Question

A CRNA provided the anesthesia service and placed a TEE probe for monitoring. Dr. Larson was medically directing this case only. Dr. Larson inserted an arterial line in the left radial artery and a central line in the RIJ after the patient was anesthetized. This patient is assigned a status of -P3.

LOCATION: Inpatient, Hospital

PATIENT: Madeline Spencerson

CRNA performed with anesthesiologist

PHYSICIAN: David Barton, M.D.

ANESTHESIOLOGIST: Janice E. Larson, M.D.

PREOPERATIVE DIAGNOSES:
1. History of coarctation, status post repair.
2. Ventricular septal defect.
3. Congenital mitral stenonsis.

POSTOPERATIVE DIAGNOSES: Same.

PROCEDURES:
1. Closure of ventricular septal defect using a Dacron patch.
2. Repair of mitral valve.

ANESTHESIA: General.

BRIEF PREOPERATIVE HISTORY: The patient is a 10-month-old female with the diagnoses as outlined above. Patch closure of her ventricular septal defect is indicated for release of her large left-to-right shunt, which is producing pulmonary hypertension. In addition, she has congenital mitral stenosis. I have met with the parents, discussed the planned procedure, indications, and risks with them. Their questions have been answered and they understand and agreed to proceed.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine upon the operating room table and general anesthesia was induced by the anesthesiologist. An adequate level of general endotracheal anesthesia was achieved. Adequate peripheral IV access was obtained. A radial arterial line was placed, as was a central venous line by the anesthesiologist. A Foley catheter was inserted. Additional monitoring placed, and the patient's chest, abdomen, and groins were prepped and draped in the usual sterile manner. A median sternotomy incision was performed. A subtotal thymectomy was performed. The pericardium was opened in the midline and suspended from the edge of incision using a 3-0 Nurolon suture to create a pericardial well. There was an innominate vein, which was slightly smaller than normal. There was a small LSVC and a reasonable-size right superior vena cava. The right superior vena cava and the inferior vena cava were loosely encircled with umbilical tapes. Heparin was administered and pursestrings wereplaced for cannulation. Aortobicaval cannulation was achieved. The patient was connected to the heart-lung machine and bypass was instituted and we cooled to 32 degrees. An antegrade cardioplegic cannula was placed. The aorta was cross-clamped and cold antegrade blood cardioplegia was injected into the aortic root. Additional doses were given every 15 to 20 minutes throughout the cross-clamp. At this point, I placed a vent in the junction of the right superior pulmonary vein and left atrium and directed this into the left ventricle. I inspected the atrial septum and that was intact. There was a large coronary sinus to the right atrium, but this was completely roofed and was continuous with the left superior vena cava. Because of innominate vein, I just went ahead and placed a bulldog clamp on the small left superior vena cava. Working through the tricuspid valve, I could identify the ventricular septal defect. I placed pledgeted 5-0 Tevdek sutures in a horizontal mattress pattern around the periphery of the VSD taking care to avoid injury to the conduction system, tricuspid valve, and aortic valve. A total of 8 sutures were required. A Dacron patch was then brought up. The sutures were passed through the patch, the patch lowered into position, and the sutures were tied down. I gently probed the margins of the patch. I could identify no residual VSD. I made sure that the tricuspid valve was not entrapped. In fact, some valvuloplasty was required and I sutured the kissing points of the commissure between the anterior and septal leaflet together using horizontal mattress sutures of 5-0 Prolene suture and with this the valve appeared quite competent. Again, I inspected the atrial septum. I cannot identify an atrial septal defect. I made an incision in the fossa ovalis. I inspected the mitral valve. The anteromedial papillary muscle appeared to have a short, thick broad attachments to the commissure and I felt that this could be improved by splitting of the distal papillary muscle and this was accomplished. With this, the valve accommodated a 14-dilator easily, which should be the adequate size for this size patient and the valve was competent. So at this point, I closed the atrial septum using running 5-0 Prolene suture. Just prior to closing the septum, I de-aired the left side by filling with ice-cold saline and then having the anesthesiologist inflate the lungs while I tied down the atrial septal suture line. I then closed the right atriotomy in 2 layers with 6-0 Prolene suture. The patient was now placed in Trendelenburg position. The aortic root was placed under gentle suction and the cross-clamp was released. As we rewarmed, the cardiac action returned promptly and the sinus rhythm returned spontaneously. I placed chest tubes to drain the mediastinum and atrial and ventricular pacing wires were placed. De-airing was accomplished. When we reached a bladder temperature of 35 degrees, a transesophageal echo was carried out. This suggested some residual air in the apex of the left ventricle and this was directly aspirated with a needle and the aspiration site controlled with a Prolene suture. Following this, the LV was de-aired, and at this point, mechanical ventilation was briefly halted. The left ventricular vent was removed and a left atrial wire was placed in the vent site. Now, ventilation was underway, the patient was in Trendelenburg position, the aortic root was placed on gentle suction, and then we weaned from bypass. We weaned from bypass easily on the first attempt. After we weaned from bypass, the root vent was clamped. Transesophageal echo was carried out, which showed good biventricular function. The ventricular septal defect was intact except for a tiny peripatch leak. The atrial septum was intact. So at this point, modified ultrafiltration was carried out and when this was completed, the venous cannula was removed. Protamine was administered, and when protamine administration was completed, the arterial cannula was removed. When hemostasis was complete, preparation was made for closure. Chest tubes, intracardiac lines, and pacing wires were all secured to the various sites of the skin using nylon suture. The pericardium was loosely approximated over the base of the heart. It should be noted that the bulldog clamp in the left superior vena cava was removed as we were closing the atriotomy. Once the incision was closed in layers, a dry sterile dressing was applied, and the patient was transported back to the intensive care unit in a serious, but stable condition.

Answer 1

ICD -10 -CM code is the tenth classification of disease ,used by healthcare professionals for coding purpose and insurance company for reimbursement purpose . CPT is the current procedural terminology .It is used to code a procedure. ICD -10-CM code for the following is :-

1. Ventricular septal defect - Q 21.0
2. Congenital mitral stenonsis - Q 23.2

CPT code for the following procedures:-
1. Closure of ventricular septal defect using a Dacron patch - 33684
2. Repair of mitral valve- 33430