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Code This!

Scenario Week of August 05, 2008:
View Current Scenario

Procedure:Revision of femoral-femoral bypass graft
Preoperative diagnosis:Atypical left hip and thigh pain Chronically occluded right-to-left femoral-femoral bypass graft; possible thrombus
Postoperative diagnosis:Thrombus of the artery of the lower extremity Atypical left hip and thigh pain

Indications:
This 70-year-old woman had a femoral-femoral bypass performed by me 12 years ago. In recent months she has developed some unusual left hip and thigh pain with just a few steps of walking. It is also positional while lying down and can be relieved by position changes. Her ankle/brachial index on the left is 0.54 and the skin of both feet is warm, pink, and dry with rapid capillary refill. An arteriogram demonstrated an occluded femoral-femoral graft, wide open right iliac system and distal system, occluded left iliac, and a patent femoral bifurcation with pretty good runoff in the left lower extremity.

Procedure:
The patient was placed in the supine position after spinal anesthesia. The abdomen, inguinal regions, and upper thighs were prepped and draped sterilely. A vertical incision was taken through the old left femoral scar. It was extended through subcutaneous tissue down to the left extent of the old femoral-femoral graft. This was dissected out and followed down to the femoral artery. The superficial femoral artery and profundus femoris arteries were identified and dissected free. The dissection was carried up on the lateral side of the femoral artery. The graft was transected and artery was rotated out and I was able to dissect out the medial aspect of the femoral artery.

The graft was excised from the artery. The patient was heparinized with 4000 units of heparin. Clamps were placed on the profundus femoris and superficial femoral arteries. The plaque in the common femoral artery was removed with an elevator until I exposed the open orifices of the SFA and PFA. These arteries and their orifices were soft and free of plaque.

The profundus femoris was quite a small artery and I elected to extend the incision down onto the superficial femoral artery rather than onto the profundus femoris artery. The remaining old graft was inspected. Most of the graft was filled with serum. The preoperative arteriography showed that about the first 2 cm of the right side of the graft were open.

I passed a #5 Fogarty catheter over through to the right side of the graft and withdrew it and pulled back some old thrombus and I got back some bright red blood. I passed it once again through the anastomosis and then pulled it back and got a plug of thrombus with a meniscus and an excellent arterial flow. With the graft unoccluded, there was an excellent pulse suprapubically in the graft. The graft was filled with heparinized saline and then clamped with a graft clamp.

A length of 8 mm Dacron graft was brought to the table and a portion of that was anastomosed end-to-end to the old graft with continuous 5-0 Prolene. The other end of this new graft was beveled and then anastomosed to the femoral artery with the toe extending onto the SFA. This anastomosis was completed with continuous 5-0 Prolene. Just prior to completion of the suture line, the vessels were back-flushed and clamped and the graft was flushed and clamped. The suture line was completed and the knots were tied. Clamps were released and there was noted to be an excellent pulse in the graft and also an excellent pulse in the outflow SFA and PFA.

Small bleeding points in the dissection areas were cauterized. Once I was satisfied with hemostasis, the groin wound was closed with three deep layers of continuous 3-0 Vicryl and the skin edges were approximated with continuous 4-0 Vicryl in a subcuticular fashion along with Steri-Strips. Dressings were applied.

Prior to leaving the operating room I had good Doppler signals in both feet. The patient was taken to recovery room in good condition.


CPT Codes

35883-Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium)

ICD-9-CM Codes

444.22 - Arterial embolism and thrombus of arteries of the lower extremities
719.45 - Pain in joint, pelvic region and thigh
729.5 - Pain in soft tissues of limb

Rationale:

CPT Codes

Report the revision of the femoral-femoral bypass graft with code 35883. A single code is used to report the revision of the graft with nonautogenous patch (Dacron) and thrombectomy as described in the report.

CPT guidelines indicate that code 35876 is used to report a thrombectomy of an arterial graft. However, guidelines state that code 35883 cannot be reported with code 35876. Although code 35883 does not specifically state that a thrombectomy is included when performed with the graft revision, the services of a thrombectomy cannot be reported in addition to the revision. Note that CCI edits will allow codes 35883 and 35876 to be reported with a modifier 59, but this operative report does not meet the qualifications of distinct procedure.

ICD-9-CM Codes

The thrombus of the artery of the lower extremities is the primary diagnosis and reported with 444.22. The hip and leg pain are reported as secondary diagnoses.

HCPCS Codes

As this procedure is performed in a facility, no supplies are reported separately.

 

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