CPT Coding I don\'t really know what subject this would be under. \"The followin

Question

CPT Coding

I don't really know what subject this would be under.

"The following documentation is from the health record of a patient who received hospital outpatient surgical services.

Preoperative Diagnosis: Hypertensive cardiovascular disease with end stage renal disease and congestive heart failure

Postoperative diagnosis: Same

Procedure: Placement of AV fistula with Gore-Tex graft of the right forearm for dialysis access

Description: After placement on the operating table the patient was premedicated with .05 mg of Versed. The right arm was prepped and draped in the usual sterile fashion. Following the infiltration of 1 percent lidocaine, a transverse incision was made just beyond the antecubital fossa. Dissection was carried down the basilic vein and artery were identified and mobilized and Silastic loops were placed. Another incision was then made just above the wrist. A 6-mm Gore-Tex graft was passed in a superficial subcutaneous tunnel through the loop. End to end anastomosis was accomplished. The clamps were removed, allowing the blood to flow through the graft. Anastomosis was satisfactory. The skin incisions were repaired with a layered closure. Dressing was applied and patient returned to the outpatient recovery.

Provide CPT code(s) with description from coding manual."

Explanation / Answer

CPT Codes :

1.  Hypertensive cardiovascular disease with end stage renal disease and congestive heart failure

CPT Code : ICD-10-CM used for Hypertentive Heart Disease, Hypertension and Chronic Kidney Disease.

Assessment: For Hypertension with hypertensive chronic diastolic and congestive heart failure

CPT Codes : I11.0 for the hypertensive heart disease with heart failure and I50.32 for chronic diastolic heart failure.

2. Surgery :

CPT Code : 10021 – 69990.

3. Placement of AV fistula with Gore-Tex graft of the right forearm for dialysis access

CPT Code : 36901, 76937, placement of AV fiscula with Gore-Tex graft of the right forearm for dialysis access is performed for new right forearm AVF that is not maturing.

4. Dressing was applied and patient returned to the outpatient recovery.

CPT Code : 99211, is used for outpatient recovery and medical assistant for performing services such as dressing change, wound checks etc.

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