Cardiovascular System

Total questions:55

Diagnosis: Cardiac Tamponande Ten-year-old boy was admitted with cardiac tamponade. initial pericardiocentasis yielded pus. Procedure: A subxiphoid tube-pericardiostomy was done and thick, purulent material was drained out. At surgery, however, an intrapericardial mass was discovered. Successful excision was performed and the patient made an uneventful recovery. histopathology of the mass revealed features of an intrapericardial teratoma.

Code the CPT and ICD-9 Procedural Codes for the Op Report Below: Diagnosis: Multiple Myeloma Operation: Placement of P.A.S. Port, left arm. Indications: The patient, age 48, is currently under therapy for multiple myeloma and will require chronic venous access for continued treatment. She was referred for placement of a P.A.S. port device in the left arm. The risks, benefits and options associated with this procedure are understood by the patient and she has elected to proceed with surgery under local anesthesia as described. Procedure: This patient was placed on the operating room table in the supine position with appropriate warming and monitoring devices in place. The left arm was circumferentially prepped with Betadine and sterilely draped. 1% plain Xylocaine was used to infiltrate the tissue of the antecubital fossa and good anesthesia was obtained. A transverse incision was fashioned through which a branch of the basilic vein was identified. A 5.6 French catheter and sensing wire assembly was inserted into the vein and its tip was advanced to the caval atrial junction. Catheter position was confirmed electromagnetically. The sensing wire was removed and the catheter was attached to a miniature port which was anchored in a subcutaneous space of the forearm. The system was flushed with heparinized saline, and dynamics were found to be excellent. With hemostasis intact and sponge and needle counts being correct the wound was irrigated with saline and closed in layers using 3-0 Vicryl on the subcutaneous tissues and 4-0 Vicryl subcuticular sutures in the skin. Sterile dressing was applied and the patient was transported to the AKU in good condition.

Preoperative diagnosis: 68-year-old male in coma Postoperative diagnosis: 68-year-old male in coma Procedure performed: Placement of a triple lumen central line in right subclavian vein. With the usual Betadine scrub to the right subclavian vein area and with a second attempt, the subclavian vein was cannulated and the wire was threaded. The first time the wire did not thread right, and so attempt was aborted to make sure we had good identification of structures. Once the wire was in place the needle was removed and a tissue dilator was pushed into position over the wire. Once that was removed, then the central lumen catheter was pushed into position at 17 cm and the wire removed. All three ports were flushed. The catheter was sewn into position, and a dressing applied.

What code would you use to report the percutaneous insertion of a dual chamber pacemaker by means of the subclavian vein?

Preoperative diagnosis: Atherosclerotic heart disease Postoperative diagnosis: Atherosclerotic heart disease Operative procedure: Coronary bypass grafts x 2 with a single graft from the aorta to the distal left anterior descending and from the aorta to the distal right coronary artery. Procedure: The patient was brought to the operating room and placed in a supine position. Under general intubation anesthesia, the anterior chest and legs were prepped and draped in the usual manner. A segment of greater saphenous vein was harvested from the left thigh, utilizing the endoscopic vein harvesting technique, and prepared for grafting. The sternum was opened in the usual fashion, and the left internal mammary artery was taken down and prepared for grafting. The flow through the internal mammary artery was very poor. The patient did have a 25-mm difference in arterial pressure between the right and left arms the right arm being higher. The left internal mammary artery was therefore not used. The pericardium was incised sharply and a pericardial well created. The patient was systemically heparinized and placed on bicaval to aortic cardiopulmonary bypass with the sump in the main pulmonary artery for cardiac decompression. The patient was cooled to 26, and on fibrillation an aortic cross clamp was applied and potassium-rich cold crystalline cardioplegic solution was administered through the aortic root with satisfactory cardiac arrest. Subsequent doses were given down the vein grafts as the anastomoses were completed and via the coronary sinus in a retrograde fashion. Attention was directed to the right coronary artery. The end of the greater saphenous vein was then anastomosed thereto with 7-0 continuous Prolene distally. The remaining graft material was then grafted to the left anterior descending at the junction of the middle and distal third. The aortic cross clamp was removed after 149 minutes with spontaneous cardioversion. The usual maneuvers to remove air from the left heart were then carried out using transesophageal echocardiographic technique. After all the air was removed and the patient had returned to a satisfactory temperature, he was weaned from cardiopulmonary bypass after 213 minutes utilizing 5 g per kilogram per minute of dopamine. The chest was closed in the usual fashion. A sterile compression dressing was plied, and the patient returned to the surgical intensive care unit in satisfactory condition.

The physician performed a four-vessel autogenous (one vein, three arteries) coronary bypass. Select the CPT code(s) for this procedure

A patient presented for a median sternotomy for exploration of the space around the lung sacs. A cyst was excised in the mediastinum. Select the CPT code for this procedure.

A patient presents to the cardiac procedure room for placement of a ventricular electrode. Select the CPT code for this procedure.

A 57-year-old man has a Tesio catheter placed via the subclavian vein. Both catheter sites are attached to a subcutaneous port. Choose the code(s) for the service.

The man in the previous question had to return to the OR to have the Tesio catheter and port removed 6 weeks later due to infection. Choose the code(s) and modifiers for this subsequent service.

Patient has to return to the OR 6 weeks after the initial combined arterial/venous grafting coronary artery bypass operation. The CABG was done with a saphenous veing and an internal mammary artery.

Coronary AV fistula correction + coronary endarterectomy

What code would you report for a cervical approach of a mediastinotomy with exploration, drainage, removal of foreign body, or biopsy?

Dr. Sacra performed a CABG surgery on Fred five months ago. Today, Dr. Sacra completed another coronary artery bypass using three venous grafts with harvesting of a femoropopliteal vein segment. How would Dr. Sacra report her work for the current surgery?

What do the primary codes 33880 and 33881 include?

Mrs. Reyes had a temporary ventricular pacemaker placed at the start of a procedure. This temporary system was used as support during the procedure only. How would you report the temporary system?

Mr. Azeri, a 68-year-old patient, has a dual-chamber pacemaker. The leads in this system were recalled. The leads were extracted via transvenous technique, the generator was left in place, and new leads were inserted via transvenous technique. How would you report this procedure?

A 35-year-old female patient with a venous catheter requires a blood sample for hematology testing. The sample is collected via her PICC catheter. How would you report this procedure?

A patient underwent a secondary percutaneous transluminal thrombectomy for retrieval of a short segment of embolus evident during another percutaneous intervention procedure. How would you report this secondary procedure?

Procedure: Dual chamber pacemaker defibrillator implantation. Indications: A 67-year-old white gentleman who has significant underlying ischemic cardiomyopathy with EF of 25 percent, prior infarcts, remote history of syncope and at high risk for malignant ventricular arrhythmias. He has had a recent T wave alternans test which was clearly abnormal. He has had episodes of resting bradycardia also noted. He also meets Madit II criteria for ICD implantation. Description of Procedure: After informed consent had been obtained, the patient was brought to the outpatient hospital lab in the fasting state. The left anterior chest was prepped and draped in a sterile fashion. Intravenous sedation and local anesthetic were given. After local anesthetic, a 5 cm incision was made at the left deltopectoral groove. With blunt dissection and cautery, this was carried down through the prepectoralis fascia. The cephalic vein was identified and ligated distally. Through the venotomy, a subclavian venogram was performed to provide a roadmap. The atrial and ventricular leads were then advanced into the vessel to the level of the right atrium under fluoroscopic guidance. The ventricular lead was maneuvered to the right ventricular outflow tract and then through the RV apex where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. The atrial lead was maneuvered to the anterolateral right atrial wall where it was actively fixed. Good sensing and pacing thresholds were demonstrated. The lead was anchored to the pre-pectoralis fascia with interrupted 2-0 Tycron sutures. 10 volt pacing did not result in diaphragmatic capture. A subcutaneous pocket was created with good hemostasis achieved. The pocket was subsequently irrigated with solution of Bacitracin. The generator was connected to the lead and then placed in the pocket with no tension on the lead. The deep fascial layer was closed with interrupted 2-0 Vicryl suture. The subcutaneous closure was made with running 3-0 Vicryl suture. Subcuticular closure was made with running 4-0 Vicryl suture. Steri-strips were applied. Ventricular fibrillation was induced with a T wave shock. This was successfully sensed and terminated with a 15 joule shock to sinus rhythm. High voltage impedence was 39 ohms. Dry dressing was placed over the wound. The patient returned to the floor in stable condition without apparent complications. Which of the following codes accurately describes the basic procedure summarized in this report?

At the patient’s bedside in the hospital, a PICC line is inserted. Using Xylocaine local anesthesia, aseptic technique and ultrasound guidance, a 21 gauge needle was used to aspirate the right cephalic vein of a 72-year-old patient. When blood was obtained, a 0.018 inch platinum tip guidewire was advanced to the central venous circulation. A 6 French dual lumen PICC was introduced through a 6 French peel-away sheath to the SVA RA junction and after removal of the sheath, the catheter was attached to the skin with a STAT-LOCK device and flushed with 500 units of Heparin in each lumen. A sterile dressing was applied and the patient was discharged in improved condition. Code the procedure(s).

A 62-year old female with three-vessel disease and supraventricular tachycardia, which has been refractory to other management. She previously had pacemaker placement and stenting of the coronary artery stenosis, which has failed to solve the problem. She will undergo CABG with autologous saphenous vein and a modified MAZE procedure to treat the tachycardia. The risks and benefits have been discussed and the patient wishes to proceed. She is brought to the cardiac OR and placed supine on the OR table. She is prepped and draped and adequate endotracheal anesthesia is assured. A median sternotomy incision is made and cardiopulmonary bypass is initiated. The endoscope is used to harvest an adequate length of saphenous vein from her left leg. This is uneventful and bleeding is easily controlled. The vein graft is prepared and cut to the appropriate lengths for anatomosis. Three bypasses are performed, one to the LAD, one to the circumflex and another distally on the circumflex. A modified maze procedure was then performed and the patient was weaned from bypass. Once the heart was once again beating on its own again, we attempted to induce an arrhythmia and this could not be done. At this point, the sternum was closed with wires and the skin reapproximated with staples. The patient tolerated the procedure without difficulty and was taken to the PACU. Choose the procedure code(s) for this service.

The patient is a 67 -year-old gentleman with metastatic colon cancer recently operated on for a brain metastasis, now for placement of an Infuse-A-Port for continued chemotherapy. The left subclavian vein was located with a needle and a guide wire placed. This was confirmed to be in the proper position fluoroscopically. A transverse incision was made just inferior to this and a subcutaneous pocket created just inferior to this. After tunneling, the introducer was placed over the guide wire and the power port line was placed with the introducer and the introducer was peeled away. The tip was placed in the appropriate position under fluoroscopic guidance and the catheter trimmed to the appropriate length and secured to the power port device. The locking mechanism was fully engaged. The port was placed in the subcutaneous pocket and everything sat very nicely fluoroscopically. It was secured to the underlying soft tissue with 2-0 silk stitch. What code should be used for this procedure?

The patient is a 59-year-old white male who underwent carotid endarterectomy for symptomatic left carotid stenosis a year ago. A carotid CT angiogram showed a recurrent 90% left internal carotid artery stenosis extending into the common carotid artery. He is taken to the operating room for re-do left carotid endarterectomy. The left neck was prepped and the previous incision was carefully reopened. Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was systematically heparinized and after a few minutes clamps applied to the common carotid artery and its branches. A longitudinal arteriotomy was carried out with findings of extensive layering of intimal hyperplasia with no evidence of recurrent atherosclerosis. A silastic balloon-tip shunt was inserted first proximally and then distally, with restoration of flow. Several layers of intima were removed and the endarterectomized surfaces irrigated with heparinized saline. An oval Dacron patch was then sewn into place with running 6-0 Prolene. Which CPT code should be used?

79-year-old male with symptomatic bradycardia and syncope is taken to the Operating Suite where an insertion of a DDD pacemaker will be performed. A left subclavian venipuncture was carried out. A guide wire was passed through the needle, and the needle was withdrawn. A second subclavian venipuncture was performed, a second guide wire was passed and the second needle was withdrawn. An oblique incision in the deltopectoral area incorporating the wire exit sites. A subcutaneous pocket was created with the cautery on the pectoralis fascia. An introducer dilator was passed over the first wire and the wire and dilator were withdrawn. A ventricular lead was passed through the introducer, and the introducer was broken away in the routine fashion. A second introducer dilator was passed over the second guide wire and the wire and dilator were withdrawn. An atrial lead was passed through the introducer and the introducer was broken away in the routine fashion. Each of the leads were sutured down to the chest wall with two 2-0 silk sutures each, connected the leads to the generator, curled the leads, and the generator was placed in the pocket. We assured hemostasis. We assured good position with the fluoroscopy. What code should be used for this procedure?

This 67 year-old man presented with a history of progressive shortness of breath, mostly related to exercise. He has had a diagnosis of a secundum atrioseptal defect for several years, and has had atrial fibrillation intermittently over this period of time. He was in atrial fibrillation when he came to the operating room, and with the patient cannulated and on bypass, The right atrium was then opened. A large 3 x 5 cm defect was noted at fossa ovalis, and this also included a second hole in the same general area. Both of these holes were closed with a single pericardial patch. What CPT and ICD-9 codes should be reported?

The patient is a 77 year-old white female who has been having right temporal pain and headaches with some visual changes and has a sed rate of 51. She is scheduled for a temporal artery biopsy to rule out temporal arteritis. A Doppler probe was used to isolate the temporal artery and using a marking pen the path of the artery was drawn. Lidocaine 1% was used to infiltrate the skin, and using a 15 blade scalpel the skin was opened in the preauricular area and dissected down to the subcutaneous tissue where the temporal artery was identified in its bed. It was a medium size artery and we dissected it out for a length of approximately 4 cm with some branches. The ends were ligated with 4-0 Vicryl, and the artery was removed from its bed and sent to Pathology as specimen. What code should be used for this procedure?

A patient underwent single lung transplant with cardiopulmonary bypass employed during the procedure.

A patient with a diagnosis of bradycardia underwent placement of permanent atrial pacemaker, but subsequently developed infection due to the battery after the surgery. Therefore, he was taken to the operating room for replacement of the battery. The patient was out of the postoperative period. The CPT codes are:

A 15-day-old preemie with birth weight of 2.5 kg underwent aortic valve plasty using transventricular dilation with cardiopulmonary bypass. The CPT codes are:

A patient with severe coronary artery disease underwent coronary artery bypass surgery. The surgeon performs repair of left anterior descending artery by procuring saphenous vein and repair of right coronary artery by procuring radial artery. Surgical assistance was required for procurement of saphenous vein. The appropriate codes the surgeon should bill for are:

A surgeon performs repair of abdominal aortic aneurysm, caused by high-grade atherosclerosis.

Donor undergoes bone marrow harvesting for transplantation.

A patient with subarachnoid hemorrhage underwent selective catheterization of left and right common carotid arteries, left and right internal carotid arteries and arch aortogram. The physician should for:

Which of the following codes involves an arterial graft?

This moduar bifurcated device is used for what type of repair, how many docking limbs and reported with which 2005 CPT code?

Code for the reposition of a single chamber transveous pacemaker electrode after 16 days

Code for endovenous ablation therapy of 4 incompetent veins, lower leg. Approach was percutaneous. Technique used radiofrequency wave.

The bypass graft was performed in axillary brachial using vein graft

Code for intramural unroofing of an aortic origin of coronary artery.

A 56-year-old patient refractory ventricular tachycardia receives an implantable cardioverter-defibrillator with leads placed transvenously into the right atrium and right ventricle. This is the first time the patient is receiving such an implant. What is the correct CPT codes to report this procedure?

A patient with significant coronary artery disease undergoes a coronary artery bypass graft procedure. The surgeon performs the procedure using two venous grafts taken from the saphenous vein and one arterial graft taken from the right internal mammary artery. Assign the correct CPT codes for this procedure.

A 62-year-old patient with severe claudication of bilateral lower extremities undergoes a percutaneous angioplasty of the left external iliac artery via right common femoral approach using imaging guidance. Assign the correct CPT code(s) for this procedure.

Complete the following statement: To qualify as a central venous access device (CVAD), the catheter:

A 78-year-old patient is seen for a poorly functioning ortacath. After evaluation, the physician determines the catheter needs to be replaced. He removes the tunneled, centrally inserted CVAD with a subcutaneous port and replaces the same type through the same access site. Assign the correct CPT codes for this procedure.

Where can more codes relating to the cardiovascular system be found in CPT?

Patient undergoes a 3 venous, 2 arterial CABG using the saphenous vein, femoropopliteal vein and the radial artery, harvested by the surgeon performing the grafts. The venous grafts were procured using endoscopiv harvesting techniques. What CPT codes are reported?

Patient presents for removal and replacement of her permanent dual chamber pacemaker system (generator and leads). What CPT codes are reported?

Patient had mitral valve prolapsed, and a mitral valve ring was inserted with cardiopulmonary bypass. What CPT code is reported?

Catheter advanced from the left femoral artery into the aorta, manipulated into both the left and right renal arteries for imaging. What CPT code(s) is/are reported?

During an inpatient stay, patient is taken to the cath, lab. A catheter is placed in the aortic arch, right and left vertebral arteries, and right and left common carotids. Imaging with interpretation and report is performed in each location. What CPT codes are reported?

A 5 French pigtail catheter was placed in the abdominal aorta and a run-off was performed following injection of 80 cc of contrast. Oblique DSA images of the iliac circulation were performed following 2 injections, each 15 cc. The catheter was not moved to another position within the aorta for the additional injections. What CPT codes are reported?

A catheter was advanced into the left and right renal artery, and the superior mesenteric artery (SMA), and imaging was performed in all vessels. What CPT codes are reported?

A catheter is placed at the level of the renal arteries for the abdominal aortography and then moved to the level of the bifurcation of the aorta for pelvic angiography demonstrating stenosis in the left external iliac. The right external iliac, femoral, and popliteal arteries are normal. What CPT codes are reported?

Catheter placed in the main trunk, contrast may be injected, images may be taken, the catheter is not moved into any other branches is called