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Direct Repair or Excision of Aneurysm or Pseudoaneurysm

P R o C E D U R E :

Aneurysm is defined as an abnormal dilation of an artery. Artery size varies by age, sex, and other factors, so attempts to define absolute size is difficult. Aneurysms are generally defined as a localized increase in size greater than 50% compared to the adjacent normal artery. The infrarenal abdominal aorta is the most common clinical location, but many different vessels may become aneurysmal. A true aneurysm involves dilation and weakness in all the layers of the artery versus pseudoaneurysms that do not. Causes include collagen vascular disease, dissection, infections, trauma, and atherosclerosis. Decreased elastin levels are commonly found, as well as increased familial incidence suggesting genetic factors, with atherosclerosis playing less a role than originally thought. Pseudoaneurysms (e.g., false anastomotic) often involve the separation of the graft from the native vessel. They may also be traumatic (knife wound) or iatrogenic (from needle punctures during catheterization procedures). A pseudoaneurysm is a collection of blood outside the native vessel. The surgical approach and type of repair varies with anatomic location and type of aneurysm. This may involve a thoracic incision, a median sternotomy, transabdominal, retroperitoneal, or peripheral approach. In general, proximal and distal control is achieved, systemic heparinization may be utilized, and repair is undertaken. Endoaneurysmorrhaphy involves incision into the aneurysm with removal of thrombus and oversewing of lumbar or collateral vessels. The graft (usually polyester or PTFE) is anastomosed proximally and distally to reestablish flow, and the aneurysm sac is sewn over the graft to prevent exposure of graft to the intestines. Smaller peripheral aneurysms may utilize excision with interposition graft. Extracranial aneurysms may undergo resection with graft placement, endoaneurysmorrhaphy, or ligation. Popliteal aneurysms are often bypassed with aneurysm exclusion. The CPT codes describing these procedures include repair of associated occlusive disease.

C l i n i C A l i n D i C AT i o n S :

aneurysms tend to increase in diameter over time with a corresponding increase in the chance of rupture. Ruptured aneurysms carry a significant risk of mortality and so the decision to undertake repair may involve many factors such as the medical condition of the patient and the risk of rupture versus the risks of surgery. general indications include size greater than 5 cm for abdominal aortic aneurysms, rapidly enlarging aneurysms (greater than 5 mm growth in 6 months), or symptomatic aneurysms (e.g., pain or compression symptoms). in general, pseudoaneurysms should be repaired when discovered.

CPT © 2008 American Medical Association All Rights Reserved

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C o D E S :

aortiC aneurysm repair

cPt cODe assistant at suRgeRY Allowed glObal suRgeRY 90 days cOsuRgeOns Paid with Documentation

PROceDuRe DescRiPtiOn Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, carotid, subclavian artery, by neck incision

CPT © 2008 American Medical Association All Rights Reserved

35001

35002

Allowed

90 days

Paid with Documentation

257

© 2003-2009 ZHealth Publishing All Rights Reserved

PROceDuRe DescRiPtiOn Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, vertebral artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, axillary-brachial artery, by arm incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal)

CPT © 2008 American Medical Association All Rights Reserved

cPt cODe

35005

assistant at suRgeRY Allowed

glObal suRgeRY 90 days

cOsuRgeOns Paid with Documentation

35011

Allowed

90 days

Paid with Documentation

35013

Allowed

90 days

Paid with Documentation

35021

Allowed

90 days

Paid with Documentation

35022

Allowed

90 days

Paid with Documentation

35045

Allowed

90 days

Paid with Documentation

35081

Allowed

90 days

Paid with Documentation

35082

Allowed

90 days

Paid with Documentation

35091

Allowed

90 days

Paid with Documentation

35092

Allowed

90 days

Paid with Documentation

258

© 2003-2009 ZHealth Publishing All Rights Reserved

PROceDuRe DescRiPtiOn Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, splenic artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, splenic artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, iliac artery (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral)

cPt cODe

35102

assistant at suRgeRY Allowed

glObal suRgeRY 90 days

cOsuRgeOns Paid with Documentation

35103

Allowed

90 days

Paid with Documentation

35111

Allowed

90 days

Paid with Documentation

35112

Allowed

90 days

Paid with Documentation

35121

Allowed

90 days

Paid with Documentation

35122

Allowed

90 days

Paid with Documentation

35131

Allowed

90 days

Paid with Documentation

35132

Excluded

90 days

Paid with Documentation

35141

Excluded

90 days

Paid with Documentation

CPT © 2008 American Medical Association All Rights Reserved

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© 2003-2009 ZHealth Publishing All Rights Reserved

PROceDuRe DescRiPtiOn Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, popliteal artery Reimplantation, visceral artery to infrarenal aortic prosthesis, each artery (List separately in addition to code for primary procedure)

cPt cODe

35142

assistant at suRgeRY Excluded

glObal suRgeRY 90 days

cOsuRgeOns Paid with Documentation

35151

Excluded

90 days

Paid with Documentation

35152

Excluded

90 days

Paid with Documentation

35697

Excluded

90 days

Paid with Documentation

Add-on Code Inpatient Only Procedure

C o D i n g i n S T R U C T i o n S :

1. Codes include establishing both local inflow and outflow by whatever procedure needed (e.g., endarterectomy) (2009 CPT, Section - Arteries & Veins, just before code 34001). 2. Per the National Correct Coding Initiative Policy Manual for Medicare Services (Version 14.3), Chapter 5, D. Cardiovasular System, pages V8-9, #5, "An aneurysm repair may require direct repair with or without graft insertion, thromboendarterectomy, and/or bypass. When a thromboendarterectomy is performed at the site of an aneurysm repair or graft insertion, the thromboendarterectomy is not separately reportable. If a bypass procedure requires an endarterectomy to insert the bypass graft, only the code describing the bypass may be reported. The endarterectomy is not separately reportable. If both an aneurysm repair (e.g., after rupture) and a bypass are performed at separate non-contiguous sites, the aneurysm repair code and the bypass code may be reported with an anatomic modifier or modifier -59. If a thromboendarterectomy is medically necessary due to vascular occlusion in a different vessel, the appropriate code may be reported with an anatomic modifier or modifier -59 indicating that the procedures were performed in non-contiguous vessels. At a given site, only one type of bypass (venous, non-venous) code may be reported. If different vessels are bypassed with different types of grafts, separate codes may be reported. If the same vessel has multiple obstructions and requires bypass with different types of grafts in different areas, separate codes may be reported. However, it is necessary to indicate that multiple procedures were performed by using an anatomic modifier or modifier -59."

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3. Completion angiograms are included, as well as confirmatory, positioning, sizing, and roadmapping angiograms. 4. Includes sympathectomy when performed during aortic procedure. 5. In 2005, two codes were deleted: 35161 ­ direct repair of aneurysm, pseudoaneurysm and other associated occlusive disease, other arteries; 35162 ­ for ruptured aneurysm, other arteries. To report these procedures, use unlisted code 37799. 6. For open repair of infrarenal aortic aneurysm or dissection plus associated arterial trauma repair following unsuccessful endovascular repair by tube prosthesis, use code 34830. · · · Use code 34831 for aorto-bi-iliac prosthesis. Use code 34832 for aorto-bifemoral prosthesis. Do not code failed endovascular procedure codes additionally.

7. For thoracic aortic aneurysms, open repair, use codes 33860 ­ 33877. 8. For intracranial aneurysm, open repair, use codes 61697 ­ 61705. 9. For ligation of carotid artery, use codes 37600 ­ 37606. 10. For endovascular repair of abdominal aortic aneurysm, use codes 34800 ­ 34826 plus S&I codes. Also code for additional procedures outside the stent graft deployment zone and catheter placements. Diagnostic angiography of the aorta, aortic branch vessels, and run-off is bundled. 11. For endovascular repair of thoracic aorta, use codes 33880 ­ 33891 plus S&I codes. Also code for additional procedures outside the stent graft deployment zone and catheter placements. Diagnostic angiography of the thoracic aorta, aortic branch vessels, and run-off is bundled. 12. For endovascular graft placement for repair of iliac artery aneurysm, pseudoaneurysm, AVM, or trauma, use codes 34900 and 75954 and catheter placement codes. Diagnostic angiography of the iliac and run-off vessels is bundled. 13. Use code 35697 (add-on code) for reimplantation of visceral artery to infrarenal aortic prosthesis.

E x A M P l E ( S ) :

1) A seventy-two year old patient presents with an infrarenal 6 cm AAA diagnosed by CT scan. Preoperative diagnostic angiograms are performed for decreased femoral pulses and reveal significant stenosis at the proximal iliac level. At surgery, heparin is given after dissection is performed, and cross clamps are placed just inferior to the renals after occluding the external iliacs. Lumbars are oversewn with silk ligature. The proximal aorta requires a localized endarterectomy secondary to significant, calcified plaque at the intended anastomotic site (no code ­ inflow procedure included). A PTFE aorto-bi-iliac graft is sewn in place (35102). Clamps

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are slowly released to reestablish flow. (Completion bilateral run-off angios are performed (no code), showing excellent results without distal embolization.) The aneurysm sac is closed over the graft to prevent aortoenteric fistula. A routine abdominal closure is performed. 2) A seventy-three year old presents to the emergency department (ED) with severe abdominal pain and hypotension. A CT scan reveals a large ruptured AAA. The patient is emergently brought to the OR for a transabdominal repair. After proximal and distal control, the blood pressure is stabilized, and a cell saver is utilized. Aortotomy is performed, and poor back bleeding is noted from the iliacs. A Fogarty embolectomy catheter is utilized with retrieval of a small amount of clot with improved back bleeding noted (no code ­ local outflow procedure). A tube graft is sewn end-to-end (35082). Because of sparse IMA bleeding and subjective dusky appearance to the bowel after clamp release, a decision is made to reattach the IMA. A punch graft aortotomy is made, and a Carrel patch technique is used to anastomose the IMA to the Dacron graft (35697). 3) After preoperative assessment, a patient with an infrarenal abdominal aortic aneurysm (AAA) is brought to the OR/angio suite for a planned endovascular repair with a modular stent graft. After bilateral femoral cutdowns, roadmapping angiograms are performed. In placing the second sheath, difficulty is encountered, and intraoperative angio confirms external iliac artery disruption. The patient becomes moderately hypotensive. Transfusions are initiated, and a retroperitoneal exposure is made. Open repair of the AAA with an aorto-bi-iliac graft and repair of the external iliac trauma is accomplished (34831). Note: Code 34831 includes the initial attempt at endovascular repair as well as repair of the external iliac artery. 4) A patient presents with a pulsatile mass in the right groin. A suboptimal CTA suggests a common femoral aneurysm. In the OR, a left femoral access is made, and a catheter is placed at the renal artery level with diagnostic angiography, revealing normal renal and visceral arteries and no aneurysmal disease (75625, 36200). The catheter is then placed in the right common iliac artery for unilateral extremity run-off, showing mild iliac disease, a large common femoral aneurysm, and good run-off (36245; 75710; delete 36200, as bundled). The aneurysm is repaired with an interposition prosthetic graft (35141). Completion angios show no evidence of distal embolization with continued 3-vessel run-off (no code). 5) A patient presents with a large internal carotid aneurysm. Preoperative ICA back pressures are measured by temporary balloon occlusion and found acceptable (see "Embolization" section). Plan is for primary repair, but, even with submandibular subluxation, this is not possible. Distal ligation is performed without neurologic sequalae (37605). 6) A popliteal artery aneurysm is diagnosed by CT and preoperative contrast angiography. Repair is via a medial approach. The popliteal aneurysm is excluded, and flow is established with a vein graft extending from the above-knee popliteal artery proximal to the aneurysm to the below-knee popliteal artery beyond the aneurysm (35151). Intraoperative completion angiogram is performed (included). 7) A patient presents with a proximal left subclavian artery pseudoaneurysm secondary to trauma. This is approached via a left thoracotomy to obtain proximal and distal control. An interposition prosthetic graft is used to reestablish blood flow (35021 - includes approach). 8) A multiparous female presents to the ED with abdominal pain and subsequent vascular collapse. Fluid reCPT © 2008 American Medical Association All Rights Reserved

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suscitation is initiated, and a CT scan reveals hemoperitoneum and a ruptured splenic artery aneurysm. Since the spleen is important for immunity, the surgeon is able to preserve the spleen by ligating the splenic artery proximally and distally to the aneurysm (35112).

R E f E R E n C E S :

CPT Assistant Dec 00:2, Dec 01:7, Sept 02:3, Feb 03:1 CPT Changes: An Insider's View 2001, 2002, 2004 National Correct Coding Initiative Policy Manual for Medicare Services, Version 14.3, Chapter V D5-8

R E l AT E D S E C T i o n S :

Endovascular Iliac Stent Grafts Endovascular Thoracic and Abdominal Aortic Stent Grafts Thoracic Aortic Aneurysm Bypass Graft Ligation Neurovascular Interventional Procedures Carotid Test Occlusion

CPT © 2008 American Medical Association All Rights Reserved

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