maneuvers, the vent was removed. We placed Blake drains into the mediastinum x 2.
What CPT® and ICD-10-CM codes are reported?
33405, 33511-51, 33508
I35.0, I25.10, I10, E11.9
CASE 10
Preoperative diagnosis: Severe two-vessel coronary artery disease and moderate valve aortic stenosis.
Postoperative diagnosis: Same.
Operation: Triple-vessel coronary artery bypass grafting: Left internal mammary artery to the left anterior descending coronary artery, reverse saphenous vein to the first diagonal branch, and a ramus intermedius. Aortic valve replacement with a 23 mm bovine pericardial bioprosthesis.
Anesthesia: General.
Indications: This is a 66 year-old white male who presented with unstable angina pectoris. He underwent coronary angiography and had a 70 percent occlusion in the distal left main, an 80 percent occlusion in the proximal left anterior descending coronary artery (LAD), a 95 percent occlusion of the proximal ramus intermedius, and a 70 percent occlusion in the proximal diagonal branch. The right coronary artery had no significant lesions. His aortic valve gradient was 40mm Hg by catheter and echocardiogram. He presented with a new onset of angina pectoris and significant coronary artery disease; surgery was warranted.
Procedure: While monitoring the intra-arterial blood pressure and EKG, the patient was anesthetized without incident. The entire chest, abdomen, and both legs were prepared and draped into the usual sterile field. A median sternotomy was performed. The left internal mammary artery was dissected off the chest wall. Simultaneously, the greater saphenous vein was endoscopically harvested from the left leg and the layers were closed with Vicryl and Dermabond. A sterile compressive dressing was applied.
The pericardium was opened and tacked up to form a cradle. After heparinization, the ascending aorta and the right atrial appendage were cannulated and connected to cardiopulmonary bypass using a membrane oxygenator with an initial flow of 4.9 liters/min. Antegrade and retrograde cardioplegia catheters were inserted. On bypass, a left ventricular vent was placed through the right superior pulmonary vein. The coronaries were dissected out and found to be suitable for grafting although the circumflex branches were less than 1 mm in diameter. The ramus intermedius was identified as well as the diagonal branch which was small. The heart was then arrested with cold enriched blood cardioplegia, given antegrade after cross-clamping the ascending aorta. Once diastolic arrest was obtained, the heart was cooled with cold blood cardioplegia given initially antegrade and subsequently retrograde. Additional doses were given retrograde as well as down the vein graft. At the end, a hot shot was given. Systemic temperature was lowered to 32 degrees. Myocardial temperature was maintained around 20 degrees.
The ramus intermedius was opened first. This was found to be a 1.5-2.0mm vessel. An end-to-end anastomosis using a segment of reverse saphenous vein was then performed with running 7-0 Prolene suture technique. This was felt to be a good graft with flow of 90 ml/min.
Next, the first diagonal branch was grafted in a similar manner with a second segment of reverse saphenous vein with a resultant flow of 50 ml/min.
The left internal mammary artery was anastomosed to the left anterior descending coronary artery in an end-to-end fashion using the in situ left mammary with running 8-0 Prolene suture technique. The diagonal branch was a 1.5mm vessel and the LAD was a 1.5-2.0mm vessel.
Next, the aorta was opened in an oblique transverse fashion and a moderately calcified trileaflet aortic valve was examined. The left ventricle was irrigated with saline. The annulus sized to a 23mm pericardial tissue valve (Model #3000, Serial # 55555555). The valve was sutured; in a supra-annular fashion with interrupted 2-0 Ethibond valve sutures placed in the pledgets on the left ventricular out-flow tract side. The valve was seated and tied down securely. The aortotomy was then closed in two layers with running 4-0 Prolene reinforced with in the corners pledgets.
During the same cross-clamp time, the proximal vein grafts were then anastomosed to the ascending aorta to two separate circular openings using 6-0 Prolene suture technique. After filling the heart with blood and evacuating the air from the apex of the left ventricle with an 18-gauge needle, the cross-clamp was removed and the vein graft deaired. Rewarming had begun while constructing the proximal anastomoses. While rewarming continued, two temporary atrial, temporary ventricular, and temporary ground pacing wires were placed, as well as two Blake drains for mediastinal drainage.
Once the patient reached a rectal temperature of 36 degrees, he was weaned off cardiopulmonary bypass without any inotropic support and without any difficulties. The venous cannula was removed, the heparin was reversed with protamine, and the aortic cannula was removed. The mediastinum was irrigated with copious amounts of saline and Bacitracin solution, using the pulse lavage irrigator.
The sternum was reapproximated with the surgical Pioneer Sternal Cable System using four figure-of-eight cables. After pulse irrigating and pulse lavaging the fascia and subcutaneous tissue, the incision was closed in layers with Vicryl and the skin reapproximated with a subcuticular closure and Telfa sterile dressing was applied. There were no difficulties and the patient was taken to the ICU in stable condition.
What CPT® and ICD-10-CM codes are reported?
33405, 33533-51, 33518, 33508
I35.0, I25.110
