AAPC Chapter 10 Practical Applications

Case 1: Triple Vessel Bypass and Aortic Valve Replacement

• Preoperative diagnoses include severe two-vessel coronary artery disease and moderate aortic stenosis.
• Postoperative findings confirmed the same diagnoses.
• Operative procedures included triple-vessel coronary bypass grafting and aortic valve replacement.
• Key occlusions: 70% in distal left main, 80% in proximal left anterior descending (LAD), and 95% in proximal ramus intermedius.
• Significant aortic valve gradient measured at 40 mm Hg, indicating severe stenosis.
• Anesthesia was general; performed under cardiopulmonary bypass.
• Vein and arterial grafts included left internal mammary to LAD and reverse saphenous veins to diagonal branches.
• 23 mm bovine pericardial bioprosthesis used for the aortic valve replacement.
• CPT® and ICD-10-CM codes: 33405, 33533-51, 33518, 33508, I35.0, I25.110.

Case 2: Coronary Artery Bypass Graft x 4

• Preoperative diagnoses: Coronary artery disease and hypercholesterolemia.
• Surgical intervention included four coronary artery bypass grafts (CABG).
• Operative techniques: Left internal mammary artery to obtuse marginal artery, right internal mammary artery to LAD, with two reverse saphenous vein grafts.
• Patient history included hypertension; presented with a positive stress test indicating ischemic heart disease.
• Anesthesia: General endotracheal; procedure completed with use of cardiopulmonary bypass.
• Five bypass grafts methodically anastomosed using 6-0 and 7-0 Prolene sutures.
• CPT® and ICD-10-CM codes: 33534, 33518, 33508, I25.10, E78.00.

Case 3: Aortic Valve Replacement and CABG x 2

• Preoperative diagnoses: Critical aortic valve stenosis, coronary artery disease, hypertension, diabetes mellitus.
• Aortic valve replacement performed with a 19 mm St. Jude bioprosthesis.
• Two coronary artery bypass grafts executed using reverse saphenous vein grafts.
• Significant findings included severe calcification of the aortic valve as well as critical aortic valve stenosis.
• General anesthesia induced; procedure involved opening of the mediastinal cavity.
• Cardiopulmonary bypass employed to facilitate precise surgical intervention during valve reemplazo.
• Thorough examination confirmed graftable vessels with satisfactory flow measurements.
• CPT® and ICD-10-CM codes: 33405, 33511-51, 33508, I35.0, I25.10, I10, E11.9.

Case 4: Insertion of Ventricular Pacemaker Lead

• Preoperative diagnoses comprised ischemic cardiomyopathy, intraventricular conduction delay, and congestive heart failure.
• Procedure focused on the insertion of a left ventricular epicardial pacemaker lead and generator change.
• Patient had a dual-system pacemaker that required generator replacement.
• Surgery accessed through a left posterior thoracotomy technique for lead placement.
• Antibiotic saline used for irrigation post-explantation; reconnections verified adequate thresholds.
• Single left pleural drain placed; patient transferred to the coronary care unit post-op in stable condition.
• CPT® and ICD-10-CM codes: 33202, 33224-51, I25.5, I45.9, I50.9.

Case 5: Repair of Sinus of Valsalva Aneurysm

• Preoperative diagnosis indicated a sinus of Valsalva aneurysm on the left coronary sinus.
• Postoperative status confirmed the same diagnosis post-repair.
• Operation involved the repair of the aneurysm using a pericardial patch.
• Factors included administration of general endotracheal anesthesia and standard surgical preparations.
• Rectal temperature monitoring, Foley catheter, and TEE probe utilized during the surgery.
• Patient care included meticulous surgical techniques and procedural rigor to ensure patient safety.### Procedure Overview
• Median sternotomy used for chest opening, allowing access to the heart and surrounding structures.
• Patient fully heparinized and placed on cardiopulmonary bypass for surgical intervention.

Pericardial Dissection

• Significant adhesions and blood-tinged fluid encountered upon opening the pericardium.
• Tonsil clamps assisted in managing the pericardial sac and dissecting adhesions.
• Right atrium and aorta exposed; lighter adhesions on the left ventricle addressed by finger dissection.

Aortic Aneurysm Repair

• Aortotomy performed to access and identify the aneurysm.
• Removal of thrombus; decision made not to debride laminar thrombus adhered to aneurysm.
• Aneurysm located at the left side of the sinus of Valsalva, with coronary artery easily probed.

Surgical Technique

• Bovine pericardial patch sized and sutured in place using 4-0 Prolene suture in a running technique.
• Ensured complete exclusion of the aneurysm while retaining tissue integrity for coronary reconnection.

Postoperative Monitoring and Closure

• Cardioplegia given retrograde, confirming competent repair with no aortic insufficiency noted.
• Chest closed with stainless steel wires, fascia closed using Vicryl sutures, and skin closed with similar technique.

CPT® and ICD-10-CM Code Definition

• CPT® Code: 33720
• ICD-10-CM Code: Q25.49

Case Details for Aortic Aneurysm Repair

• Left thoracotomy performed for a 6.7 cm descending thoracic aortic aneurysm with type B dissection.
• Heparin administered, followed by partial bypass to maintain lower extremity blood pressure during surgery.
• Aortic cross-clamping and controlled luminal resection ensured proper repair technique.

Graft Placement

• 34 mm Gelweave graft utilized for repair; careful attention to anastomosis to prevent leaks.
• Utilized pledgeted sutures for reinforced closure.

Postoperative Condition

• Patient tolerated procedure well; all incisions closed and monitored post-anesthesia.
• CPT® Code: 33875; ICD-10-CM Codes: I71.2, I71.01

Tricuspid Valve Replacement

• Re-replacement of a 10 year-old tricuspid valve performed due to prosthetic valve endocarditis.
• Systemic heparin and cannulation of vessels for bypass prior to valve removal.

Valve Replacement Procedure

• 31 mm Carpentier-Edwards pericardial bioprosthesis selected; sutures placed in ventriculoatrial fashion around new valve.
• Thorough inspection and closure of the atrium to ensure stable hemodynamics post-procedure.

Postoperative Follow-Up

• Temporary drains placed; hemostasis checked before surgical site closure.
• CPT® Codes: 33465, 33530; ICD-10-CM Codes: T82.6XXA, I07.9

Varicose Vein Removal

• Multiple incisions performed for the removal of varicose veins in the right lower leg, addressing both major saphenous systems.
• All segments excised down to the knee with meticulous hemostasis.

Postoperative Management for Varicose Veins

• Wrapped leg for support after surgery; no complications noted.
• CPT® Codes: 37722-RT, 37718-51-RT; ICD-10-CM Code: I83.811

Pericardial Window for Tamponade

• Subxiphoid approach utilized for pericardial window to relieve cardiac tamponade due to malignant effusion.
• Approximately 500 ml of serosanguineous fluid suctioned for cytology.

Drain Placement and Closure

• Blake drain placed on the heart's diaphragmatic surface; wounds closed post-procedure for stability.
• CPT® Code: 33025; ICD-10-CM Codes: C79.89, C34.90, I31.4

Vas-Cath Placement for Dialysis

• Left subclavian Vas-Cath placed for CVVHD; successful insertion using Seldinger technique.
• Excellent flow achieved; patient prepared for ICU transfer post-operation.
• CPT® Code: 36556; ICD-10-CM Code: N17.9