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Code This!

Scenario Week of July 16, 2014:
View Current Scenario

Assign the appropriate CPT diagnosis and procedure code(s) for the following scenario.

Preoperative Diagnosis
Critical right carotid artery stenosis

Postoperative Diagnosis
Critical right carotid artery stenosis

Operation Performed
Right carotid endarterectomy

Procedure in Detail: The patient was taken to the operating room, placed on the table in the supine position and placed under adequate general anesthesia. EEG monitoring was used throughout the procedure. Once under general anesthesia, the patient was prepped and draped in the normal sterile fashion on the anterior right chest and neck. Once positioned appropriately, an incision was made along the anterior aspect of the sternocleidomastoid muscle. Hemostasis was maintained with electrocautery. The dissection was carried down to the sternocleidomastoid muscle, a retractor was inserted to gain adequate exposure, and the muscle was retracted laterally.

The dissection was then carried down to the carotid sheath, which was then opened. The anterior facial vein was ligated and cut with #2-0 silk ties. The carotid sheath was opened, and the common carotid artery was dissected out proximally and then we carried dissection up to the external and internal carotid artery. The superior thyroid artery was identified going up the external carotid all the way up to the level of the hypoglossal nerve, which was identified and spared throughout the procedure. Once these arteries were completely mobilized, vessel loops were placed around the distal internal carotid, external carotid, and the proximal common carotid. Heparin 10,000 units was administered per anesthesia. A clamp was then placed first on the internal carotid, then the external carotid, and then the common carotid. The common carotid artery was opened sharply with a #11 blade, and the internal carotid artery was opened up to pass the level of the stenotic lesion.

Once this was opened, an endarterectomy was performed using a Penfield dissector and forceps. The internal carotid artery lesion was dissected out nicely, and this feathered out well with no plaque remaining in the internal carotid. The plaque was completely removed. The external carotid artery plaque was also removed without complications, and this also tapered off well. The area was then irrigated with heparinized saline solution. All intimal plaque was removed. The arteriotomy was then closed with #6-0 Prolene suture, starting distally on the internal carotid and running down proximally. A second suture was started proximally on the common carotid artery and brought out to the middle of the arteriotomy. The internal, external and common carotid arteries were flushed to remove air or debris.

The closure was then completed. The clamp was then taken off the external carotid and the common carotid to flush out any debris out the external, and then the internal carotid clamp was removed. The area was irrigated with antibiotic saline solution. Hemostasis was achieved. The suture line looked very good without any sign of bleeding. The right neck incision was then closed appropriately. The wounds were dressed in a sterile manner. Instrument counts and sponge counts were correct at the end of the procedure. The patient tolerated it well and was sent back to recovery room in a very stable condition.

Please assign the correct CPT codes for the procedure above.


CPT Code
35301-RT Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision

In the index of CPT 2014, Professional Edition, under the main term “carotid artery,” the coder is directed to see “artery, carotid.” Under the main term “artery” and subterms “carotid” and then “thromboendarterectomy,” the codes provided are 35301 and 35390. Reviewing these codes in the main section of the book, the code description for 35301 describes a “Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision.”

CPT guidelines indicate that the code for thromboendarterectomy is used when “plaque or thrombus” is removed from the artery. There is not a CPT code for carotid endarterectomy. In this case it would be appropriate to use CPT code 35301 with modifier RT, because the procedure was performed on the right carotid artery.

The index also referenced code 35390 for a reoperation of a carotid thromboendarterectomy. There is no documentation in the procedure note that indicates this is a reoperation. It would be inappropriate to also report this code. It is important that coders turn to the body of the CPT to verify the code description and not rely on the index only.

Diagnosis Code
433.10 Occlusion and stenosis of carotid artery without mention of cerebral infarction

In the alphabetic index, the main term “Stenosis” and subterms “artery,” “carotid,” and “carotid artery” direct the coder to see “Narrowing, artery, carotid.” The main term “Narrowing” and subterms “artery” and then “carotid” direct the coder to see code 433.1 and indicate that an additional digit is required. Confirmation is made by reviewing the code in the tabular section and selecting the appropriate 5th digit. In this case the appropriate 5th digit is a “0-without mention of cerebral infraction” because the record does not mention the presence of a cerebral infarction.

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