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CPT Clinical Vignettes

Please note: These examples do not suggest limiting the use of a code, but only represent the typical patient and service/procedure. They do not describe the universe of patients from whom the service/procedure would be appropriate. In addition, third-party payer reporting practices may differ.

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|0003T |  |Clinical Example (0003T) |

| | |A woman presents for her routine gynecologic examination. She is or has been sexually active and may or may not|

| | |have had any sexually transmitted diseases in the past. She may or may not be a smoker. More than likely, she |

| | |has not been recently diagnosed with any precancerous cervical disease, but she could be a follow-up patient |

| | |for low-grade disease or for post-treatment. |

| | |Description of Procedure (0003T) |

| | |At the time of the pelvic examination, after the Pap smear has been obtained, the cervix is wiped in a set |

| | |procedure with 5% acetic acid (white vinegar). The physician/practitioner takes 2 pictures within a specified |

| | |period of time with a special fixed focus flash camera. The remainder of the examination proceeds as usual for |

| | |a routine gynecologic examination. |

| | |The patient identification, cervigram numbers and her identifying data are recorded on a patient log sheet. |

| | |Usually the cervicography procedure is done on 10 patients before the patient log sheet and exposed film are |

| | |sent to National Testing Laboratories, where the film is developed into cervigram slides. The slides are |

| | |evaluated by NTL-certified evaluators only. The evaluators are experts in both colposcopy and cervicography |

| | |evaluation. Once the evaluation is complete, a cervigram report is returned to the physician/practitioner along|

| | |with a 4 x 6 color photograph of the cervigram slide. |

| | |Evaluations can be negative, atypical, positive or technically defective. The picture is to be placed in the |

| | |patient's chart for future reference. Negative and atypical evaluations require no immediate |

| | |physician/practitioner response. A positive evaluation recommends colposcopy. A technically defective |

| | |evaluation suggests a repeat cervicography procedure. The cervigram results are correlated with the Pap smear. |

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|0005T, |  |Clinical Example (0005T, 0007T) |

|0007T | |A 72-year-old male has recurrent unilateral transient ischemic attacks (upper extremity weakness and numbness) |

| | |and a corresponding side (contralateral) carotid bruit. Neurologic evaluation reveals no fixed neurological |

| | |deficit. Carotid arteriography shows an 80% focal internal carotid stenosis. Lesion calcification is modest and|

| | |no vascular filling defect is angiographically apparent. The patient has severe chronic obstructive pulmonary |

| | |disease and is considered to be in a relatively high-risk group for carotid endarterectomy. |

| | |Description of Procedure (0005T, 0007T) |

| | |The physician discusses the rationale for carotid endarterectomy, carotid stenting, alternatives and possible |

| | |complications. The patient desires carotid stenting and gives informed consent. A cerebral angiogram is |

| | |performed to evaluate all cerebral vasculature and intracranial hemodynamics (coded separately). The physician |

| | |performs quantitative arterial analysis to determine the appropriate size stent to be placed. The diagnostic |

| | |catheter is exchanged for an arterial guiding catheter. A guidewire and low-profile balloon are inserted into |

| | |the target artery and across the lesion. The balloon is gently inflated, then removed and replaced by a stent |

| | |deployment system. The stent is deployed. Bradycardia and hypotension are treated with intravenous boluses of |

| | |fluid and/or vasopressors as necessary. Angiography shows a suboptimal result and a balloon is inserted over |

| | |the guidewire to expand the stent further. Final angiography is performed and the guiding catheter is removed. |

| | |The patient's neurological status is checked by the physician at the end of the procedure and then again in 4 |

| | |and 12 hours. The femoral arterial sheath is removed when the ACT drops low enough. The procedure and results |

| | |are discussed with the patient. Reports of the interventional procedure and the diagnostic interpretation are |

| | |generated. |

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|0008T |  |Clinical Example (0008T) |

| | |A 28-year-old patient presented with uncomplicated gastroesophageal reflux disease (GERD). GERD history was |

| | |obtained including: (1) length of time (months) patient has experienced GERD symptoms, (2) description and |

| | |severity of symptoms using a GERD Scoring System, and (3) a detailed medication history, dose and frequency. |

| | |Endoscopy was conducted previously and showed esophagitis grade 2 and < 2 cm hiatus hernia. Manometric testing |

| | |revealed a lower esophageal sphincter (LES) average resting pressure of 8-mm Hg. 24-hour ambulatory pH |

| | |measurement showed that the patient sustained a pH < 4 for more than 4 percent of the time following |

| | |discontinuation of all GERD medications. |

| | |Description of Procedure (0008T) |

| | |Under appropriate anesthesia, the endoscope is inserted and prior endoscopic findings are confirmed. An |

| | |esophageal overtube is placed. The endoscope is withdrawn and the endoscopic suturing system is introduced |

| | |transorally. |

| | |The endoscopic suturing system is advanced through the overtube and just beyond the squamocolumnar junction. By|

| | |application of wall suction, a fold of tissue is suctioned into the suturing capsule and a stitch is placed |

| | |into the mucosa. The system is withdrawn pulling the running suture through the gastric fold. |

| | |The suture is reloaded into the system and the endoscope/suturing system is reinserted. A second stitch is |

| | |place at a location adjacent to the first. The suturing system is withdrawn. Knots are tied extracorporally and|

| | |pushed through the overtube to oppose the sutured tissue and create an internal gastric plication. Using a |

| | |suture cutter, excess suture material is cut off. The process is repeated one or more times to create |

| | |additional gastric plication as warranted based on clinical conditions. The system and overtube are removed. |

| | |The patient is reintubated with the endoscope to evaluate lower esophageal sphincter tone post-procedure. |

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|0009T |  |Clinical Example (0009T) |

| | |A 35-year-old woman presents to her physician with the complaint of heavy menstrual bleeding and fatigue which |

| | |disrupts her lifestyle and normal daily activities for up to 10 days during each month. Blood work results, |

| | |including hemoglobin and hematocrit, show her to be borderline anemic. Her physician performs an in-office |

| | |hysteroscopy and finds no evidence of submucosal fibroids or polyps which would explain the etiology of her |

| | |heavy bleeding. He performs a biopsy to rule out malignancy which is negative. Her physician prescribes |

| | |non-steroidal anti-inflammatory drugs with little effect. He then prescribes hormone therapy which seems to |

| | |work for a few months, but the side effects of the medication are not tolerated well by the patient. She has |

| | |completed childbearing but would prefer to retain her uterus, and desires a procedure which could be completed |

| | |in the physician's office or surgery center with minimal anesthesia. A procedure which would allow her to |

| | |return to her regular daily activities the first post-operative day would be optimal. |

| | |Description of Procedure (0009T) |

| | |Under appropriate anesthesia such as a paracervical block with or without oral or IV sedation, the patient is |

| | |placed in a dorsal lithotomy position. Using abdominal or vaginal ultrasound, the physician evaluates the size |

| | |and shape of the uterine cavity. Saline may be instilled in the bladder to facilitate ultrasound visualization.|

| | |The uterus is also sounded to evaluate the intrauterine length. The cervix may be dilated to 5-6 hegar and the |

| | |cryoprobe is inserted up to the fundus. Depending on the size of the uterine cavity, the physician may perform |

| | |up to 4 freeze cycles to adequately ablate the intrauterine cavity. Following the procedure, the patient is |

| | |ready to be discharged home with transportation assistance in 15 minutes to 2 hours, depending on the level of |

| | |sedation or if sedation is used. |

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|0010T |  |Clinical Example (0010T) |

| | |The patient is a 25-year-old male university student whose room-mate recently developed tuberculosis. The |

| | |patient is asymptomatic and has a clear chest x-ray. There is no record of a previous skin test for |

| | |tuberculosis and the patient does not recall ever having had a tuberculin skin test. |

| | |Description of Procedure (0010T) |

| | |A venous blood sample is taken and shipped to a pathology reference laboratory with a request to perform an in |

| | |vitro test for tuberculosis infection. Using a commercially available kit the laboratory measures gamma |

| | |interferon release from white cells in whole blood following incubation with tuberculin antigen. The results |

| | |are determined using a validated algorithm (supplied with the kit). The results are positive (significant |

| | |production of gamma interferon) indicating that the patient has become infected with tuberculosis. Tuberculosis|

| | |prophylaxis will be recommended. |

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|0012T, |  |Clinical Example (0012T, 0013T) |

|0013T | |An arthroscopic examination was performed where the anterior cruciate ligament (ACL) was noted to be totally |

| | |disrupted and a 15 mm-diameter chondral defect of the medial femoral condyle was identified. There was also a |

| | |lateral meniscal tear and small chondral fragments in the synovial fluid. The arthroscopic procedure performed |

| | |was as follows: joint fluid and fragment lavage, meniscal repair, ACL reconstruction and osteochondral |

| | |transplantation (the procedure in question). |

| | |Description of Procedure (0012T, 0013T) |

| | |Osteochondral transplantation is performed to transfer bone and articular cartilage from a non-weight or |

| | |minimally articulating area to a weight-bearing or often articulating area. A commercially available sharper |

| | |trocar is introduced to and through the articular surface of the intercondylar notch. In this harvester now is |

| | |an osteochondral cylinder. Routinely three or four transplants are harvested and range from 4-12 mm in |

| | |diameter. If allograft implantation is planned then up to a 3 cm implant may be used. A drill is inserted into |

| | |the knee, and very precisely, a tunnel is created through the exposed bone of the chondral defect. It is |

| | |mandatory that the tunnel is created perpendicular to the surface, or the soon-to-be placed implant will not |

| | |sit appropriately in the tunnel. If the transplant and its surface are malaligned, then there is risk to the |

| | |transplant and the adjacent articular surface. The chondral cap of the implant can be sheared off if there is |

| | |tunnel disorientation, or the transplant will "gouge" the adjacent articular surface. Once proper alignment is |

| | |assured, then the osteochondral graft is forced out of the trocar and into the tunnel. Every attempt is made to|

| | |get the transplant aligned and at the appropriate depth to restore a "normal" articular surface. |

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|0014T |  |Clinical Example (0014T) |

| | |A 30-year-old mechanic suffers acute onset of pain in the knee while squatting and twisting during work. He is |

| | |seen by his orthopaedic surgeon, who performs an arthroscopic subtotal medial meniscectomy for an irreparable |

| | |meniscal tear. He is treated conservatively, but develops increasing pain and difficulty with activities of |

| | |daily living. He is placed on anti-inflammatory medication, pain medication, is referred to physical therapy, |

| | |and is placed in a brace. The knee is injected with intra-articular medications without relief. The knee pain |

| | |is localized to the medial compartment and x-rays reveal minimal if any degenerative changes. |

| | |Description of Procedure (0014T) |

| | |An x-ray, MRI, or CT scan is obtained and sent to a meniscal allograft procurement institution. An appropriate |

| | |meniscus, for size, thickness and compartment is obtained and returned to the operating room for implantation. |

| | |The meniscal allograft, if cryopreserved, must remain completely frozen during this period. The patient is |

| | |taken to the OR and an arthroscopic total meniscectomy is performed. Depending on the surgeon's preference, |

| | |either a keyhole or two-tunnel approach is undertaken to insert and secure the meniscal transplant. A |

| | |two-tunnel approach will be described. Arthroscopically, the anterior and posterior attachments of the meniscus|

| | |are identified. Utilizing an ACL guide, two tunnels are created from the anterior tibia to the attachments of |

| | |the native anterior and posterior meniscal horns. These tunnels measure from 6-10 mm in diameter. The allograft|

| | |is prepared by preserving an anterior and posterior bone plug to fit into each bone tunnel that has been |

| | |created. Sutures are placed through the plugs. A small parapatellar or posterior medial arthrotomy is made to |

| | |allow introduction of the now thawed meniscal allograft. Once the often-difficult introduction is accomplished,|

| | |the sutures on the meniscus bone plugs are transported down and out the tunnels to the anterior tibia. The |

| | |sutures are tensioned to pull the meniscal bone plugs into the tibial tunnels, therefore stabilizing the |

| | |anterior and posterior attachments of the meniscus. Once stabilized, the arthrotomy is closed and an |

| | |arthroscopic suturing of the body of the meniscus is performed. Generally, 8-10 sutures are placed to secure |

| | |the transplant. A posterior medial incision is made to expose the sutures and posterior medial anatomic |

| | |structures. The sutures are then tied over the capsule, taking care to protect the saphenous nerve from injury.|

| | |The incisions are closed, and the patient is placed in a brace locked in full extension. |

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|0016T |  |Clinical Example (0016T) |

| | |A 72-year-old woman notes blurred vision of three months duration. On examination, the vision in the affected |

| | |eye is 20/100, and there is distortion on the Amsler grid. The remainder of the complete ophthalmic exam is |

| | |normal except for the presence of a serious elevation of the affected macula. Fluorescein angiography reveals |

| | |an occult choroidal neovascular membrane beneath the fovea. |

| | |Description of Procedure (0016T) |

| | |Transpupillary thermotherapy is delivered through a slit lamp laser delivery system. The surgeon uses a |

| | |modified infrared diode laser at 810 nm with an adjustable beam width and a 3 mirror Goldman lens. Treatment is|

| | |initiated with one spot for 60 seconds duration at a power setting between 360 and 1000 mW so that no visible |

| | |change or barely detectable light-gray appearance to the choroidal lesion is present at the end of the |

| | |treatment. |

| | |If any retinal whitening was observed, the power of the laser was decreased by 100 mW. Retreatment is performed|

| | |if there was no change in subretinal elevation on slit lamp biomicroscopy and when persistent leakage was |

| | |observed on late-phase fluorescein angiograms. |

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|0017T |  |Clinical Example |

| | |The service(s) is(are) continued for an additional 15 minutes with the same patient. |

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|0018T |  |Clinical Example (0018T) |

| | |The patient is a 34-year-old female with a six-year history of major depression. Her symptoms include severely |

| | |depressed mood on a daily basis, diminished activities with inability to conduct daily activities of living, |

| | |decreased sexual interest, initial insomnia, guilt feelings, somatic gastrointestinal complaints, intermittent |

| | |suicidal ideation, anxiety, and diminished concentration with a 17-item Hamilton Depression Rating Scale Score |

| | |of 27. She has failed to respond to two, six-week trials of different classes of antidepressants at therapeutic|

| | |doses and meets criteria for electroconvulsive therapy. She has no unstable medical conditions, and has no |

| | |contraindications to repetitive transcranial magnetic stimulation. |

| | |Description of Procedure (0018T) |

| | |The patient is seated in a chair and the physician places the ground, stimulating and reference surface EMG |

| | |electrodes in order to record motor-evoked potential (MEPs) of either the right abductor pollicis brevis (APB) |

| | |or right first dorsal interosseus (FDI). The physician then determines the motor threshold of the individual by|

| | |placing the therapy head over the top third of the left ear/left central scalp area. The patient is stimulated |

| | |at 1 Hz with an initial power setting of 20% while the physician moves the therapy head in one direction at a |

| | |time (up-down, back-forth) and increases the power setting in 2% increments as necessary until the lowest |

| | |stimulation intensity capable of inducing 5 out of 10 MEPs at an amplitude of at least 50 "V in the right APB |

| | |or FDI is identified. This position is marked through the positioning hole with the positioning rod dipped in |

| | |marking paint. The physician then measures 5 cm forward on a saggital line from the motor threshold mark and |

| | |this site that identifies the left dorsolateral prefrontal cortex is highlighted with marking paint. The |

| | |positioning rod is placed tangentially through the positioning hole in the therapy head and the therapy head |

| | |lowered down on a 90° angle against the scalp and the positioning rod removed. The patient is then stimulated |

| | |at the desired treatment settings that have been preprogrammed into the patient prescription card, which must |

| | |comply with published safety guidelines. A typical treatment would be at 10 Hz at an intensity of 110% of motor|

| | |threshold consisting of 10-20, 5-second trains beginning 30 seconds apart. This procedure is repeated on a |

| | |daily basis, Monday through Friday, for 10- 20 times to complete a course of treatment. |

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|0019T |  |Clinical Example |

| | |Tennis elbow is a condition in which there is inflammation or degeneration of the tendons attached to the |

| | |outside (lateral side) of the elbow. This disease process is generally characterized as an abrupt or subtle |

| | |tearing of the tendonous area around the lateral aspect of the elbow and normally affects people between the |

| | |ages of 30 and 50. Although many tennis players suffer with tennis elbow, the majority of people affected are |

| | |not involved in sports. Because pain occurs from injured or damaged tendons near the elbow, people in |

| | |occupational settings that require repetitive wrist and forearm movements such as painters, mechanics, and |

| | |clerical workers are also likely to suffer from lateral epicondylitis. |

| | |The diagnosis of lateral epicondylitis is normally made through a physical examination, and radiographic |

| | |studies if necessary. Patients with tennis elbow experience pain at the lateral aspect of the elbow that can |

| | |radiate or travel into the forearm and occasionally the hand. The pain occurs with grasping activities and may |

| | |be accompanied by a sense of weakness. |

| | |High-energy ESW surgery is indicated for use in patients with chronic lateral epicondylitis who have failed to |

| | |respond to conservative treatment such as physical therapy and stretching exercises, orthotics, bracing, |

| | |NSAIDs, cortisone injections, or previous surgery. |

| | |Description of Procedure |

| | |Prior to the administration of anesthesia, the area of tenderness on the affected area is palpated, and clearly|

| | |designated with a marking pen. High-energy ESW surgery with appropriate delivery devices is painful; therefore,|

| | |the procedure should be performed with anesthesia. The choice of anesthesia (local, regional, MAC, bier block, |

| | |or general), after discussion with the patient, is the responsibility of the physician or anesthesiologist. The|

| | |patient is placed supine on the stretcher with the affected arm placed in the lateral position. The head of the|

| | |device is pointed downward towards the floor, and the table is raised to bring the elbow into the F2 area (F2 |

| | |is the focal zone/treatment area of the shock wave). |

| | |Coupling gel is applied to the area of maximum tenderness or the treatment head. The shock head is coupled to |

| | |the patient’s elbow and positioned by the physician. It is important that there is good contact between the |

| | |patient’s elbow and the shock head to ensure that the treatment area remains within F2 throughout the |

| | |procedure. The physician instructs the technician to set the device shock wave delivery rate to 4 Hz. |

| | |The procedure starts at 14 kV and the power is increased in increments until reaching a maximum power of 18 kV |

| | |level to evaluate the effect of anesthesia. (The power level is not to exceed 18 kV.) The treatment protocol |

| | |for soft tissue application of high-energy ESW surgery is as follows: |

| | |25 shocks @ 14 kV |

| | |25 shocks @ 15 kV |

| | |50 shocks @ 16 kV |

| | |1400 shocks @ 18 kV (Total 1500 shocks) |

| | |Ensuring that the elbow remains in constant contact with the shock head, the physician moves the affected area |

| | |within the shock wave path (F2), and pronates and supinates the patient’s hand during the procedure to ensure |

| | |the entire tendon is treated to the proper depth based on the individual patient’s anatomy and pathophysiology.|

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|0020T |  |Clinical Example (0020T) |

| | |A 49-year-old athletic male presents with chronic heel pain. It is worst on getting out of bed in the morning |

| | |but persists while bearing weight during the day. The patient has failed 6 months of conservative therapy |

| | |including non-steroidal anti-inflammatory drugs, heel cups, stretching exercises, night splints and cortisone |

| | |injections into the painful area. Work-up for systemic or other causes of the problem are negative and the |

| | |patient's pain level is > 5/10. |

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|0021T |  |Clinical Example (0021T) |

| | |The patient should be in active labor (dilation > 2 cm, vertex -2 station or lower) with ruptured membranes. |

| | |The placement of the fetal oxygen sensor is then appropriate if the fetal heart rate tracing shows evidence of |

| | |one or more of the following nonreassuring fetal heart rate (FHR) patterns: |

| | |• Baseline FHR between 100-110 with no accelerations > 15 beats per minute (bpm) for more than 15 seconds |

| | |• Baseline FHR < 100 bpm with accelerations |

| | |• Increased variability > 25 bpm for > 30 minutes |

| | |• Mild or moderate variable decelerations for > 30 minutes |

| | |• Late decelerations (at least 1 per 30 minutes) |

| | |• Decreased variability < 5 bpm for > 30 minutes |

| | |• Persistent late decelerations (> 50% of contractions) for > 15 minutes |

| | |• Tachycardia > 160 bpm with long-term variability < 5 bpm |

| | |• Sinusoidal pattern |

| | |• Variable decelerations with any of the following: |

| | |• a relative drop of > 70 bpm or an absolute drop to < 70 bpm for 60 seconds |

| | |• persistent slow return to baseline |

| | |• long-term variability < 5 bpm |

| | |• tachycardia > 160 bpm |

| | |• Recurrent prolonged decelerations (2 or more below 70 bpm for > 90 seconds in 15 minutes) |

| | |Description of Procedure/Service (0021T) |

| | |The sensor is inserted transcervically such that the optical components are positioned in contact with the |

| | |fetus' cheek or temple. The monitor (connected to a conventional electronic fetal monitor) provides a printout |

| | |of the fetus' FSpO2 on the UA trace of the FHR strip. |

| | |In the presence of a non-reassuring (Class II) FHR pattern, if the FSpO2 value is >=30% between contractions, |

| | |labor may be allowed to continue. If the FSpO2 value is below 30% between contractions or no signal is |

| | |available (despite sensor adjustments) then management is by FHR alone and includes all non-operative measures |

| | |intended to improve the FHR pattern. If such measures do not improve the FHR pattern, additional evidence of |

| | |fetal well-being should be obtained via scalp pH or by observing the presence of spontaneous or elicited |

| | |accelerations. |

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|0023T |  |Clinical Example (0023T) |

| | |Patient is a 36-year-old, white female. During a recent medical exam she tested positive for HIV. Approximately|

| | |three years ago she had sexual contact for 3 months with a partner who she has recently learned may have AIDS. |

| | |She has not received further care and is unaware of her HIV RNA level and CD4 cell count. Her current partner |

| | |is her husband of 3 years who is HIV negative. Antiretroviral therapy is prescribed with instructions to return|

| | |after 4 weeks. |

| | |The patient is seen after 4 weeks at which time her viral load is 150,000. HIV viral load response in |

| | |treatment-naive patients who are adherent should show a rapid, significant decline of greater than 1 log in two|

| | |to four weeks following treatment initiation. The patient states that she has been highly adherent to her |

| | |medication. Current medication regimen appears to be failing. |

| | |HIV virtual phenotype drug resistance testing is ordered to determine correct course of therapy. The patient is|

| | |instructed to return in three weeks to adjust the antiretroviral therapy based on results of resistance test. |

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|0024T |  |Clinical Example (0024T) |

| | |Patient with hypertrophic obstructive cardiomyopathy (HOCM) with medically refractory symptoms of at least |

| | |Class III or Class IV New York Heart Association (NYHA) for congestive heart failure, or Class III or Class IV |

| | |Canadian Heart Association for angina pectoris or repeated episodes of syncope. Following the diagnosis of |

| | |HOCM, an electrocardiogram, exercise treadmill test and Doppler echocardiogram are performed to assess |

| | |appropriateness for procedure. The following echocardiographic criteria must be met: ventricular septal |

| | |thickness of at least 1.6 cm or more, septal to posterior wall ratio >1.3 cm with left ventricular outflow |

| | |tract gradient of 30 mm Hg at rest or 60 mm Hg during dobutamine provocation. There must be systolic anterior |

| | |motion of the mitral valve during left ventricular outflow tract (LVOT) obstruction. |

| | |Description of Procedure (0024T) |

| | |Venous and arterial access are obtained through the right groin. A bipolar temporary pacing electrode catheter |

| | |is introduced into the right femoral vein and passed to the apex of the right ventricle where appropriate |

| | |capture threshold will be demonstrated. Pullback pressures to the aorta will be measured by arterial catheter, |

| | |followed by a full set of left coronary arteriograms. The patient is then sedated. The radiographic view of the|

| | |coronaries best showing the septal perforator arteries and their origins will be selected, and a guidewire |

| | |passed through the left anterior descending coronary artery. The guidewire will then be positioned in the |

| | |appropriate septal perforator. The balloon will be passed over the guidewire and inflated. A brief left |

| | |coronary arteriogram to establish patency of the left anterior descending will then be performed. The central |

| | |guidewire will be removed. An arteriogram will be carried out of the septal perforator through the balloon |

| | |lumen to ascertain the exact bed of coronary arteries to be infarcted with ethanol and to insure there is no |

| | |spillage of contrast into the left anterior descending coronary or into the coronary venous system. Depending |

| | |on the septal artery size, septal thickness and the area delineated, 1-4 cc of absolute ethanol will be |

| | |instilled through the lumen of the inflated balloon catheter at a rate of 1-1.5 cc per min and left in place |

| | |for 5 minutes. If the gradient is not less than 30 mm Hg, another septal artery will be injected if available. |

| | |The above procedure may be repeated. After the final injection of ethanol, a coronary arteriogram is carried |

| | |out of the left coronary system and the guide catheters removed. The temporary pacemaker will remain in place |

| | |for at least 24-hours, or longer if needed to treat heart block. |

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|0025T |  |Clinical Example (0025T) |

| | |A 68-year-old female underwent cataract surgery 6 weeks ago. The patient presented this date for a |

| | |postoperative refractive examination. |

| | |Description of Procedure/Service (0025T) |

| | |The exam revealed a refractive error of plano -7.00 at 90 degrees of axis. This patient would benefit from |

| | |postoperative refractive surgery to correct the imbalance in her vision due to the large amount of residual |

| | |astigmatism. The patient will need a complete corneal evaluation prior to undergoing refractive surgery. This |

| | |exam would consist of a cycloplegic and non-cycloplegic refraction, corneal topography to determine |

| | |abnormalities and corneal pachymetry to assure sufficient thickness to undergo the procedure. |

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|0028T |  |Clinical Example #1 (0028T) |

| | |A 36-year-old woman with a BMI of 40 kg/m2 undergoes a gastric bypass procedure and loses about 50 pounds in a |

| | |3-month period. She also notes generalized weakness. A complete history and physical did not reveal any |

| | |localizing findings. There was concern regarding possible malnutrition and degree of muscle versus fat loss. |

| | |The physician orders body composition assessment by DEXA. This is performed either in the ambulatory clinical |

| | |diagnostic center or in a hospital's diagnostic center. The DEXA was obtained and revealed that her lean body |

| | |mass was appropriate and that most of her weight loss was due to reduction in fat. |

| | |Clinical Example #2 (0028T) |

| | |A 21-year-old woman with anorexia enters an eating disorder clinic for assessment. There are no medical, |

| | |gastrointestinal or hormonal causes for her weight loss. Baseline body composition data is obtained for |

| | |subsequent comparison to objectively assess changes in body composition in response to therapy. |

| | |Description of Procedure (0028T) |

| | |The patient enters the examination suite and lays on the scanning table. The body is scanned in a rectilinear |

| | |or fan-beam manner using two low-dose x-rays at different energies, typically at 70 and 140 keV. The effective |

| | |dose of radiation is equal to one day's background radiation. A whole-body scan is performed and takes between |

| | |5 and 20 minutes depending on the machine used. The body can then be analyzed by region with respect to grams |

| | |of fat and total body mass. A percentage of fat is then calculated for each region as well as for the total |

| | |body. |

| | |The interpreting physician assesses the quality of images and data obtained prior to releasing the report to |

| | |the patient and/or referring physician. |

| | |Clinical Example #2 (0028T) |

| | |A 21-year-old woman with anorexia enters an eating disorder clinic for assessment. There are no medical, |

| | |gastrointestinal or hormonal causes for her weight loss. Baseline body composition data is obtained for |

| | |subsequent comparison to objectively assess changes in body composition in response to therapy. |

| | |Description of Procedure (0028T) |

| | |The patient enters the examination suite and lays on the scanning table. The body is scanned in a rectilinear |

| | |or fan-beam manner using two low-dose x-rays at different energies, typically at 70 and 140 keV. The effective |

| | |dose of radiation is equal to one day's background radiation. A whole-body scan is performed and takes between |

| | |5 and 20 minutes depending on the machine used. The body can then be analyzed by region with respect to grams |

| | |of fat and total body mass. A percentage of fat is then calculated for each region as well as for the total |

| | |body. |

| | |The interpreting physician assesses the quality of images and data obtained prior to releasing the report to |

| | |the patient and/or referring physician. |

|[pic] |

|0029T |  |Clinical Example (0029T) |

| | |The patient is a 55-year-old woman who is complaining of involuntary loss of urine with activities such as |

| | |coughing or lifting. The patient has had symptoms for at least 3 months and is having to use pads or other |

| | |protection for daily activities. The initial evaluation has confirmed symptoms and signs of urinary |

| | |incontinence and has excluded transient causes. Urinalysis fails to reveal evidence of hematuria or active |

| | |urinary infection. Urinary retention is excluded by clinical examination, post-void catheterization or |

| | |ultrasound scan. The patient has used Kegel exercises without success. The clinician ensures that there is no |

| | |contra-indication to ExMI, such as pregnancy, major pelvic organ prolapse, or cardiac pacemaker. |

| | |Description of Procedure (0029T) |

| | |Based on the diagnosis, the physician determines dosage and modulation parameters. This prescription is encoded|

| | |on a treatment card. The patient treatment involves patient instruction and positioning on the NeoControl |

| | |system. The therapy head, which is positioned in the seat of the treatment chair, produces a rapidly changing |

| | |pulsed magnetic field that will induce neuron depolarization resulting in contractions of the muscles of the |

| | |pelvic floor. Patient tolerance is tested and output power adjusted as required. The treatment cycle includes |

| | |20 to 30 minutes of intermittent stimulation to improve sphincter function and bladder control. During the |

| | |interval treatment, the patient follows a program of education using an interactive video screen technology. |

| | |The patient learns about the causes of incontinence, the factors that may worsen or improve symptoms, and |

| | |strategies to maintain bladder health during and after ExMI treatment. This procedure is repeated 16 to 20 |

| | |times to complete a course of therapy. Patient progress is assessed after 8 treatments or sooner if changes in |

| | |patient condition present. Treatment parameters may need to be adjusted. |

| | |Clinical Example (0029T) |

| | |The patient is a 75-year-old woman who is complaining of involuntary loss of urine with activities such as |

| | |standing up from sitting. The patient has had symptoms for at least 3 months and is having to use pads or other|

| | |protection for daily activities. The initial evaluation has confirmed symptoms and signs of urinary |

| | |incontinence and has excluded transient causes. Urinalysis fails to reveal evidence of hematuria or active |

| | |urinary infection. Urinary retention is excluded by clinical examination, post-void catheterization, or |

| | |ultrasound scan. The patient has used Kegel exercises without success. The therapist ensures that there is no |

| | |contra-indication to ExMI such as major pelvic organ prolapse or cardiac pacemaker. |

| | |Description of Procedure (0029T) |

| | |Based on the diagnosis, the physician will determine dosage and modulation parameters. This prescription is |

| | |encoded on a treatment card. The patient treatment involves patient instruction and positioning on the |

| | |NeoControl system. The therapy head, which is positioned in the seat of the treatment chair, produces a rapidly|

| | |changing pulsed magnetic field that will induce neuron depolarization resulting in contractions of the muscles |

| | |of the pelvic floor. Patient tolerance is tested and output power adjusted as required. The treatment cycle |

| | |includes 20 to 30 minutes of intermittent stimulation to improve sphincter function and bladder control. During|

| | |the interval treatment, the patient follows a program of education using an interactive video screen |

| | |technology. The patient learns about the causes of incontinence, the factors that may worsen or improve |

| | |symptoms, and strategies to maintain bladder health during and after ExMI treatment. This procedure is repeated|

| | |16 to 20 times to complete a course of therapy. Patient progress is assessed after 8 treatments or sooner if |

| | |changes in patient condition present. Treatment parameters may need to be adjusted. |

| | |Clinical Example (0029T) |

| | |The patient is a 65-year-old woman who is complaining of urinary frequency, urgency, and involuntary loss of |

| | |urine before she is able to make it to the bathroom. Leakage may be provoked by standing or by the sound of |

| | |running water. The patient has had symptoms for at least 3 months and is having to use pads or other protection|

| | |for daily activities. The initial evaluation has confirmed symptoms and signs of urinary incontinence and has |

| | |excluded transient causes. Urinalysis has failed to reveal evidence of hematuria or active urinary infection. |

| | |Urinary retention is excluded by clinical examination, post-void catheterization or ultrasound scan. The |

| | |patient has used Kegel exercises without success. The therapist ensures that there is no contra-indication for |

| | |ExMI such as major pelvic organ prolapse, severe estrogen deficiency, or cardiac pacemaker. |

| | |Description of Procedure (0029T) |

| | |See previous descriptive listing. |

|[pic] |

|0030T |  |Clinical Example (0030T) |

| | |A middle-aged male presents with arthritis, fever, progressive weight loss, generalized lymphadenopathy, and |

| | |erythematous skin rash. Lymph node biopsy shows atypical plasmacytosis. Serum protein electrophoresis shows |

| | |hypergammaglobulinemia, serum IgM is elevated to 1030 mg/dL (normal, 60-263 mg/dL), and lupus anticoagulant |

| | |(LA) test is performed with strongly positive results. |

| | |Description of Procedure (0030T) |

| | |The strongly positive LA results prompted an antiphospholipid antibody evaluation to determine the risk for |

| | |thrombosis and consider anticoagulation therapy. Patient sera are tested for anti-cardiolipin (aCL), |

| | |anti-phosphatidylserine (aPS), anti-beta 2 glycoprotein I (aB2GPI), and anti-prothrombin (aPT). Antibody levels|

| | |are positive for aCL IgG and IgM, aPS IgG and IgM, and aPT IgM, but negative for aB2GPI. The strong lupus |

| | |anticoagulant activity in this patient is most likely due to the elevated anti-Prothrombin antibody levels, |

| | |since aB2GPI levels are negative. The patient later develops arterial thrombosis (stroke). Risk for thrombosis |

| | |in this patient is due to elevated aPT levels. Without the aPT levels being tested, the risk of thrombosis |

| | |would have been misinterpreted due to the normal aB2GPI levels. |

|[pic] |

|00326 |  |Clinical Example (00326) |

| | |The patient is a 4-month-old noted to have noisy breathing worsening on excitement. The patient was born at 35 |

| | |weeks gestational age. The patient was discharged home on day four after bilirubin levels were noted to be |

| | |decreasing. Stridor was noted to be present on inspiration when crying and has become worse in the past 2 |

| | |weeks. There is no significant family history for congenital diseases or adverse anesthesia reactions. The |

| | |patient is on iron fortified formula and takes no medications. There are no known allergies. The patient weighs|

| | |5 kg. Vital signs are appropriate for age. The baby is noted to be of normal color and has a mild suprasternal |

| | |notch tug on quiet inspiration. When crying there is inspiratory stridor associated with significant chest |

| | |retractions. No change in color is noted. The airway is noted to be of normal appearance. The breath sounds are|

| | |clear bilaterally. The heart is auscultated finding normal rate and rhythm. No murmur is heard. No other |

| | |obvious congenital abnormalities are noted. Significant laboratory test results include a hematocrit of 32%. |

| | |Description of Procedure (00326) |

| | |A general anesthesia with induction by mask is agreed to by the parents. An intramuscular injection of atropine|

| | |is administered. The baby is transported to the operating room where monitors are placed. A forced air mattress|

| | |is in place as are heating lamps. Anesthesia is gradually induced by volatile agent through a mask. Intravenous|

| | |access is secured. The anesthetic is slowly deepened with careful attention to blood pressure, heart rate, and |

| | |oxygenation. When the baby is sufficiently anesthetized, laryngoscopy is performed and topical local anesthesia|

| | |is sprayed in the trachea and on the larynx. The airway is again secured by mask, and vital signs are checked. |

| | |Caffeine 10 mg/kg is intravenously administered. The baby is turned to the bronchoscopist with careful |

| | |attention to the patency of the airway. The mask is removed and the bronchoscopist performs laryngoscopy and |

| | |placement of a rigid bronchoscope into the trachea. The anesthesia circuit is attached to the bronchoscope and |

| | |adequate ventilation is determined by carbon dioxide monitoring, chest excursion with positive pressure |

| | |ventilation, and, if necessary, auscultation of breath sounds. Pulse oximetry and end tidal carbon dioxide are |

| | |continuously and closely monitored throughout the procedure. The bronchoscopy continues and nearing the end of |

| | |the procedure the anesthetic gases are decreased and eventually turned off. An endotracheal tube is placed by |

| | |the anesthesiologist after bronchoscopy if airway patency is in question. Emergence from anesthesia ensues. |

| | |When the infant demonstrates sufficient strength and awareness by opening the eyes, the endotracheal tube is |

| | |removed and the patient observed for air movement with inspiration. Pulse oximetry and end tidal carbon dioxide|

| | |are verified. When the patient is stable, transport to recovery with monitors and supplemental oxygen takes |

| | |place. The patient is monitored for a prolonged period in the recovery room prior to transfer to the inpatient |

| | |unit. The infant is placed on continuous pulse oximetry and respiratory monitors. When the baby has been stable|

| | |for a period of 6 hours, with no evidence of apnea, discharge to home occurs. |

|[pic] |

|0041T |  |Clinical Example (0041T) |

| | |A symptomatic patient presents with a chief complaint of urinary frequency, burning, and urgency consistent |

| | |with a UTI. There is no history of recurrent UTI. A clean-catch midstream urine specimen is slightly cloudy and|

| | |straw colored. The specimen is sent to the laboratory in a vessel without preservatives for determination of |

| | |the presence of bacteriuria using the CPAS method. |

| | |Description of Procedure (0041T) |

| | |The CPAS uses "electronic nose" technology for the detection of volatile metabolites released from |

| | |microorganisms in human specimens. The principle is based on the release of volatile compounds from bacteria |

| | |into the headspace (the volume above the liquid samples) of the clinical sample. The volatile compounds are |

| | |detected by an array of gas sensors based on patented conducting polymer technology. |

| | |In the laboratory, the midstream urine specimen is pipetted into a glass vial containing reagents. The vial is |

| | |put into the instrument carousel. The specimen identification number is input to the instrument's computer. |

| | |Once the system's checks have been satisfied and input is completed, the instrument automatically starts to |

| | |analyze the samples. A report showing the patient ID and the diagnostic result as positive or negative is |

| | |automatically printed out within 5 hours of the start of the analysis. The results are communicated with the |

| | |referring physician. |

|[pic] |

|0042T |  |Clinical Example (0042T) |

| | |A 69-year-old male presents to a community hospital 1 hour after sudden onset of right hemiparesis and |

| | |intermittent aphasia that occurred while playing golf. The patient has a regular pulse but is believed to have |

| | |been in atrial fibrillation during symptom onset. An unenhanced CT scan is performed (coded separately), which |

| | |shows no evidence of hemorrhage, but a subtle low density in the left insular cortex of undetermined age. The |

| | |remainder of the scan is normal. |

| | |While the patient is still on the CT scanner table, a CT perfusion study is subsequently obtained (coded |

| | |separately); CT perfusion analysis is performed by selecting the levels of major interest and scanning |

| | |repeatedly before and during a 45-mL bolus of nonionic contrast administered at 5 mL/sec. CT perfusion is |

| | |accomplished with the scanner in cine mode. Four contiguous 5- to 10-mm-thick axial images are obtained, which |

| | |include visualization of the insula, lenticular nuclei, superior temporal lobes, inferior frontal lobes, |

| | |inferior parietal lobes, and thalamus. After a 5-second prep delay, these levels are scanned at a rate of 1 |

| | |image per second for 45 seconds. Within 5 to 10 minutes of scan completion, CT perfusion maps of cerebral blood|

| | |flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) are constructed at a freestanding |

| | |workstation using dedicated software by a radiologist in attendance. These images take approximately 15 to 20 |

| | |minutes to generate. The images demonstrate a large region of delayed mean transit time in the distribution of |

| | |the left middle cerebral artery, a portion of which demonstrates low cerebral blood volume. Because of the |

| | |concern for a large-vessel distribution ischemic region, a CT angiogram may then be requested. In this case, a |

| | |CTA demonstrated thrombus in the mid M1 division left MCA thrombus and the absence of a significant left |

| | |internal carotid artery bifurcation stenosis. The patient is removed from the CT table in anticipation of IV |

| | |thrombolytic treatment. |

| | |The CBV maps in this case show a small region of low blood volume, which corresponds to the untenanted CT |

| | |findings. The cerebral blood flow and mean transit time maps, however, show a much larger surrounding area of |

| | |diminished blood flow and increased blood transit time over the entire visualized MCA territory. Quantitative |

| | |CBF values are at or below 20 mL/100 g/min at many locations; quantitative MTT values exceed 6 seconds at some |

| | |locations. Because this data suggests an extensive area with poor collateral blood flow, unlikely to be |

| | |irreversibly infarcted but potentially at risk for stroke in the absence of MCA recanalization (ischemic |

| | |penumbra), and because recanalization is more likely to be successful in response to intra-arterial (IA) rather|

| | |than IV thrombolysis, the decision is made to start IV thrombolysis and to immediately transport the patient to|

| | |a nearby tertiary care center for definitive intra-arterial thrombolytic therapy. In this case, the CT |

| | |perfusion demonstrated tissue at risk of infarction, leading to a CTA and more aggressive thrombolytic therapy.|

|[pic] |

|0043T |  |Clinical Example (0043T) |

| | |The patient is a male infant 39+ weeks of gestation, delivered by normal spontaneous vaginal delivery. There |

| | |were no complications during pregnancy or delivery. Birth weight is 3100 g. Maternal blood type is O+; the |

| | |baby's blood type is A+. At 24 hours of age, the ETCOc breath test for hemolysis is administered. |

| | |Description of Procedure (0043T) |

| | |Administration of the test involves placement of a catheter into a patient's nostril, secured to lip with |

| | |adhesive; insertion of filter cartridge to analyzer port; and sampling of patient's breath with background air |

| | |check for base levels. |

| | |Test results are documented in the patient's record. A normal ETCOc level could qualify the infant for early |

| | |discharge. An elevated ETCOc indicates that the infant is at high risk for the development of |

| | |hyperbilirubinemia. The cause of hemolysis should be identified, appropriate treatment should be initiated, and|

| | |the patient should be monitored closely. |

|[pic] |

|0044T |  |Clinical Example (0044T) |

| | |A 30-year-old woman has several moles, which vary in color, shape and size. She has noticed a slight change in |

| | |size on one of the moles and doesn't know if there has been any changes in her other moles. She has fair skin |

| | |and is concerned because she has had several sunburns in her youth. She is single and reports that it is |

| | |virtually impossible for her to scan her body for changes and developments regarding moles and lesions. She is |

| | |aware of skin cancer and how its occurrence is linked to sun exposure. |

| | |Description of Procedure (0044T) |

| | |A review of the woman's medical history is performed, as well as education regarding preventative programs |

| | |designed to minimize skin cancer risk. Education can include the use of sunscreens, hats, UV sunglasses, long |

| | |sleeves and pants, avoiding hottest part of the day, protection of children in the same manner, brochures and a|

| | |web site containing information on the ABCs of skin cancer, monitoring suspect moles and lesions and the |

| | |importance of scheduled screenings. |

| | |Two non-physician technicians perform a full body imaging procedure. Suspicious moles or lesions may be |

| | |isolated and imaged on a micro basis and tagged with a millimeter measuring identification tag. The tag will |

| | |specify the date, the patient's name and body section where the suspect mole or lesion is being micro imaged. |

| | |Once the images have been developed, a copy of the images will be forwarded to the referring physician for |

| | |review. The physician will interpret the images and acknowledge any areas of concern and communicate his |

| | |initial findings with his patient on the next office visit. A copy of the CD ROM disk will also be sent to the |

| | |patient. This allows the patient to have a record of her skin, moles, and lesions and will help her to monitor |

| | |her skin in between appointments with her doctor. |

|[pic] |

|0045T |  |Clinical Example (0045T) |

| | |The patient's medical history is reviewed. The patient is educated regarding preventative programs designed to |

| | |minimize skin cancer risk. Education can include the use of sunscreen, hats, UV glasses, long sleeves and |

| | |pants, avoiding the hottest part of the day, protection of children in the same manner, brochures and a web |

| | |site containing information on the ABC's of skin cancer, monitoring suspect moles and lesions and the |

| | |importance of scheduled screenings. |

| | |The full body imaging procedure is performed. Suspicious moles or lesions may be isolated and imaged on a micro|

| | |basis and tagged with a millimeter measuring identification tag. The tag will specify the date, the patient's |

| | |name, and body section where the suspect mole or lesion is being managed. |

| | |Once the images have been developed, a copy of the images will be forwarded for review. |

|[pic] |

|0046T, |  |Clinical Example (0046T-0047T) |

|0047T | |A 44-year-old woman recently discovered that her sister (age 46) has been diagnosed with breast cancer. The |

| | |patient's mother died of lung cancer in her mid-forties but was not known to have had any breast disease. The |

| | |patient is nulliparous, menarche was at age 11, and has had one previous breast biopsy, which was benign. The |

| | |patient presents to her obstetrician-gynecologist concerned about her breast cancer risk. She has a physical |

| | |exam, which is unremarkable except for a well-healed surgical biopsy scar in the upper outer quadrant of her |

| | |left breast. Her mammogram is unremarkable. She is referred to a high-risk breast clinic. |

| | |Upon further evaluation in the breast cancer clinic, her Gail risk is calculated and is found to be 2.6%. The |

| | |patient is counseled that she has a moderately increased risk of breast cancer and that potential management |

| | |options include simply close surveillance or tamoxifen for risk reduction. The patient is advised that |

| | |tamoxifen reduces breast cancer risk in high-risk women, but has some potential serious adverse side effects |

| | |(including increased risks of pulmonary emboli, strokes, endometrial cancer) as well as some more common minor |

| | |side effects (hot flashes, vaginal atrophy with corresponding pain on intercourse). She is offered cytological |

| | |evaluation of intraductal cells with nipple aspirate fluid (NAF) and, with fluid-yielding ducts, cell |

| | |collection with lavage. She is told that the finding of atypical cells on lavage would confer a significant |

| | |increase in her relative risk of developing breast cancer. She also is told that if she had atypical cells on |

| | |her lavage but no family history of breast cancer, her relative risk would be increased approximately 5-fold. |

| | |However, with her family history of breast cancer, if she also had atypical cells on her lavage, her relative |

| | |risk of developing breast cancer would likely be increased dramatically (18-fold). The patient states that she |

| | |would be willing to consider taking tamoxifen if there is any evidence of atypia in her breast and undergoes |

| | |the procedure. |

| | |The woman has a topical anesthetic cream placed over both nipples for 20-30 minutes prior to the procedure. The|

| | |procedure begins with the patient gently massaging each breast to encourage any fluid residing in the milk |

| | |ducts to move toward the nipple. A manual breast aspirator is placed over each nipple and gentle suction |

| | |applied to elicit nipple aspiration fluid (NAF) which appears as minute droplets on the nipple surface. One |

| | |NAF-yielding duct is identified and lavaged in the left breast. Lavage involves insertion of the ductal lavage |

| | |microcatheter approximately 1 centimeter into the duct, filling the duct with normal saline, and then massaging|

| | |and aspirating the duct to collect fluid and cells through the microcatheter. The filling, massage, fluid |

| | |collection steps are repeated through 3-5 cycles to ensure adequate cell collection. The returned ductal lavage|

| | |effluent is deposited into preservative and sent for cytological analysis. |

| | |Mild atypia is reported by the lab. The physician recommends and the patient consents to tamoxifen |

| | |chemoprevention. |

|[pic] |

|0048T |  |Clinical Example (0048T) |

| | |A patient is admitted to the emergency room in frank acute distress. A detailed history obtained from both the |

| | |patient and accompanying family members indicate a cardiac history with several risk factors. |

| | |Physical examination revealed a profoundly diaphoretic patient with severe shortness of breath and chest pain. |

| | |Airway was patent, breathing labored and circulation markedly impaired. Patient was tachycardic, with cool and |

| | |clammy extremities, poor peripheral pulses, and was disoriented to time and place. BP was recorded a 90mm Hg. |

| | |EKG revealed an acute injury pattern consistent with acute myocardial infarction (MI) of the anterior wall. The|

| | |patient was diagnosed in acute heart failure due to acute MI. Cardiology Services was notified. Intravenous |

| | |therapy was started and a central line was inserted. The patient was placed on high-flow nasal oxygen. Morphine|

| | |was administered and vassopressor and inotropic support was initiated. |

| | |The patient was diagnosed in cardiogenic shock, transferred to Cardiology Services and admitted to the Coronary|

| | |Intensive Care Unit. |

| | |Description of Procedure (0048T) |

| | |The patient is taken to the cardiac catheterization laboratory where he is prepped for the procedure. Cannula |

| | |access is achieved through the femoral arterial and venous systems. Using the femoral vein, a transseptal |

| | |cannula is advanced into the left atrium from where it draws oxygenated blood into the blood pump. The blood is|

| | |returned to systemic circulation via the femoral artery using single or dual cannulation. The physician |

| | |performing the implantation procedure must be skilled in transseptal puncture technique and arterial and venous|

| | |cannulation. |

| | |The ventricular assist device requires priming using aseptic technique. In addition to the physician and an |

| | |assistant working in the sterile field performing the implantation procedure, two people working together are |

| | |required to set up the controller: a pump technician to assist in the sterile field and a controller operator |

| | |to manage the non-sterile controller. The lower housing of the pump is primed with sterile water and set up |

| | |while the physician is performing the implantation procedure. The upper housing is primed with the patient's |

| | |blood or heparinized saline following arterial cannulation. |

| | |For transseptal cannulation, the physician first gains access to the left atrium, usually from the right |

| | |femoral vein via standard transseptal puncture technique using a transseptal needle assembly, similar to the |

| | |transseptal technique in transseptal heart catheterization. The fossa ovalis is then dilated with the |

| | |transseptal catheter after which the needle is withdrawn, and a guidewire is introduced into the left atrium |

| | |through the transseptal catheter. The catheter and sheath are then removed and the guidewire is left in place. |

| | |Next, the two-stage dilator is introduced over the guidewire until the largest diameter section of the dilator |

| | |enters the left atrium. The assembled atrial drainage cannula and obturator are de-aired using a heparinized |

| | |flush solution. The two-stage dilator is removed, and the de-aired cannula-obturator assembly is inserted into |

| | |the left atrium over the guidewire. The obturator is then disengaged from the cannula. While holding the |

| | |obturator steady, the cannula is advanced into the left atrium until properly positioned over the tip of the |

| | |obturator. Once correct positioning of the cannula is confirmed via fluoroscopy, the guidewire is removed. The |

| | |obturator is then partially pulled back to a point beyond the clamp area of the cannula; the obturator hub is |

| | |left in place temporarily to control blood loss while proceeding with cannula clamping. Once the transseptal |

| | |cannula is clamped, the obturator and obturator hub are completely removed. The transseptal cannula is |

| | |temporarily secured in place to prevent dislodgment during arterial cannulation, and until definitive tie-down |

| | |sutures are secured. |

| | |For arterial cannulation, the physician confirms the artery size with a suitable imaging technique and selects |

| | |an appropriately sized arterial cannula. An arterial puncture is performed using a needle with stylet to |

| | |prevent arterial backflow during the puncture. The stylet is removed and a guidewire is inserted through the |

| | |needle. The needle is then removed and, if necessary, the artery is dilated. An arterial cannula and introducer|

| | |assembly is advanced over the guidewire. After confirming arterial placement, the guidewire is removed and the |

| | |introducer is partially withdrawn from the cannula. The arterial cannula is clamped; the remainder of the |

| | |introducer is removed, and the arterial cannula is back-bled. Once the cannula is filled, it is secured to the |

| | |patient. If dual arterial cannulation is required, the procedure is repeated. |

| | |Next, the clamped, back-bled arterial cannula is connected to the outflow port on the pump housing; if dual |

| | |arterial cannulation is required, the cannulae are first connected to each other with a Y-connector. A piece of|

| | |tubing is then connected to the inflow port of the pump and clamped off. The clamp(s) on the arterial |

| | |cannula(e) is (are) removed and the upper housing of the pump is primed with blood by carefully releasing the |

| | |clamp on the inflow tubing. When fully de-aired, the inflow tubing is connected to the transseptal cannula |

| | |using a wet-to-wet connection. Using appropriate de-airing techniques, potentially entrapped air is purged from|

| | |the system. The transseptal cannula is secured to the patient to prevent dislodging during mechanical |

| | |circulatory support using fixation spools and sutures. Imaging (ie, trans-esophageal echocardiogram or |

| | |fluoroscopy) is performed to reconfirm the position of the transseptal cannula in the left atrium before |

| | |starting the pump. |

| | |Once the position of the cannula is confirmed, the pump is started. Speed is gradually increased until the |

| | |desired level of support is obtained. The clamps on the inflow tubing (transseptal cannula) are released first,|

| | |followed by the outflow tubing (arterial cannula(e)). The pump is placed in the holster and secured to the |

| | |patient's leg. The patient is transported from the cardiac catheterization laboratory to the Coronary Care Unit|

| | |for monitoring and follow-up. |

|[pic] |

|0049T |  |Clinical Example (0049T) |

| | |Support was maintained for 31/2 days, during which time the patient's hemodynamic, neurological and |

| | |anti-coagulation status was routinely monitored. Following implantation, cardiac function improved. Cardiac |

| | |index increased to 2.4 L/min per m2; blood pressure increased to 90 mm Hg; pulmonary capillary wedge pressure |

| | |decreased to 14 mm Hg; central venous pressure dropped to 9 and pulmonary artery pressure dropped to 23. |

|[pic] |

|0050T |  |Clinical Example (0050T) |

| | |To initiate weaning, the blood pump flow rate is reduced by 50%; the physician may also consider a slower |

| | |weaning procedure by reducing the flow by 25% increments. For each step reduction in flow, the patient is |

| | |observed under this step-reduction condition for at least 1 hour. If the patient is not stable under this |

| | |step-reduction condition, the flow rate of the blood pump is restored to the original value and the weaning |

| | |attempt is aborted. |

| | |If the patient remains stable under the weaning conditions (ie, continues to satisfy weaning criteria) the |

| | |device is reduced again by an additional 50% (25%) for a minimum of 1 hour. Continued reductions take place as |

| | |long as the patient remains stable, down to the minimum allowable flow rate of 1 L/min. If the patient remains |

| | |stable for more than 1 hour at the minimum allowable flow rate, the device and cannulae are removed according |

| | |to standard hospital protocol for femoral catheter removal. |

| | |Weaning is usually completed in a 6-12 hour period of time. |

| | |After the weaning procedure is complete, the pump is turned off and arterial and transseptal cannulae are |

| | |immediately clamped. The inflow/outflow pump lines are disconnected and the transseptal cannula is removed; |

| | |compression is applied directly to the cannulation site. The left arterial cannula is removed and the artery |

| | |closed. The procedure is repeated for the right arterial cannula. Compression is maintained at both arterial |

| | |cannulae sites until hemostasis is achieved. |

| | |Cannulation site wounds are cleaned and dressed. The patient is checked continuously for signs of bleeding. A |

| | |transthoracic echocardiogram is performed within 24 hours of cannulae removal, to evaluate the patient for any |

| | |residual atrial-septal defect. |

|[pic] |

|0051T, |  |Clinical Example (0051T-0053T) |

|0052T, | |A 55-year-old male with diabetes mellitus presented in severe end-stage congestive heart failure. He had |

|0053T | |previous multiple myocardial infarctions involving both coronary artery distributions and resulting in severe |

| | |biventricular failure. Despite aggressive medical therapy, he had progressed to the point where he was in end |

| | |stage Class IV heart failure. He was seen by the heart failure and transplant team and felt not to be a |

| | |transplant candidate due to severe malnutrition, high pulmonary vascular resistance, and significant renal |

| | |dysfunction likely related to diabetes mellitus. A complete evaluation confirmed that he was not a transplant |

| | |candidate and not a candidate for either conventional or experimental therapies other than implantation of a |

| | |totally implantable replacement heart. |

| | |Description of Procedure (0051T-0053T) |

| | |Institutional Review Board (IRB) approved consent form is signed by patient and family. CT scan followed by a |

| | |virtual surgery implantation of the implantable replacement heart to determine if replacement heart will fit in|

| | |chest. Positioning, prepping, and draping the patient with placement of appropriate monitoring lines and |

| | |administration of general anesthetic was performed. The operative procedure began with an incision in the |

| | |infraclavicular area and a pocket was created above the pectoralis muscle fascia for placement of the internal |

| | |TET coil (energy transfer coil). A sternotomy was then performed. Separate preperitoneal pockets were made in |

| | |the left and right for placement of the internal battery and internal controller. Cannulas were placed for |

| | |institution of cardiopulmonary bypass, which was then initiated. Cross clamp was placed on the aorta and |

| | |ventricles were excised, leaving the native atria and annulus intact. The left atrial cuff was trimmed to |

| | |appropriate size and sewn to the native left atrium. This was done using a felt strip for reinforcement and |

| | |requires two layers of suture. A similar procedure was done to attach the right atrial cuff to the native right|

| | |atrium, again at the level of the annulus and also using two layers of suture. A model of the thoracic unit is |

| | |then placed in the chest to determine the length and orientation of the grafts to be sewn to the aorta and |

| | |pulmonary artery. The model of the replacement heart is removed, and the outflow grafts are sewn end-to-end to |

| | |the aorta and pulmonary artery using a single layer of Prolene suture. The thoracic unit is then passed up to |

| | |the operative field. Appropriate tunneling of cables is then performed and appropriate electrical connections |

| | |are made. The thoracic unit is then placed in the pericardial cavity and fastened to the atrial cuffs and |

| | |outflow grafts via twist-lock connectors. A rigorous protocol is then performed to completely evacuate the air |

| | |from the implantable replacement heart. Any residual air that is not evacuated can resulted in significant |

| | |neurologic injury. Once the heart has been completely de-aired, the cross clamp is removed from the aorta, the |

| | |patient is gradually removed from cardiopulmonary bypass support and the replacement heart takes over control |

| | |of the circulation. Once we have demonstrated normal hemodynamics, the final electrical connections are |

| | |performed and appropriate drainage tubes are placed. Aggressive hemostasis is obtained by the surgical team |

| | |followed by standard wound closure. Echocardiography is used throughout the procedure and especially at the |

| | |time of chest closure to ensure that the heart does not impinge on surrounding structures such as the left |

| | |pulmonary veins. |

|[pic] |

|00528 |  |Clinical Example (00528) |

| | |A 60-year-old male with a 30-year history of smoking, coronary artery disease and mild chronic obstructive |

| | |pulmonary disease (COPD) presents with large perihilar masses on chest radiograph and computed tomography (CT).|

| | |No distinct masses are present in the lungs. Lung washings are non-diagnostic. The patient has well-controlled |

| | |hypertension and no recent angina. Current medications include an antihypertensive agent and a bronchodilator. |

| | |The echocardiogram (ECG) shows evidence of an old infarction but no acute changes. Hemoglobin is slightly |

| | |elevated and electrolytes are within normal limits. He is scheduled for a diagnostic mediastinoscopy with |

| | |biopsy under general anesthesia. |

| | |Description of Procedure (00528) |

| | |Intravenous access is obtained. The patient is transported to the operating room (OR). Routine monitors are |

| | |applied and placement confirmed after patient is positioned on OR table. The patient is preoxygenated by mask |

| | |and anesthesia induced with intravenous lidocaine, propofol and a neuromuscular blocking agent. After insertion|

| | |of endotracheal tube, the tube position is confirmed and secured with tape. Efforts are made to protect the |

| | |eyes, extremities, and pressure points. Delivery of inhalational and intravenous anesthetics are delivered |

| | |with: constant attention to vital signs; constant monitoring of oxygenation and respiratory status and degree |

| | |of neuromuscular block; and intervention to maintain normothermia, regulation of depth of anesthesia and |

| | |control of BP and cardiac output. IV fluids given to maintain hydration and treat hypotension. |

| | |To prepare for emergence, inhalation agents are withdrawn and residual neuromuscular blockage is reversed using|

| | |anticholinesterase and anticholinergic drugs. Tracheal extubation occurs after determining adequacy of |

| | |spontaneous ventilation. The patient is moved to a stretcher and transferred with supplemental oxygen by |

| | |facemask to the post-anesthesia care unit (PACU). |

|[pic] |

|00529 |  |Clinical Example (00529) |

| | |A 65-year-old man presents with a 6-month history of lower lateral chest wall pain and shortness of breath. The|

| | |chest x-ray shows pleural thickening of the entire lateral chest wall. He is taken to the operating room for |

| | |diagnostic thoracoscopy under general anesthesia, which reveals mesiothelioma. |

| | |Description of Procedure (00529) |

| | |Intravenous access is obtained. Pre-medication (sedation, anti-aspiration, anti-asthmatic drugs, etc) is |

| | |administered. The patient is transported to the OR. Routine monitors are applied and placement is confirmed |

| | |after patient is positioned on the OR table. Preoxygenation is performed by mask. Induction of anesthesia is |

| | |performed with intravenous lidocaine, fentanyl, propofol and a neuromuscular blocking agent. An endobronchial |

| | |tube is inserted and the position is confirmed with fiberoptic bronchoscope and auscultation. The endotrachial |

| | |tube is then secured with tape. Eyes, extremities and pressure points are protected. The patient is placed in |

| | |the lateral decubitus position. |

| | |Endobronchial tube placement is reconfirmed with fiberoptic bronchoscopy and auscultation. Ventilation |

| | |parameters are adjusted as required by the change in patient position. Inhalational and intravenous anesthetics|

| | |are delivered. Constant attention is given to vital signs. Constant monitoring of oxygenation and respiratory |

| | |status and degree of neuromuscular block is performed. Single-lung ventilation is initiated. Ventilator |

| | |settings are adjusted, and normoxia and normocarbia are assured. Continuous positive airway pressure (CPAP) |

| | |and/or positive end-expiratory pressure (PEEP) is applied as needed. Intervention is performed to maintain |

| | |normothermia, regulation of depth of anesthesia and control of blood pressure and cardiac output. IV fluids are|

| | |given to maintain hydration and treat hypotension. Preparation is made for emergence. Two-lung ventilation is |

| | |resumed, and atelectasis is managed. Inhalation agents are withdrawn and residual neuromuscular blockage is |

| | |reversed using anticholinesterase and anticholinergic drugs. Trachea is extubated after determining adequacy of|

| | |spontaneous ventilation. The patient is moved to a stretcher and transferred with supplemental oxygen by |

| | |facemask to PACU. |

|[pic] |

|00537 |  |Clinical Example (00537) |

| | |A 32-year-old man, in good general health, complains of palpitations and occasional shortness of breath, not |

| | |associated with activity. Evaluation included an electrocardiogram, which revealed findings consistent with the|

| | |Wolff-Parkinson-White Syndrome (WPW). Given that patients with WPW are at increased risk for fatal rhythm |

| | |disturbances, he is scheduled for cardiac electrophysiologic studies and possible ablation of the aberrant |

| | |pathways. |

| | |Description of Procedure (00537) |

| | |The patient will be seen by an anesthesiologist for a pre-anesthesia evaluation. At that time, the patient's |

| | |medical history will be reviewed, including current medications, drug allergies, previous operations and |

| | |anesthetics, and family history of problems with anesthetics. Physical examination will include evaluation for |

| | |airway problems and the ease of obtaining intravenous access. Laboratory studies, the EKG, and any imaging |

| | |studies will be reviewed. |

| | |The anesthetic technique to be used, given the nature of the procedure, the requirements of the physician |

| | |performing the procedure as well of those of the patient will be discussed with the patient, and informed |

| | |consent will be obtained. Either a general anesthetic with the patient's trachea being intubated, or a |

| | |technique including infiltration of local anesthetic by the "operator" combined with the intravenous |

| | |administration of narcotics, benzodiazepines, and perhaps an hypnotic agent (commonly referred to as Monitored |

| | |Anesthesia Care - MAC) will be used. |

| | |Monitoring of the patient will include blood pressure, either by cuff or perhaps also with an intra-arterial |

| | |catheter, multi-lead EKG, pulse oximetry, and end-tidal carbon dioxide analysis. A central venous catheter may |

| | |also be utilized, and if the clinical situation dictates, a pulmonary artery catheter may be inserted. |

| | |During the course of the procedure, attempts will be made to identify the aberrant pathways. Stimulation of |

| | |these pathways will initiate rhythm problems that, if not recognized and the stimulus aborted or the rhythm |

| | |disturbance otherwise stopped may result in an undesirable outcome. Thus, continuous and diligent vigilance in |

| | |monitoring of the patient, an understanding of treatment options, and readiness to treat and initiate other |

| | |resuscitation efforts are required for anesthesiologists involved in cases such as these." |

|[pic] |

|00539 |  |Clinical Example (00539) |

| | |A 47-year-old woman is scheduled to undergo tracheal resection and reconstruction for tracheal stenosis. The |

| | |patient sustained chest and abdominal trauma from a motor vehicle accident 5 years ago. As a result of the |

| | |injuries, she had a prolonged hospitalization complicated by ARDS, sepsis, and renal failure. The patient |

| | |required mechanical ventilatory support for 6 weeks. During that hospitalization the patient underwent |

| | |tracheotomy to facilitate long-term mechanical ventilation and bronchopulmonary hygiene. Since removal of the |

| | |tracheotomy tube, the patient has had clinical evidence of severe tracheal stenosis and several episodes of |

| | |severe stridor. |

| | |Description of Procedure (00539) |

| | |Pre-anesthesia: The patient requiring tracheobronchial reconstruction has known abnormalities of the airways, |

| | |necessitating a more thorough preoperative evaluation and more careful planning for airway management at the |

| | |time of surgery. The evaluation includes review of neck and chest radiographs, cine-radiographs and CT or MRI |

| | |scans to assess the caliber of the airway and the degree of tracheomalacia. This assessment is essential to |

| | |determine the most appropriate approach to tracheal intubation and airway management during the procedure. |

| | |Because of the known tracheal abnormalities, the patient is also at increased risk for infection and |

| | |aspiration, necessitating preoperative preparation with medications to reduce the likelihood of respiratory |

| | |failure. |

| | |Intra-operative: In order to provide the surgical conditions necessary to complete the tracheal reconstruction,|

| | |the surgeon and anesthesiologist must carefully coordinate the intraoperative management of the patient's |

| | |airway, ventilation, and gas exchange. Since both the surgeon and anesthesiologist are sharing the airway |

| | |during tracheobronchial reconstruction, the anesthesiologist and surgeon must coordinate the manipulation of |

| | |the trachea and artificial airway to allow the surgical procedure to be completed without loss of airway |

| | |integrity or life-threatening compromise in ventilation and oxygenation. The anesthesiologist must carefully |

| | |coordinate mechanical ventilation, hand ventilation, and airway suctioning to ensure that the airway remains |

| | |clear of blood and secretions that would be aspirated into the lungs. The endotracheal tube position must be |

| | |frequently adjusted to provide surgical conditions that facilitate the repair of the trachea and ensure |

| | |ventilation and oxygenation of the patient. Because of the blood and secretions in the surgical field, the |

| | |anesthesiologist must provide regular suctioning of the airway and repositioning of the endotracheal tube. |

| | |After completion of the surgical repair, the anesthesiologist must ensure that the airway is properly |

| | |positioned to protect the airway from aspiration, ensure gas exchange, and prevent pressure necrosis on |

| | |surgical suture lines. |

| | |Postanesthesia: The patient who undergoes tracheal resection requires meticulous management after the surgical |

| | |procedure to ensure that the suture line remains intact and that there is no compromise in tracheal blood flow.|

| | |The initial goal is to remove the endotracheal tube as soon as possible, after the procedure, while also |

| | |ensuring that the patient has a clear airway. After the tracheal resection, mucociliary clearance is impaired, |

| | |necessitating intensive respiratory care and careful suctioning of pulmonary secretions to optimize |

| | |bronchopulmonary hygiene without disrupting the tracheal anastomosis. Pain relief is carefully titrated to |

| | |achieve patient comfort. |

|[pic] |

|00541 |  |Clinical Example (00541) |

| | |A 64-year-old male is scheduled for a thoracoscopic left upper lobectomy for carcinoma of the lung. The patient|

| | |has a long smoking history. He has coronary artery disease with previous myocardial infarction, although his |

| | |ventricular function is good. He has had no recent chest pain. The surgeon is concerned about possible |

| | |post-obstructive infection in the left upper lobe. To facilitate the surgical procedure, the surgeon has |

| | |requested isolation of the lung. A double lumen endotracheal tube will be placed and the positioning of the |

| | |tube confirmed by fiberoptic bronchoscopy. |

| | |Description of Procedure |

| | |Intra-operative: To isolate one lung from another and provide one lung ventilation, a placement of double lumen|

| | |endotracheal tube or, less commonly, placement of a bronchial blocker is required. The placement of a double |

| | |lumen endotracheal tube required intubation of the trachea with a special endotracheal tube that has a tracheal|

| | |and bronchial lumen. The tube is initially placed through the vocal cords and subsequently passed into the |

| | |mainstem bronchus. To guide proper tube positioning, a fiberoptic bronchoscope is placed through the special |

| | |double lumen endotracheal tube into the mainstem bronchus. Once the airways are properly identified, the double|

| | |lumen endotracheal tube is placed in the mainstem bronchus, its positioning confirmed by bronchoscopy. Once the|

| | |tube is in proper position, the tracheal and bronchial cuffs of the tube are inflated and ventilation is |

| | |provided to each lung independently to confirm proper positioning. After confirming proper positioning of the |

| | |tube with the patient in the supine position, the patient is turned to the position required for the surgical |

| | |procedure, most often the lateral decubitus position. Once positioned for the surgery, the patient undergoes |

| | |repeat bronchoscopy to confirm proper position of the endotracheal tube. |

| | |Postanesthesia: After completion of the surgical procedure, the patient who has undergone a procedure that |

| | |isolated one lung from another is at greater risk for atelectasis, lung consolidation, and impaired gas |

| | |exchange. Prior to tracheal extubation, the non-ventilated lung must be re-expanded without compromising |

| | |pulmonary vascular resistance or lung perfusion. Many of the patients require postoperative mechanical |

| | |ventilatory support, necessitating tracheal reintubation with a single lumen endotracheal tube to prevent |

| | |trauma to the mainstem bronchi and minimize the risk of tracheobronchial malacia or stenosis. |

|[pic] |

|0054T |  |Clinical Example (0054T) |

| | |A 35-year-old male is brought to a trauma center for treatment of multiple injuries suffered in a high-speed |

| | |motor vehicle accident. He has a chest injury and multiple fractures, including a vertically unstable pelvic |

| | |ring fracture. Following insertion of a chest tube, he is placed in traction to stabilize his pelvic injury and|

| | |allow management of hypotension in the intensive care unit. On the second hospital day, he is deemed stable |

| | |enough to undergo definitive treatment of his displaced sacral fracture and anterior pelvic ring fracture. |

| | |Description of Procedure (0054T) |

| | |Under general anesthesia, the patient is positioned supine on a radiolucent table. Following sterile prep and |

| | |drape, a manipulative reduction of the pelvis is performed, and a temporary external fixator is placed to |

| | |maintain reduction. Adequacy of reduction is confirmed with intraoperative C-arm fluoroscopy. |

| | |A reference frame (tracker) is attached either to the iliac wing or the external fixator. The C-arm |

| | |fluoroscope, retrofitted with a calibration target for image-guided surgery, is brought in to obtain images of |

| | |the fractured areas of the pelvis. The patient and C-arm are tracked by an optical camera interfaced with the |

| | |image-guided surgery (IGS) system. Multiple stored images are simultaneously displayed on the IGS monitor. The |

| | |system then tracks the surgical instruments (drill guide or probe), and displays their position relative to the|

| | |stored images. Small stab incisions allow precise insertion of the drill guide in predetermined safe zones, and|

| | |large-diameter cannulated screws are placed percutaneously into the sacrum and superior pubic ramus to |

| | |stabilize the patient's pelvic ring disruption. |

| | |The use of the IGS system allows great accuracy in screw placement with minimal radiation exposure to patient |

| | |and surgeon, while decreasing the surgical time when compared to a standard, formal, open approach. The |

| | |multiply-traumatized patient need not be exposed to further surgical trauma, and can be mobilized immediately |

| | |with a low anticipated complication rate. |

|[pic] |

|00550 |  |Clinical Example (00550) |

| | |A 34-year-old man suffered penetrating trauma of the thorax with a resultant cardiac injury that required a |

| | |median sternotomy for surgical repair. On postoperative day six, dehiscence of the sternal wound was noted. The|

| | |patient is to return to the operating room for wound debridement. |

| | |Description of Procedure (00550) |

| | |The preanesthetic care of the patient includes a history and physical examination noting the method and course |

| | |of the previous anesthetic and determining the presence of any cardiovascular instability secondary to the |

| | |initial injury or subsequent infection. Anesthetic goals include maintenance of hemodynamic stability while |

| | |providing the optimum surgical condition. After reviewing the information, the patient is premedicated for the |

| | |surgery as appropriate. Upon arrival to the operating room, monitors are applied and venous access is obtained.|

| | |General anesthesia is induced and maintained, the trachea is intubated, and positive pressure ventilation is |

| | |initiated and maintained. The patient may be given a neuromuscular blocking agent to facilitate muscle |

| | |relaxation during the procedure. The patient's hemodynamics are maintained throughout the procedure, with |

| | |vasoactive therapeutic agents given as necessary. At the end of surgery, depending on the patient's condition, |

| | |the patient will either be awakened from anesthesia and the trachea extubated in the operating room or the |

| | |patient will be transported to the intensive care unit and ventilated as necessary. The patient is observed for|

| | |recovery and need for pain therapy. |

|[pic] |

|00561 |  |Clinical Example (00561) |

| | |The infant was noted to have trisomy 21 and a heart murmur at birth. Subsequent studies determined the presence|

| | |of an atrioventricular (AV) canal defect. The patient was followed closely after starting digoxin and |

| | |furosemide by mouth. At his six-month check-up, the infant was noted to have tachypnea and failure to gain |

| | |weight. The oxygen saturation was noted to have decreased from previous measurements, and radiologic |

| | |examination of the chest noted signs consistent with cardiac failure. The repair of the congenital heart defect|

| | |under cardiopulmonary bypass was scheduled. |

| | |Description of Procedure (00561) |

| | |Anesthetics were calculated based on weight and administered intramuscularly, after sterile preparation, into |

| | |the deltoid muscle. Once the infant was noted to be under the influence of the anesthetic, he was transferred |

| | |to the operating room. Monitors were placed for five-lead electrocardiogram, pulse oximetry, and blood |

| | |pressure. A saphenous vein was cannulated with a 20-gauge catheter, and intravenous narcotic anesthesia and |

| | |muscle relaxant were infused. Manual ventilation with 100% oxygen was begun. After appropriate demonstration of|

| | |paralysis with a nerve blockade monitor, the trachea was intubated with the appropriate age-calculated and |

| | |sized endotracheal tube (separately reported). Auscultation of breath sounds and capnography confirmed the |

| | |correct tube placement. The endotracheal tube was secured with waterproof tape so as not to be disturbed by |

| | |placement of the transesophageal echo probe. A radial artery was cannulated with a catheter and a left |

| | |subclavian central line was placed under sterile conditions (both reported separately). Both lines were |

| | |connected to the pressure transducers after calibrating to zero as recommended. Blood samples were drawn for |

| | |blood gas analysis and activated clotting time (ACT). A 1 mL test dose of aprotinin was administered and after |

| | |noting no adverse reaction, the continuous infusion was started. The remaining cardioactive infusion drugs were|

| | |connected to the central line but not started. Intravenous medications to prevent infection and inflammation |

| | |were administered. Anesthesia charting was performed. Ventilation was adjusted as indicated by the blood gas |

| | |results. Surgery commenced and ventilation was momentarily stopped during sternotomy. Intermittent blood gas |

| | |analysis and ACT were measured throughout the surgery. Narcotics and muscle relaxants were intermittently |

| | |administered as necessary and blood pressure was titrated. After the surgeons adequately dissected the great |

| | |vessels, anticoagulant was administered intravenously and ACT was measured to be over 400 seconds. |

| | |Cardio-pulmonary bypass commenced soon after cannulation of the aorta and right atrium, and ventilation was |

| | |discontinued. During bypass, the anesthesiologist, in conjunction with the perfusionist, administered |

| | |anesthetic agents and relaxants as appropriate. Surgical repair of the atrio-ventricular canal ensued with |

| | |graft closure of the septal defects and suture repair of the valvular insufficiency. The anesthesiologist and |

| | |the surgeon worked together to assure venting of air from the heart prior to release of the aortic cross-clamp.|

| | |Near the anticipated end of bypass and after adequate re-warming, ventilation was restarted and inotropic |

| | |cardiac support was begun with infusions of dopamine and dobutamine. Afterload reduction was produced by an |

| | |infusion of milrinone. Heating the infant was partially accomplished with a forced warm air mattress controlled|

| | |by the anesthesiologist. After discontinuing bypass, the pulmonary artery was cannulated by the surgeon and the|

| | |pressure line was passed to the anesthesiologist for connection to a transducer. As is typically seen with |

| | |atrioventricular (AV) canal repair in children less than one year of age, the pulmonary artery pressure was |

| | |discovered to be high and inhaled nitric oxide gas was added to the inspiratory anesthetic circuit. Flows were |

| | |adjusted to obtain the correct concentration as measured in the inspiratory limb. Once cardiac and pulmonary |

| | |parameters were stabilized, the heparin anticoagulation was reversed with intravenous medication and the |

| | |activated clotting time (ACT) was measured as normal. Blood gases were intermittently checked. Due to the |

| | |patient's weight and the effects of cardiopulmonary bypass on the coagulation system, coagulopathies are |

| | |commonly seen after discontinuation from bypass. After the conclusion of surgery, a portable monitor and |

| | |ventilation circuit were connected to the patient for transport of the infant to the intensive care unit. The |

| | |nitric oxide circuit was tested to ensure adequate delivery of the vasodilator during transport. The infusion |

| | |pumps delivering cardiovascular medications were checked for proper function prior to transport. On arrival to |

| | |the intensive care unit, hemodynamic and respiratory monitors were transferred to the unit's system. |

| | |Ventilation was transferred to a bedside ventilator and parameters adjusted to satisfaction. The continued |

| | |administration of nitric oxide was confirmed. Vital signs were monitored. |

|[pic] |

|00563 |  |Clinical Example (00563) |

| | |A 3-day-old female with transposition of the great arteries with ventricular defect is prepared for a Jatene |

| | |type operation. Based upon the anatomy of this congenital heart defect, cardiac surgery with pump oxygenator |

| | |using deep hypothermic circulatory arrest is selected for the surgical procedure. |

| | |Description of Procedure (00563) |

| | |The preanesthetic care of the patient by the anesthesiologist is the same provided for surgery with |

| | |cardiopulmonary bypass. Anesthetic goals include sufficient anesthetic depth to protect the brain, heart and |

| | |other organ systems during deep hypothermic circulatory arrest as well as the avoidance of significant |

| | |hemodynamic instability after CPB, which exacerbates ischemia and bleeding tendencies. The manipulation of |

| | |blood gas management during cooling, topical head cooling, and the use of vasoactive substances is common |

| | |before CPB. The introduction of air into the left and right heart due to cardiac surgical incision on the left |

| | |side of the heart as well as the aortic and venous cannulae promotes the opportunity for air emboli. Meticulous|

| | |monitoring and removal of air is required prior to the reinstitution of CPB and rewarming. Additional brain |

| | |monitoring such as transcranial Doppler or the use of transesophogeal echocardiography may be indicated to |

| | |treat the suspicion of air emboli. Episodes of hemodynamic instability after rewarming and the cessation of CPB|

| | |are common due to mild cardiac ischemia, a direct result of the use of deep hypothermic circulatory arrest. |

| | |Hemodynamic instability and low cardiac output can further aggravate any organ system dysfunction due to |

| | |circulatory arrest and must be treated urgently and aggressively. Often this requires the careful titration of |

| | |anesthetic drugs as well as the use of several inotropes or vasodilators. The anesthesiologist administers |

| | |drugs so as to promote hemodynamic stability and to increase cardiac output. The use of deep hypothermic |

| | |circulatory arrest also disrupts liver metabolism and the level of procoagulants, often resulting in excessive |

| | |bleeding. This requires the anesthesiologist to more aggressively monitor the activated clotting time and |

| | |platelet function, and often requires multiple blood component therapy. |

|[pic] |

|00566 |  |Clinical Example (00566) |

| | |A 68-year-old man with progressive coronary artery is prepared for coronary artery bypass. Based upon the |

| | |anatomy, a direct coronary artery bypass surgery without pump oxygenator is selected for the surgical |

| | |procedure. |

| | |Description of Procedure (00566) |

| | |The preanesthetic care of the patient by the anesthesiologist is the same as that provided for surgery with |

| | |cardiopulmonary bypass. Anesthetic goals include an awake, extubated patient at the end of the surgical |

| | |operation and before the patient is transferred to the PACU or ICU. One-lung ventilation is common. |

| | |Short-acting drugs are used in the lowest doses required by the patient. Episodes of hemodynamic instability |

| | |are common from ischemic preconditioning, coronary artery clamping which produces ventricular regional ischemia|

| | |and contractile dysfunction, and cardiac manipulation. In contrast to CABG with cardiopulmonary bypass (CPB) |

| | |that may or may not have hemodynamic problems after CPB, the direct CABG operation always produces hemodynamic |

| | |perturbations during the coronary artery grafting phase. Either a pulmonary artery catheter or transesophageal |

| | |echocardiography or both may be indicated for diagnosis and treatment of sudden hemodynamic alterations |

| | |including hypotension, hypertension, tachycardia, bradycardia, dysrhythmias, myocardial ischemia and |

| | |ventricular dysfunction. Although the intention is to avoid CPB, anticoagulating doses of heparin are |

| | |administered in case there is the need to use CPB emergently (ie, "crash onto bypass"). It is desirable to slow|

| | |the heart rate in order to facilitate the microsurgical opening of the coronary artery and sewing of the graft |

| | |to it. The anesthesiologist administers drugs to slow the heart (eg, beta blockers, adenosine) and in so doing,|

| | |has to contend with the consequences of reduced cardiac output and hypotension. These same steps are repeated |

| | |for each coronary artery to be grafted. This part of the procedure requires continuous and intense monitoring |

| | |and treatment of the patient. |

|[pic] |

|0057T |  |Clinical Example (0057T) |

| | |A 66-year-old female reports chronic heartburn and regurgitation symptoms three times or more per week, not |

| | |responding to lifestyle management strategies and intensive daily pharmacologic therapy. Upper gastrointestinal|

| | |endoscopy (EGD), 24-hour ambulatory pH testing, and esophageal manometry testing are performed. The patient |

| | |demonstrated a peak esophageal peristaltic amplitude >30 mm Hg, LESP >5 mm Hg, complete LES relaxation in |

| | |response to swallow, and a DeMeester score >14.7. She had Hetzel grade 1 esophagitis and no hiatal hernia >2 |

| | |cm. |

| | |The patient is provided a trial of daily full dose proton pump inhibitor therapy. Her symptoms improve but are |

| | |not completely relieved. Double dose treatment is instituted with control of the symptoms but she is desirous |

| | |of pursuing other means to allow her to control the disease. Given that the patient is inadequately controlled |

| | |on intensive drug therapy, she is counseled regarding the treatment options. Given the risk/benefit of each |

| | |option, the patient and physician choose endoluminal delivery of thermal energy to the muscle of lower |

| | |esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease. |

| | |The procedure is performed on an outpatient basis in a hospital-associated endoscopy unit or ambulatory surgery|

| | |center using intravenous conscious sedation or monitored anesthesia care (as indicated). After informed consent|

| | |is obtained, the patient is prepared as for standard EGD, with monitoring of vital signs. Intravenous access is|

| | |obtained and conscious sedation administered by the physician. |

| | |Description of Procedure (0057T) |

| | |An EGD is performed to confirm the absence of pathology that would represent a contraindication to the |

| | |performance of the proposed procedure. The upper endoscope is then positioned in the gastric antrum, and a |

| | |guidewire is passed through the endoscope into the duodenum or gastric antrum. The endoscope is withdrawn while|

| | |noting the distance from the incisors to the gastroesophageal junction. The thermal catheter is passed over the|

| | |guidewire and positioned 1 cm proximal to the squamocolumnar junction. The thermal catheter balloon is |

| | |inflated, needle electrodes deployed, and radiofrequency (RF) energy delivery commenced. This treatment is |

| | |repeated after rotating the catheter 45 degreees and then again by advancing it 5 mm (4 treatments thus far). |

| | |The catheter is then advanced into the stomach. An endoscope is re-introduced per-oral and passed along side |

| | |the catheter to confirm accurate positioning of the first 2 rings. The endoscope is then withdraw0n. Third and |

| | |fourth rings, comprised of eight lesions per ring, are then placed in 5 mm increments distal to the second |

| | |ring, adjusting the measurements according to the endoscopic findings. The catheter is then advanced into the |

| | |stomach, fully inflated to 25 cc of air, and withdrawn into the gastric cardia. Three such deployments and |

| | |lesion sets are created, totaling 12 lesions in the distal cardia. This is repeated with a balloon inflated to |

| | |22 cc, creating 12 lesions in the proximal cardia. |

| | |A third EGD is performed to confirm lesion placement. The catheter is then withdrawn. Post procedure vital |

| | |signs are checked and the patient is transferred to the recovery suite. The patient is monitored for signs of |

| | |complications. At two hours post treatment, the patient is reassessed for complications arising from the |

| | |procedure (perforation, chest pain, nausea and/or vomiting). Prescriptions for pain medication and anti-emetics|

| | |are provided and the patient is discharged with instructions regarding potential delayed complications. |

|[pic] |

|0058T |  |Clinical Example (0058T) |

| | |A 25-year-old female was diagnosed with a solid tissue tumor. She will undergo chemotherapy which does not |

| | |spare the reproductive tissue. Ovarian biopsy was performed as the method by which ovum will later be isolated |

| | |and used for in vitro assisted fertilization. Cryopreservation and storage of her ovarian tissue was indicated |

| | |prior to therapy for future use in building a family. |

| | |Ovarian tissue is obtained surgically. Ovarian tissue is assessed prior to freezing. An appropriate |

| | |cryoprotectant agent is added, with or without dilution or extension based on whether tissue will be frozen as |

| | |a mince or as intact tissue. Tissue is either minced or frozen intact by direct contact methods or is loaded |

| | |into straws or vials specifically constructed for storage at ultra-low temperatures and the samples are cooled |

| | |to -270'C using programmable, controlled-rate freezers with or without manual seeding at the heat of |

| | |crystallization. |

| | |Description of Procedure (0058T) |

| | |Preparation of culture media and protein supplementation, different than routine culture and fertilization |

| | |media, including but not limited to testing using a suitable bioassay to ascertain toxicity or growth promoting|

| | |properties and infectious disease testing of protein or cellular components. There must be evidence of proper |

| | |instrument function prior to use of controlled rate freezing device for reproductive tissue cryopreservation. |

| | |Prior to reproductive tissue freezing there must be evaluation of back-up systems for culture to ensure backup |

| | |capability should the culture chamber or any other electrical device necessary for maintaining human tissue |

| | |growth fail during operation. Preparation of culture media with increasing concentrations of cryoprotectant for|

| | |use in cryopreservation including quality control. Review of patient records to determine candidacy for |

| | |procedure and consents. Documents necessary to protect the interests of the owner of the frozen reproductive |

| | |tissue must be maintained. |

| | |Human reproductive tissue is assessed and a cryoprotectant is selected based on this assessment. Using direct |

| | |visualization under the microscope, minced or intact reproductive tissue is moved through solutions of |

| | |increasing cryoprotectant concentration and is frozen by direct contact methods or is loaded into straws or |

| | |vials for subsequent freezing (cryopreservation) and storage. Reproductive tissue is placed into straws or |

| | |vials specifically constructed for storage at ultra-low temperatures. Each vessel containing reproductive |

| | |tissue is clearly labeled to ensure chain of custody, including but not restricted to patient name, accession |

| | |number and contents. The reproductive tissue is cooled from 37°C to -270°C gradually using a controlled-rate |

| | |freezing chamber with manual or mechanical seeding initiated at the heat of crystallization. There must be |

| | |evidence of proper instrument function during use of controlled rate freezing device for reproductive tissue |

| | |cryopreservation. Reproductive tissue is stored in the vapor phase of or submerged under liquid nitrogen at |

| | |-270°C. Location of vessels unique to each patient is documented and stored in duplicate. |

| | |Consultation with patient and physician concerning quality of reproductive tissue and number of vials or straws|

| | |available for future use. Documentation of location, identification and sample chain of custody of the frozen |

| | |reproductive tissue is made in duplicate. |

|[pic] |

|0059T |  |Clinical Example (0059T) |

| | |A 25-year-old female was diagnosed with cancer and a combination of chemotherapy and radiotherapy was |

| | |recommended. The female requests cryopreservation and storage of her oocytes prior to therapy for future use in|

| | |building a family. |

|[pic] |

|00604 |  |Clinical Example (00604) |

| | |A 4-year-old patient with Down's syndrome was diagnosed with acute lymphoblastic leukemia after presenting with|

| | |fatigue, fever and weight loss. Significant history includes surgical repair of a ventricular septal defect at |

| | |2 years old. The patient is extremely anxious and the parents request the child be anesthetized for cerebral |

| | |spinal fluid testing and administration of intrathecal methotrexate. |

| | |Description of Procedure (00604) |

| | |Description of anesthetic services for this patient include a pertinent history with emphasis on the present |

| | |illness and significant past history specifically reviewing cardiac function and other systemic involvement |

| | |from Trisomy 21. Previous anesthesia records are reviewed, and a physical examination is performed. An |

| | |anesthetic plan is formed and discussed with the parents for approval. Premedication with agents used to |

| | |decrease anxiety is used as needed. Monitors are placed and anesthesia is induced through the use of systemic |

| | |medications or inhaled anesthetics alone or in combination. The patient is turned to allow access to the lumbar|

| | |region after the airway is appropriately secured. General anesthesia is maintained and the patient's |

| | |hemodynamics are maintained throughout the procedure, with vasoactive therapeutic agents given as necessary. At|

| | |the end of the procedure, anesthesia is discontinued and the patient is awakened. The patient is transported |

| | |when stable to the postanesthesia care unit. When the patient has been observed to be adequately recovered from|

| | |the anesthetic, the anesthetist will discharge the patient back to the care of the referring physician. |

|[pic] |

|0060T |  |Clinical Example (0060T) |

| | |All asymtomatic patients under 40 years of age, who present to their doctors for an annual check-up to include |

| | |a Clinical Breast Exam (CBE) would be candidates for an Electrical Impedance Scan (T-Scan) of both breasts. |

| | |Description of Procedure (0060T) |

| | |The service includes physician performance or supervision of patient preparation and positioning. The patient |

| | |is recumbent and a Clinical Brest Exam is conducted on both breasts. The results of the CBE are duly entered |

| | |into the T-Scan System for record keeping and documentation. The patient's age is also entered into the system.|

| | |Patients above the age of 40 are not eligible for T-Scan and the exam cannot be conducted to assure that T-Scan|

| | |does not defer women from annual mammography. |

| | |A positive CBE is an indicator that the patient should be sent for follow-up with other imaging modalities for |

| | |breast cancer detection such as mammography and/or ultrasound. Regardless of T-Scan results. |

| | |Proceeding with T-Scan procedure, the patient is instructed to hold a transducer in the opposite hand to the |

| | |breast being examined. The transducer sends a safe, low-level current (2.5 volts) through the breast tissue to |

| | |enable the measurement of tissue impedance |

| | |An ultrasound type gel is applied to a hand held probe and the operator scans each breast in a 9-sector format |

| | |beginning with the nipple in the center. All sectors are recorded and the system provides an objective result |

| | |of positive or negative indicated by a red or green bar on the computer screen. A positive T-Scan prompts a |

| | |repeat of the clinical breast exam to again determine if anything is palpable, but also is an indicator that |

| | |this patient is at higher risk for breast cancer and should be referred for additional work-up with other |

| | |imaging modalities such as mammography or ultrasound. |

|[pic] |

|0061T |  |Clinical Example (0061T) |

| | |Mrs. Smith is a 47-year-old female with locally-advanced, primary breast cancer, clinical stage III. |

| | |Description of Procedure (0061T) |

| | |After initial patient assessment and photodocumentation of the breast, the patient laid prone on the treatment |

| | |table and the right breast was placed through the opening on the treatment table. Seven skin temperature |

| | |sensors were taped to her breast to monitor her skin temperature. Compression was applied on the medio-lateral |

| | |direction. Minimum compression of the breast was 5 cm. The lesion was identified and centered by palpation and |

| | |by the use of ultrasound. |

| | |At this point the skin of the breast was prepped with Betadine and draped in the usual sterile fashion. 0.5% |

| | |Lidocaine with epinephrine was infiltrated in the skin and a small incision was made with a #11 blade. The |

| | |initial skin incision was made at the 10:00 position. With the use of a mosquito-Kelly clamp, and under |

| | |ultrasound guidance, a single use disposable closed end flexiguide 16 gauge catheter and metal introducer was |

| | |advanced through the skin opening, and advanced manually up to 5 cm proximal to the tumor and parallel to the |

| | |polarization of the microwave emitters. Once inserted into the tumor, the metal introducer was pulled out and a|

| | |sterile combined fiberoptic temperature probe/microwave sensor was placed inside the catheter. Final placement |

| | |of the probe was confirmed with ultrasound. Maximum treatment compression of the breast was 6 cm. The emitters |

| | |were phase-tuned (synchronized) in order for the microwave energy to be focused on the tumor and breast tissue |

| | |immediately adjacent to the tumor (Unique pre-focusing procedure). The fan cooling system (part of the APA 1000|

| | |system) was turned on to keep the skin surface of the breast cool during treatment. |

| | |Total treatment time was 25 minutes. Thermal dose was 180 minutes. A high temperature of 46 degrees C was |

| | |reached in the tumor. The maximal temperature on the superior/medial skin was 41° C, on the inferior/lateral |

| | |skin was 38.2° C and it was 29.7° C on the nipple. Thermotherapy concluded at 10:25. |

|[pic] |

|00625 |  |Clinical Example (00625) |

| | |A 50-year-old male is undergoing anterior arthrodesis of the thoracic spine for degenerative disc disease via |

| | |the anterior transthoracic approach, for performance of disc excision and preparation of the end-plates for |

| | |fusion. The decision is made to proceed using two-lung ventilation. |

| | |Description of Procedure (00625) |

| | |In the preanesthesia holding area, intravenous (IV) access is established and the patient receives sedation. |

| | |The patient is transferred to the operating room and appropriate monitoring devices are applied. (Placement of |

| | |invasive monitoring devices such as an arterial and/or central venous catheter is separately reportable.) The |

| | |mandated "pause and reflect" confirmation of right patient, right side, right surgery is performed. |

| | |Anesthesia is induced and once an adequate neuromuscular blockade is established, the anesthesiologist performs|

| | |direct laryngoscopy and intubates the trachea. Proper tracheal placement is confirmed and the tube is secured. |

| | |The patient is placed in the lateral position for the surgical procedure. Bilateral breath sounds are |

| | |auscultated, proper functioning of the monitors and vascular access are confirmed, and the pressure points are |

| | |padded. A warm-air heating blanket is positioned. |

| | |During the procedure, the anesthesiologist adjusts the ventilator to assure adequate ventilation without |

| | |compromising the surgical field. Because the lung is retracted and packed off so that the vertebral body |

| | |elements are exposed, the anesthesiologist carefully monitors the patients oxygenation status with pulse |

| | |oximetry and obtains serial arterial blood samples as indicated. |

| | |As these procedures can result in significant blood loss, the anesthesiologist carefully monitors the central |

| | |venous pressure and urine output and initiates blood transfusions as needed, after verifying that the blood |

| | |products are appropriate and intended for the patient. |

| | |During the portion of the surgical procedure that involves manipulation of the spinal elements, the anesthetic |

| | |technique is adjusted to facilitate neurophysiologic monitoring. This requires close communication between the |

| | |anesthesiologist and the individual performing the neuromonitoring. |

| | |At the conclusion of the vertebral element manipulation and instrumentation, the lung retractors and packs are |

| | |removed and the anesthesiologist adjusts the ventilation to assure complete re-expansion of the compressed |

| | |lung. The patient is hand ventilated to facilitate the closure of the chest wall. |

| | |At the conclusion of the procedure, the patient is returned to the supine position. Anesthetic agents are |

| | |discontinued and any residual neuromuscular blockade is reversed with a combination of anticholinesterase and |

| | |anticholinergic agents as prepared by the anesthesiologist. |

| | |The anesthesiologist evaluates the patients respiratory effort, oxygenation, level of consciousness, and the |

| | |reversal of neuromuscular agents. If the patient meets the acceptable criteria, the anesthesiologist extubates |

| | |the patients trachea. If the patient cannot tolerate early extubation, the patient is taken to the |

| | |postanesthesia care unit (PACU) or intensive care unit (ICU) while intubated and ventilated en route by the |

| | |anesthesiologist. Careful monitoring of the patients vital signs is continuously performed during the |

| | |transport. |

|[pic] |

|00626 |  |Clinical Example (00626) |

| | |A 50-year-old male is undergoing anterior arthrodesis of the thoracic spine for degenerative disc disease via |

| | |the anteior transthoracic approach, for performance of disc excision and preparation of the end-plates for |

| | |fusion. The decision is made to proceed using one-lung ventilation. |

| | |Description of Procedure (00626) |

| | |In the preanesthesia holding area, intravenous (IV) access is established and the patient receives sedation. |

| | |The patient is transferred to the operating room and appropriate monitoring devices are applied. (Placement of |

| | |invasive monitoring devices such as an arterial and/or central venous catheter is separately reportable.) The |

| | |mandated "pause and reflect" confirmation of right patient, right side, right surgery is performed. |

| | |Anesthesia is induced and once an adequate neuromuscular blockade is established, the anesthesiologist performs|

| | |a direct laryngoscopy. A double-lumen endotracheal tube is passed into the trachea using the appropriate |

| | |technique. The double-lumen tube placement is confirmed by passing a fiber optic bronchoscope down the trachea |

| | |portion and the bronchial portion. The double-lumen tube is manipulated and adjusted to ensure proper |

| | |placement. The tube is secured with tape. |

| | |The patient is placed in the lateral position for the surgical procedure. Bilateral breath sounds are |

| | |auscultated, proper functioning of the monitors and vascular access are confirmed, and the pressure points are |

| | |padded. A warm-air heating blanket is positioned. |

| | |A repeat bronchoscopic examination is performed to confirm that the tube has remained in the correct position. |

| | |The breath sounds are auscultated as well to confirm selective ventilation. Tube placement must be constantly |

| | |monitored and adjusted based on surgical needs. Once the thoracic cavity is entered, the anesthesiologist |

| | |initiates one-lung ventilation by clamping the lumen to the operative lung. |

| | |As these procedures can result in significant blood loss, the anesthesiologist carefully monitors the central |

| | |venous pressure and urine output and initiates blood transfusions as needed, after verifying that the blood |

| | |products are appropriate and intended for the patient. |

| | |During the period of single-lung ventilation, the anesthesiologist carefully monitors the patients oxygenation |

| | |status with pulse oximetry and, if indicated, with serial arterial blood gasses (ABG's). Should the patient |

| | |become hypoxemic during the period of one-lung ventilation, the anesthesiologist initiates procedures to |

| | |increase oxygenation (eg, selective lung continuous positive airway pressure [CPAP] or intermittent manual |

| | |ventilation). |

| | |During the portion of the surgical procedure that involves manipulation of the spinal elements, the anesthetic |

| | |technique is adjusted to facilitate neurophysiologic monitoring. This requires close communication between the |

| | |anesthesiologist and the individual performing the neuromonitoring. At the conclusion of the spinal |

| | |instrumentation, the anesthesiologist resumes two-lung ventilation, adjusting ventilation as needed to assure |

| | |complete re-expansion of the operative lung. The patient is hand ventilated to facilitate the closure of the |

| | |chest wall. |

| | |At the conclusion of the procedure, the patient is returned to the supine position. Anesthetic agents are |

| | |discontinued and any residual neuromuscular blockade is reversed with a combination of anticholinesterase and |

| | |anticholinergic agents as prepared by the anesthesiologist. |

| | |The anesthesiologist evaluates the patients respiratory effort, oxygenation, level of consciousness, and the |

| | |reversal of neuromuscular agents. If the patient meets acceptable criteria, the anesthesiologist extubates the |

| | |patients trachea. If the patient cannot tolerate early extubation, the anesthesiologist performs a direct |

| | |laryngoscopy and exchanges the double-lumen tube for a single-lumen tube. The patient is then transferred to |

| | |the postanesthesia care unit (PACU) or intensive care unit (ICU) while intubated and is ventilated en route by |

| | |the anesthesiologist. Careful monitoring of the patients vital signs is continuously performed during the |

| | |transport. |

|[pic] |

|0062T |  |Clinical Example (0062T) |

| | |A 32-year-old female with low back pain radiating into her right buttock presents 9 months after a lifting |

| | |injury at home. Conservative treatment has been unsuccessful. Physical examination reveals restricted spinal |

| | |motion without signs of neurologic deficit. X ray findings are negative. A magnetic resonance imaging (MRI) |

| | |scan demonstrates a contained single level (L4-L5) central disc protrusion with preservation of disc height |

| | |without spinal nerve compression. A discogram confirms concordant pain provocation from that disc and the |

| | |presence of annular disruption. The discogram also confirms that adjacent discs are painless and |

| | |morphologically normal. During surgery, a percutaneous annuloplasty is performed. Postoperative hospital care |

| | |and office visits are conducted as necessary throughout the 90-day global period. |

| | |Description of Procedure (0062T) |

| | |The medical record is reviewed to ensure that the patient is stable for the planned surgical procedure. The |

| | |radiographic studies are reviewed. Imaging studies are correlated with the clinical exam and the surgical plan |

| | |is confirmed. The surgeon confers with the patient and the patients family to explain again the current |

| | |condition and the need for surgical intervention. Questions are answered, consent is obtained, and a note is |

| | |written in the record. The physician confers with the anesthesiologist and the operating room staff to review |

| | |the positioning of the patient, the intra-operative plan, and the equipment needs. After monitoring lines are |

| | |placed, the patient is positioned on the operative table. Fluoroscopy (reported separately) is utilized to |

| | |localize the correct level. The surgical site is prepped and draped into a sterile field. Intravenous |

| | |antibiotics are administered under physician supervision. |

| | |The physician marks the skin at the point of intended entry and local anesthetic is injected. A spinal needle |

| | |is placed adjacent to the L4-L5 disc, depth is measured, and a local anesthetic is injected. An introducer |

| | |needle is placed into the disc and advanced obliquely into the anterolateral quadrant of the disc space. This |

| | |position is confirmed by fluoroscopy. The annuloplasty catheter is checked for any defects and to ensure that |

| | |it is in proper working condition. The catheter is then advanced through the introducer needle and navigated |

| | |into the area of disc pathology. Final position is confirmed by fluoroscopy. The catheter is connected to the |

| | |generator and the disc is treated. The patient is monitored during the procedure by the physician for pain |

| | |response that may require adjusting treatment intensity or increasing the level of sedation. The patient is |

| | |also monitored for any radicular symptoms that would indicate impending nerve injury and necessitate |

| | |repositioning the catheter. If complete treatment of the disc cannot be accomplished from a unilateral |

| | |approach, the procedure is repeated from the contralateral side. At the completion of the procedure, antibiotic|

| | |solution may be injected into the disc. The catheter and needle are then removed. |

| | |Dressings are applied. The patient is rolled onto a recovery bed and the patients neurologic status is checked.|

| | |The patient is then transported to the recovery room and observed for approximately 1 hour. Postoperative |

| | |orders are written and a note is dictated. The patients family is met in the waiting room and questions are |

| | |answered. The referring physician is contacted and informed about the results of the surgery. Arrangements are |

| | |made for outpatient physiotherapy visits after the patient is discharged. The patient is reexamined for |

| | |neurologic function and the dressing is inspected and changed as needed. Discharge planning and coordination |

| | |occurs with the patient and family. A lumbar sacral orthosis is fitted prior to discharging the patient. |

| | |After the patient is discharged, the patient returns to the office for follow-up visits. Questions regarding |

| | |physiotherapy and activity levels are answered. Phone calls are answered concerning pain levels and activity |

| | |restrictions. Subsequent follow-up office visits are scheduled to recommend progression of activity and to |

| | |monitor functional and work status. Prescription medication refills are reviewed and written. An exercise |

| | |program is recommended and printed material regarding therapy is provided to the patient. Adjustments to the |

| | |orthosis are made during the follow-up visits as necessary. |

|[pic] |

|0063T |  |Clinical Example (0063T) |

| | |A 38-year-old male with low back pain after a lifting injury at work. Conservative treatment for 7 months has |

| | |been unsuccessful. Physical examination reveals restricted spinal motion without signs of neurologic deficit. |

| | |X-rays are negative. A magnetic resonance image (MRI) demonstrates annular fissures in two lumbar discs (L4-L5,|

| | |and L5/S1) without spinal nerve compression. A discogram confirms the presence of annular tears at L4/L5 and |

| | |L5/S1 and reproduces concordant pain. The L3/L4 disc is painless and morphologically normal. At operation, a |

| | |percutaneous annuloplasty is performed at both levels. Post operative hospital care and office visits are |

| | |conducted as necessary throughout the 90-day global period. |

| | |Description of Procedure (0063T) |

| | |While the first level of annuloplasty (L5/S1-reported separately) is being treated, the physician marks the |

| | |skin at the point of intended entry for the L4/L5 level and local anesthetic is injected. A spinal needle is |

| | |placed adjacent to the disc, depth is measured and local anesthetic is injected. Then an introducer needle is |

| | |placed into the disc and advanced obliquely into the anterolateral quadrant of the disc space. This position is|

| | |confirmed by fluoroscopy. The annuloplasty catheter is checked for any defects and to ensure that it is in |

| | |proper working condition. The catheter is then advanced through the introducer needle and navigated into the |

| | |area of disc pathology. Final position is confirmed by fluoroscopy (reported separately). When treatment of the|

| | |L5/S1 level is complete the catheter at L4/L5 is connected to the generator and the disc is treated. The |

| | |patient is monitored during the procedure by the physician for pain response that may require adjusting |

| | |treatment intensity or increasing the level of sedation. The patient is also monitored for any radicular |

| | |symptoms that would indicate impending nerve injury and that would necessitate re-positioning of the catheter. |

| | |If complete treatment of the disc can not be accomplished from a unilateral approach, the procedure is repeated|

| | |from the contralateral side. At the completion of the procedure, antibiotic solution may be injected into the |

| | |disc. The catheter and needle are then removed. |

|[pic] |

|00640 |  |Clinical Example (00640) |

| | |The typical patient is one in whom office manipulations have failed to relieve the pain syndrome. The patient |

| | |may not be able to work and resists further office therapy because of the pain involved. Further manipulation |

| | |via manipulation under anesthesia should be determined after a conservative approach to manual therapy. |

| | |Description of Procedure (00640) |

| | |The patient is evaluated preoperatively by an anesthesiologist to determine the presence of coexisting medical |

| | |illness, drug therapy, allergies, previous surgical history, and applicable family history. For example, if the|

| | |patient is known to be taking cardiac medication or antihypertensives, instructions would be given to him or |

| | |her regarding the medications. Also, cardiovascular and other end organ damage due to chronic hypertension |

| | |would be sought after and emphasized during the examination. The airway is evaluated as a critical part of the |

| | |physical examination. Physical examination would also include the cardiopulmonary exam. |

| | |At this point the patient is advised of the type of anesthesia that will be used for the procedure and the |

| | |risks, benefits, and alternatives are given. Instructions for the day of surgery are given to the patient, |

| | |including the appropriate period of time for fasting prior to the surgery. |

| | |On the day of the procedure, after obtaining informed consent, the patient is again evaluated by the anesthesia|

| | |provider who will start a peripheral intravenous line and begin an infusion of lactated ringers. The anesthesia|

| | |provider will have assured that all equipment and drugs necessary for resuscitation are available and working. |

| | |The patient is placed on the OR table and monitoring devices are applied (ECG, NIBP, pulse oximetry) and |

| | |baseline values are obtained. Intravenous anesthetics, with or without benzodiazepines and/or narcotics, are |

| | |most commonly used. Supplemental oxygen is given and the airway is maintained throughout. This is especially |

| | |important during manipulations of the cervical spine. Additional intravenous medication is given as required. |

| | |Blood pressure is monitored every 3 to 5 minutes, more frequently if indicated. As the procedure nears |

| | |completion, anesthetic agents are withdrawn to prepare the patient for wakefulness. Hemodynamic stability, |

| | |adequacy of ventilation, and level of consciousness are examined. If these parameters are acceptable, the |

| | |patient is transferred to the postanesthesia care unit. A complete record is maintained by the anesthesia |

| | |provider. |

| | |In the postanesthesia care unit, the patient is managed according to ASA guidelines. Any side effects of |

| | |anesthesia, most commonly nausea and vomiting, are assessed and treated if necessary. Prior to discharge, level|

| | |of consciousness, respiratory function, ability to ambulate, and availability of an escort are assessed, and |

| | |discharge instructions are issued and documented in the patient's record. |

|[pic] |

|0064T |  |Clinical Example (0064T) |

| | |The patient is a 5-year-old child with complaints from parents of periodic waking at night with trouble |

| | |breathing along with other periods of persistent wheezing. The attending physician has reviewed the clinical |

| | |history, performed a physical examination, and has ruled out other chronic obstructive diseases, foreign body |

| | |obstructions, upper airway obstructions, sinobronchitus, immune disorders, cardiac disease and other acute |

| | |diseases. The physician orders spectroscopy, expired gas analysis of the lower airways to determine if the |

| | |patient is suffering from chronic airway inflammation, a co-condition for hyper-reactive airway disease. |

| | |Description of Procedure (0064T) |

| | |The examination is performed with laser spectroscopy equipment that can perform real-time detection of nitric |

| | |oxide and carbon dioxide concentrations in an exhaled breath sample. The equipment has the necessary |

| | |sensitivity to enable the respiratory therapist (RT) to distinguish between upper airway and lower airway |

| | |breath samples and corresponding nitric oxide concentrations. |

| | |The RT briefs the patient on the breath testing procedure that consists of a slow 15 second exhalation into the|

| | |instrument. The RT evaluates the first exhalation in to the instrument and determines if the patient is capable|

| | |of delivering the breath sample based on the comparison of the patient's results from a normal carbon dioxide |

| | |concentration curve. The respiratory therapist (RT) starts the spectroscopy instrument and coaches the patient |

| | |to repeat the test three times to obtain consistent readings of lower airway nitric oxide concentrations. The |

| | |RT evaluates the three samples, reviews the results for statistical consistency, and prints the results for |

| | |attending physician evaluation. |

| | |Results will help the physician identify underlying airway inflammation and monitor effects of |

| | |anti-inflammatory treatments. |

|[pic] |

|0065T |  |Clinical Example (0065T) |

| | |An 18-month-old child is visiting with the pediatrician for a well-baby examination. Mother mentions that there|

| | |is a strong family history of strabismus and amblyopia. Clinical examination with typical office |

| | |instrumentation revealed no abnormality. In keeping with clinical practice guidelines, the pediatrician |

| | |recommends the child be screened with a photoscreening device. |

| | |Description of Procedure (0065T) |

| | |The service includes physician performance or supervision of patient preparation and equipment set-up. The |

| | |infant is positioned for the photoscreening device and an image is obtained. The image is transmitted or |

| | |conveyed to an appropriate screening laboratory for interpretation to produce a reliable assessment of ocular |

| | |abnormality vs abnormality. Conditions detected include esotropia, exotropia, anisometropia, cataracts, ptosis,|

| | |hyperopia and myopia. The result is returned to the pediatrician for action. |

|[pic] |

|0066T |  |Clinical Example (0066T) |

| | |A 65-year-old male presents with a family history of colon cancer in which conventional colonoscopy was unable |

| | |to reach the right colon. CT colonography is ordered. |

| | |Clinical Example 2 (0066T) |

| | |A 75-year-old female presents with heme-positive stools. She could not undergo conventional colonoscopy due to |

| | |risk of sedation. CT colonography is ordered. |

| | |Clinical Example 3 (0066T) |

| | |A 55-year-old male presents on Coumadin for valve replacement needs screening colonoscopy, but clinicians do |

| | |not want to stop anticoagulation. CT colonography is ordered. |

| | |Description of Procedure (0066T) |

| | |The procedure is described to the patient and informed consent is obtained where applicable. A review of any |

| | |prior applicable studies is also performed. |

| | |Rectal tube is inserted (or supervision provided during insertion) and the colon is insufflated with either air|

| | |or carbon dioxide. Next, a scout topogram of abdomen and pelvis is obtained/interpreted to ensure adequate |

| | |colonic distention. Additional air is added if necessary. The non-contrast CT images of the abdomen and pelvis |

| | |performed in the supine position are obtained/reviewed. The patient is then turned to the prone position. The |

| | |axial images of both the supine and prone data sets are interpreted.. Three-dimensional reconstructions of the |

| | |colon including endoluminal fly-throughs are supervised and/or created. An adjustment of the projection of the |

| | |three-dimensional reconstructions is provided to optimize visualization of anatomy or pathology. The 3D |

| | |endoluminal views are interpreted and compared to axial images. These are also compared to all pertinent |

| | |available prior studies. |

| | |The final report is dictated, audited, and signed. The relevant images from three dimensional (3D) colonic |

| | |flythrough are printed. Alternatively, a small video clip can be created for the patient record or referring |

| | |clinician. |

|[pic] |

|0067T |  |Clinical Example (0067T) |

| | |An 82-year-old male presents with cancer detected in the sigmoid colon on conventional colonoscopy. Due to the |

| | |size of the lesion, the endoscopist could not pass the scope and therefore could not visualize the colon |

| | |proximal to the mass. Computed tomography (CT) colonography is ordered. |

| | |Clinical Example 2 (0067T) |

| | |A 64-year-old male presents with severe diverticular disease. The endoscopist was unable to maneuver the scope |

| | |past the sigmoid stricture. CT colonography is ordered. |

| | |Description of Procedure (0067T) |

| | |The procedure is described to the patient and informed consent is obtained where applicable. A review of any |

| | |prior applicable studies is also performed. |

| | |Rectal tube is inserted (or supervision provided during insertion) and the colon is insufflated with either air|

| | |or carbon dioxide. Next, a scout topogram of abdomen and pelvis is obtained/interpreted to ensure adequate |

| | |colonic distention. Additional air is added if necessary. The non-contrast CT images of the abdomen and pelvis |

| | |performed in the supine position are obtained/reviewed. The patient is then turned to the prone position. The |

| | |axial images of both the supine and prone data sets are interpreted.. Three-dimensional reconstructions of the |

| | |colon including endoluminal fly-throughs are supervised and/or created. An adjustment of the projection of the |

| | |three-dimensional reconstructions is provided to optimize visualization of anatomy or pathology. The 3D |

| | |endoluminal views are interpreted and compared to axial images. These are also compared to all pertinent |

| | |available prior studies. |

| | |The final report is dictated, audited, and signed. The relevant images from three dimensional (3D) colonic |

| | |fly-through are printed. Alternatively, a small video clip can be created for the patient record or referring |

| | |clinician. |

|[pic] |

|0068T |  |Clinical Example (0068T) |

| | |A previously asymptomatic 56-year-old Caucasian female with the major cardiac risk factor of a 40 pack-year |

| | |smoking history presents to the emergency department complaining of shortness of breath that began |

| | |approximately an hour before arrival. The skin of the patient is prepped and the combined electrocardiogram |

| | |(ECG) and phonocardiographic electrodes are properly placed on the patient's chest as are the |

| | |electrocardiographic electrodes. Correlated audioelectric cardiographic signals are then obtained and computer |

| | |analysis performed. The results are then reviewed by the physician, interpreted, and a report generated. |

| | |Description of Procedure (0068T) |

| | |Service includes prepping the skin, applying the electrodes in their customary ECG positions, determining the |

| | |proper positioning of the dual sensors in the V3 and V4 positions, reviewing the raw recording to verify proper|

| | |placement and appropriateness of signals, acquisition of the signals, reviewing the computer analysis (sound |

| | |and ECG), and generating a report. |

|[pic] |

|0073T |  |Clinical Example (0073T) |

| | |A 71-year-old male with T2a, Gleason 7, prostate specific antigen (PSA) 12 ng/ml, prostate cancer. Elected to |

| | |undergo external beam radiation to the prostate with dose escalation to 80 Gy. The clinical target volume |

| | |included the prostate and seminal vesicles and the planning target volume with a 8mm margin around the prostate|

| | |and seminal vesicles. The prescribed dose was to the planning target volume. Dose constraints for the rectum, |

| | |bladder and femoral heads were defined. A fluence map was generated for a 5-field compensator-based beam |

| | |modulation technique to treat this patient meeting the required constraints. Once this was approved, the final |

| | |plan was generated using a single compensator for each beam of varying thickness throughout its area to |

| | |generate the required fluence map. The compensator was milled according to specifications. The treatment was |

| | |delivered to a film phantom using these compensators and images overlaid well with the dose distributions. The |

| | |treatments were delivered as prescribed 2 Gy daily 5 days a week for a total dose of 80 Gy to the PTV. |

|[pic] |

|0074T |  |Clinical Example 1 (0074T) |

| | |A 2-year old child has a history of ear infections. The child's mother would like to speak the pediatrician to |

| | |discuss the ongoing problems associated with ear infection and learn the long-term potential effects of chronic|

| | |ear infections (i.e. hearing loss, etc.) The mother has had difficulty reaching the pediatrician by telephone |

| | |and wishes to get substantial and detailed information related to ear infections and potential sequelae for her|

| | |child. The mother would prefer not to wait weeks for the next available office appointment. The pediatrician |

| | |has previously discussed the available option of online medical consultations with the patient. |

| | |Description of Procedure (0074T Example 1) |

| | |The mother and patient request an online medical consultation with the pediatrician over a secure, encrypted |

| | |and Health Insurance Portability and Accountability Act (HIPAA)/eRisk-compliant communications network via a |

| | |standard Web browser. The mother is presented with explicit service terms and charges that are understood and |

| | |agreed to, as well as reminders that online medical consultation should not be used for emergent and/or urgent |

| | |conditions presented with explicit service terms and charges that are understood and agreed to, and provides a |

| | |credit card for billing, prior to initiation of the online medical consultation. During the consultation, the |

| | |mother describes the patient's symptoms and the pediatrician uses this information plus prior information |

| | |gathered, referencing the patient chart, to provide information and a proposed follow-up plan for the mother. |

| | |As a result of this online medical consultation, the mother has new information about how to proactively manage|

| | |her child's ear infections without having to take time out of her very busy day to for an office visit. |

| | |Clinical Example 2 (0074T) |

| | |A 59-year-old post-menopausal female with a family history of breast cancer and personal history of mild |

| | |osteopenia and borderline high cholesterol who is re-considering the safety and value of hormone replacement |

| | |therapy (HRT) in light of recent publicity on the subject. Patient has been on HRT for past 8 years secondary |

| | |to initial severe menopausal symptoms and ongoing management of long-term chronic symptoms. Patient has been |

| | |tolerating the HRT and has no other medical complaints. Patient would like her physician's recommendation on |

| | |the appropriate action to take given her family history and current medical status. Patient attempted to make |

| | |an appointment with her physician but was informed that she would have to wait weeks before the next |

| | |appointment was available at this busy office. She would like her doctor's opinion as well as patient |

| | |information related to this therapy, but does not wish to take time off from work or wait weeks for an |

| | |appointment at this very busy OB/GYN physician's office. |

| | |Description of Procedures/Services (0074T Example 2) |

| | |The patient request an online medical consultation with her physician over a secure, encrypted and |

| | |HIPAA/eRisk-compliant communications network via a standard Web browser. The patient is presented with explicit|

| | |service terms and charges that are understood and agreed to, as well as reminders that online medical |

| | |consultation should not be used for emergent and/or urgent conditions. The patient is presented with explicit |

| | |service terms and charges that are understood and agreed to, and provides a credit card for billing, prior to |

| | |initiation of the online medical consultation. During the consultation, the patient poses a series of questions|

| | |and concerns to her physician. The physician addresses these questions and issues referencing the patient |

| | |chart, past medical problems, current meds, etc, to provide information and a proposed follow-up plan for the |

| | |patient. The patient receives the information and recommendations online from her physicians including a list |

| | |of hypertext links to articles produced by the American College of Obstetrics and Gynecology and the American |

| | |Medical Association related to the subject of hormone replacement therapy. Physician provides an interpretation|

| | |of recent publicity on HRT and opinion/recommendation on whether patient should continue HRT given family |

| | |history and current medical issues. Physician reminds patient she is due for her annual mammogram screening and|

| | |physical examination in 4 months. As a result of this online medical consultation, the patient has received |

| | |more timely and complete care than would likely have occurred during a routine office visit including more |

| | |complete access to valuable reference materials. |

|[pic] |

|0077T |  |Clinical Example (0077T) |

| | |A 20-year-old female, who is cardiopulmonary stable, presents with a Glasgow Coma Score (GCS) of 8 or less |

| | |following a nontraumatic subarachnoid hemorrhage. She is controlled to maintain an arterial oxygen |

| | |concentration greater than 100mmHg and an arterial CO2 of 35-40mmHg. Patients with meningitis, ventriculitis or|

| | |other infection of the central nervous system are typically excluded from this type of monitoring. |

| | |Description of Procedure (0077T) |

| | |The scalp is shaved at the appropriate location. The area of insertion is disinfected and draped. Once the |

| | |insertion site is determined, a small incision (0.5 cm) is made through the scalp to the cranium. A twist burr |

| | |hole is made with a perpendicular trajectory through the skull and through the outer and inner tables of the |

| | |skull until the dura is reached but not penetrated. Cotton tipped applicators are used to remove bone debris in|

| | |the twist burr hole. The dura is perforated with a needle. The appropriate securing device is affixed and the |

| | |thermal perfusion probe is inserted into the puncture hole in the dura, 20 to 25 mm below the level of the dura|

| | |into the cerebral tissue. The probe is secured and the scalp incision is sutured. |

| | |The "start" button on the monitor is pressed and after four minutes the perfusion measurement begins. If the K |

| | |value is greater than a defined threshold (indicating that the probe is close to a thermally significant |

| | |vessel) the probe is moved back by about 1 mm and the "calibrate" button is pushed to recalibrate the probe. |

| | |The probe is recalibrated until an acceptable K value is obtained. |

|[pic] |

|0078T |  |Clinical Example |

| | |A 67-year-old male with coronary artery disease status post myocardial infarction and chronic obstructive |

| | |pulmonary disease was found to have a 6.8-cm diameter abdominal aortic aneurysm (AAA). Imaging studies (CT |

| | |scan, MRI, and/or angiography) indicate that the aneurysm has a configuration unsuitable for infrarenal repair |

| | |but amenable to a fenestrated aortic endograft with covered extension stents to both renals and the superior |

| | |mesenteric artery. Distally the aneurysm extends to the very end of the aorta, indicating that a bifurcated |

| | |prosthesis will be required. |

| | |Note: Code 0078T does not include open femoral or iliac artery exposure, arterial catheterization, placement of|

| | |the fenestrated graft limbs to visceral vessels, or radiological supervision and interpretation. These services|

| | |are reported separately. See CPT Instructions for Endovascular Repair of Abdominal Aortic Aneurysm. |

| | |Description of Procedure |

| | |Work begins after the decision to operate is made, from the day before the operation until the skin incision. |

| | |This activity includes obtaining and reviewing the previous work-up, with special attention to potential |

| | |cardiovascular risks. In addition, an extensive and detailed review of the preoperative imaging studies (CT, CT|

| | |angiogram, CT with 3D reconstructions, MRI, and/or contrast angiogram) is required to determine the exact |

| | |measurements of the aneurysm. This is necessary because an accurate preoperative choice of component diameters |

| | |and lengths is one of the primary determinants of whether the endovascular procedure will be successful. |

| | |Initial work for aneurysm repair involving the visceral arteries also includes determining the exact location |

| | |of the visceral artery orifices so appropriate fenestrations can be placed in the main component of the |

| | |endograft. There can be no error in loading the graft into the delivery system, because the graft fenestrations|

| | |must align exactly with the visceral artery orifices when deployed. |

| | |Informed consent is obtained from the patient following a discussion of surgical risks and benefits with the |

| | |patient and the family. Other preservice work includes scrubbing, donning lead apparel, patient positioning, |

| | |waiting for the anesthetic to become effective, prepping, and draping the patient. |

| | |Note: Reporting the deployment of 0078T will follow the coding guidelines in the CPT introductory notes for |

| | |Endovascular Repair of Abdominal Aortic Aneurysm. In addition, deployment of the visceral extension prostheses |

| | |will be reported using 0079T. The intraservice work of 0078T includes performing road-mapping arteriogram with |

| | |specific attention to renal artery origins, final examination of endovascular components for correct models, |

| | |sizing, exchange of soft J-wires for superstiff wires, and reconfirming that the appropriate device has been |

| | |chosen. The main-body component is then unpackaged and the device is prepared for insertion. The patient is |

| | |anticoagulated with IV heparin. The main-body component is then loaded onto the ipsilateral superstiff wire and|

| | |advanced to the femoral artery. The tip of main device is introduced into arteriotomy site, the proximal |

| | |vascular clamp is opened, and the front of the device is advanced into the artery. Rubber constrictors are used|

| | |to limit blood loss. Under fluoroscopic guidance, the main-body device is directed through the external iliac |

| | |and advanced into the common iliac artery and, subsequently, into the aorta. The device is pushed through the |

| | |aneurysm carefully such that the tip lies above visceral artery origins and the circular orientation aligns |

| | |fenestrations with visceral artery origins. Arteriography is repeated as needed to absolutely confirm |

| | |orientation, and deployment is begun. Final precise adjustments are made to align top of device at desired |

| | |visceral level with fenestrations lying exactly over visceral artery origins. The main-body device is deployed |

| | |with constant attention to exact positioning, making final position adjustments as needed, keeping the proximal|

| | |anastomosis and fenestrations as required, and checking distally to determine that the position above the |

| | |aortic bifurcation is correct. Next, the main-body device is deployed to the point of opening the contralateral|

| | |docking port. The contralateral docking port is cannulated using a selective catheter/guidewire combination, |

| | |and the catheter advanced into the main body of the graft to the level of the proximal anastomosis. Inject |

| | |contrast and image graft is provided to confirm placement of the catheter within the graft. A final angiogram |

| | |is performed to confirm positioning of the proximal anastomosis, and any final adjustments to position of the |

| | |proximal anastomosis are made at this time. The suprarenal fixation portion of the main body component is |

| | |deployed. At this point in the procedure, one to four visceral artery extensions are deployed through the |

| | |previously placed aortic graft fenestrations. This work is reported separately as 0079T for each vessel. |

| | |Sterile dressings are applied, and the physician ensures that the patient is stable and able to leave the |

| | |suite. Help is provided to transfer the patient to a post-procedure recovery unit. |

| | |Depending on the preexisting comorbidities and operative course, it is determined if the patient requires |

| | |admission to the intensive care unit. The physician writes orders, dictates the operative note, and |

| | |communicates with the patient’s family and referring and consulting physicians. Assistance is provided for the |

| | |anesthesiologist to ensure smooth emergence from anesthesia. After this, the physician discusses the procedure |

| | |results with the patient once he is fully awake and determines when the patient is adequately recovered for |

| | |transfer to floor. Daily visits are provided during postoperative care, and orders and notes are written, etc. |

| | |Discharge day management includes communicating with all support services such as visiting nurse, meals on |

| | |wheels, etc, communication with the referring physician, provision of activity advice, warnings to the patient |

| | |and family, and arranging office follow-ups for wound checks, suture/staple removal, etc. All related office |

| | |visits for 90 days are included in the postservice work of 0078T. |

|[pic] |

|00797 |  |Clinical Vignette |

| | |A 38-year-old female has had a life-long history of obesity. She has failed numerous dietary regimens and |

| | |presents for gastric bypass surgery. Her height is 5'4" and her weight is 325 lbs. She has mild, untreated |

| | |hypertension, diabetes managed with oral hypoglycemics, and chronic asthma for which she uses bronchodilators. |

| | |Description of Procedure |

| | |The patient is positioned for surgery in the supine, reverse Trendelenburg position with attention to |

| | |protecting peripheral nerves and pressure points, including the olecranon fossae, brachial plexus and the |

| | |heels. A warm air blanket is positioned over the patient, avoiding the surgical field, to maintain |

| | |normothermia. Because of tenuous peripheral venous access, a central venous catheter is inserted (separately |

| | |reported) to assure reliable access during the intra-operative and post-operative periods. Neuromuscular |

| | |blockade is regularly monitored using peripheral nerve stimulation and additional paralytic agents administered|

| | |to maintain adequate surgical relaxation. Intravenous fluids are administered at a rapid rate to replace |

| | |substantial insensible losses and surgical blood loss. Urinary output and temperature are monitored. Serial |

| | |blood glucose determinations are made and an intravenous insulin infusion is begun as needed. A nasogastric |

| | |tube is inserted and subsequently a calibrated bougie is passed into the proximal stomach under manual guidance|

| | |to assist the surgeon. As the operation draws to an end, the dosage of narcotic is assessed and supplemented as|

| | |needed to assure adequate postoperative analgesia. Inhaled anesthetic is withdrawn gradually and neuromuscular |

| | |blockade reversed by administration of anticholinesterase and anticholinergic drugs. Inhaled bronchodilators |

| | |are administered through the anesthetic breathing circuit and endotracheal tube. The patient's level of |

| | |consciousness, ventilatory efforts, capnogram and oximetry are assessed to determine the adequacy of |

| | |spontaneous respiration. If these parameters appear satisfactory, the trachea is extubated and mask oxygen |

| | |administered. |

| | |A period of careful observation is undertaken while still in the operating room to allow swift reintubation if |

| | |respiratory decompensation occurs. If doubt exists about the adequacy of respiration, additional sedatives are |

| | |administered and a period of postoperative mechanical ventilatory support is planned. The patient is then |

| | |transported to the post-anesthesia care unit (PACU) with continuous EKG and oximetry monitoring. In the PACU, a|

| | |patient history and synopsis of intraoperative events, including fluids administered, blood loss, urinary |

| | |output, drugs administered, vital sign trends is provided to the nursing staff. The anesthesiologist continues |

| | |to participate in the management of postoperative analgesia, fluid balance and respiratory care while the |

| | |patient is cared for in the PACU. When the patient is stable, the anesthesiologist discharges the patient to |

| | |the surgical floor or intensive care unit. She is seen again on the following day to ascertain recovery from |

| | |anesthesia and to determine if any post-anesthetic complications, such as nerve injury, airway trauma, |

| | |intraoperative recall, have occurred. |

|[pic] |

|0079T |  |Clinical Example (0079T) |

| | |Note: See Clinical Example for 0078T. |

| | |Description of Procedure (0079T) |

| | |Ensure all required guidewires and extension prostheses are available for use. |

| | |The appropriate combination of guidewire and guiding sheath are advanced through appropriate fenestration in |

| | |aortic endograft, and into visceral artery. Angiogram is then performed through guiding sheath to ensure proper|

| | |fenestration alignment. A visceral extension is then advanced through guiding sheath, through fenestration and |

| | |into visceral artery. Exact positioning of extension is then checked to ensure proximal end in aortic graft and|

| | |distal in visceral artery. The visceral extension is deployed, and angioplasty of all components is provided as|

| | |needed for complete expansion and seating. Note: angioplasty within target zone is included in 0079T. An |

| | |arteriogram is then performed to confirm patency and evaluate for endoleak. The stents are deployed, if needed,|

| | |within body of extension prosthesis to seal endoleaks or treat kinks. Note: stent placement in body of graft is|

| | |included in 0079T. |

|[pic] |

|0080T |  |Clinical Example (0080T) |

| | |Note: See Clinical Example for 0078T. |

| | |Description of Procedure (0080T) |

| | |A review of MR, CT, CT with 3D reconstructions, and arteriograms for final assurance of suitability for |

| | |endovascular AAA repair using fenestrated visceral level device is performed. The physician then checks the |

| | |suite to ensure proper function and configuration of the imaging equipment including compliance with all |

| | |radiation safety issues. The physician also ensures that all technical personnel have been familiarized with |

| | |the endovascular prosthesis and are fully familiar with all required wires, balloons, stents. In addition, the |

| | |physician supervises selection of all equipment, including catheters, wires, balloons, stents, sheaths, |

| | |contrast material, etc., and assures all needed equipment is available. Radiation protection is then applied |

| | |(also ensures all others are adequately protected). The patient is then positioned (by provider or via |

| | |supervision of staff) |

| | |Technical personnel are directed throughout procedure, and an interpretation of imaging of vessel being treated|

| | |is provided. Accurate radiological views, exposures, shielding, image size, injection sequences, radiation |

| | |protection and management are ensured for the patient and staff. Real-time analysis of all imaging during |

| | |procedure is provided, including pre-treatment imaging, fluoroscopic and angiographic imaging throughout the |

| | |procedure as required to perform the procedure, as well as post-procedure fluoroscopic and angiographic |

| | |imaging. This includes all imaging to manipulate the wires, catheters, devices, into position, correct |

| | |positioning and deployment of endoprosthesis, post-deployment ballooning, assessing post-op success and |

| | |complications, complete study post-deployment, and removal of catheters. Continuous fluoroscopic imaging is |

| | |also provided during all catheter/device/balloon/stent manipulations to assess proper |

| | |position/performance/deployment of primary aortic endograft and iliac limbs |

| | |A review and interpretation of all image sequences for the main device positioning and deployment is provided. |

| | |All radiologic images are post-processed and converted to an archived form for permanent record. A review and |

| | |record of the patient fluoroscopic exposure time & contrast volume is documented. In addition, the procedure |

| | |note is dictated, including interpretation of diagnostic and therapeutic imaging. The final report is then |

| | |reviewed, revised, and sign final. A formal report is then sent to the primary care physician (PCP) and |

| | |referring providers. |

|[pic] |

|0082T |  |Clinical Example (0082T) |

| | |A 60-year-old female with long history of tobacco use is found to have a 3.5 cm peripheral nodule on chest |

| | |x-ray. A computed tomography (CT)-guided biopsy shows non-small cell cancer. Staging including CT of |

| | |mediastinum and upper abdomen and positron emission tomography shows only localized disease (stage T1b, N0, |

| | |M0). Pre-operative evaluation indicated FEV1 < 40% predicted (medically inoperable). Treatment options include |

| | |limited pulmonary resection with risk of being a pulmonary cripple, conventional fractionated radiation which |

| | |will expose considerable lung volume to ionizing radiation, or stereotactic body radiation therapy. The choice |

| | |of stereotactic body radiation therapy is made based on treatment to just the defined lesion while decreasing |

| | |radiation exposure to normal lung. |

| | |Description of Procedure (0082T) |

| | |The patient will be treated with 2000 cGy per fraction for 6 fractions. Treatment is planned using either a |

| | |frame based stereotactic system or imaging-based stereotactic unit to facilitate the precise identification of |

| | |the target(s) (the tumor or area of interest) and may include comparison with or analysis of CT scans/magnetic |

| | |resonance imaging/positron emission tomography scans (or other imaging and/or functional studies) with or |

| | |without image fusion. |

| | |The final plan (using work currently described by CPT codes 77301 and 77295) will achieve stereotaxic treatment|

| | |to the target (planned treatment volume (PTV)) and is usually associated with numerous beams that are arranged |

| | |to deliver a high focal dose to the tumor target. |

| | |Under the direct supervision of the physician, the patient is set up on the treatment table and the |

| | |positioning/immobilization devices are placed. All treatment parameters are verified by the physician. |

| | |Appropriate accounting for patient movement, respiratory motion or other types of motion is verified. With the |

| | |physician in attendance, this is followed by the delivery of the radiation dose for that fraction (which may |

| | |last for an hour or more). The entire treatment process is repeated for each of the 6 fractions. Following each|

| | |treatment, a patient assessment is performed by the physician. |

|[pic] |

|00834 |  |Clinical Example (00834) |

| | |The patient is an 11-month-old male who was noted to have a groin mass by the mother. The pediatrician |

| | |diagnosed an inguinal hernia and referred the patient to a pediatric surgeon. The patient now presents for |

| | |bilateral inguinal hernia repair. The patient's birth history was normal. The only history of significance is |

| | |recent middle ear infection, managed successfully with a course of antibiotics. Family history did not reveal |

| | |significant diseases or difficulty with anesthesia. The patient is on no medications and has no allergies. |

| | |Physical examination with emphasis on the airway, lungs, heart, and nervous system is performed. After |

| | |discussing anesthetic options with the parents, an inhalational general anesthesia is planned. |

| | |Description of Procedure (00834) |

| | |The patient is transferred to the operating room and ECG, pulse oximeter, and blood pressure monitors are |

| | |applied. Anesthesia is induced with a volatile agent by mask. Intravenous access is obtained in the lower |

| | |extremity. Muscle relaxation is administered and monitored by a twitch monitor. The airway is secured with an |

| | |orally placed endotracheal tube. Proper tracheal tube placement is determined by carbon dioxide monitoring and |

| | |auscultation of breath sounds bilaterally. A temperature monitor is placed. The patient is placed in the left |

| | |lateral decubitus position and the sacrum is palpated for sacral cornua and a sterile preparation is performed.|

| | |Using a 22-gauge styletted blunt needle, the epidural space is entered by the caudal route. After ascertaining |

| | |safe needle placement, 1 mL/kg of local anesthetic is injected. The patient is then returned to the supine |

| | |position. Breath sounds are again auscultated. Continuous monitoring and charting ensue with adjustments to the|

| | |anesthesia as necessary. A forced warm air heater is placed around the patient. Intravenous fluids are |

| | |administered accounting for hourly maintenance and deficit from denial of oral intake preoperatively. At the |

| | |end of the surgical procedure the anesthetic gases are discontinued and the muscle relaxation is |

| | |pharmacologically reversed. When the patient is making strong purposeful movement the trachea is extubated. The|

| | |patient is observed prior to transfer to the postanesthesia care unit for stability of vital signs and |

| | |satisfactory pulse oximetry results. In the postoperative period the patient is observed in the postanesthesia |

| | |care unit (PACU) for a minumum of 30 minutes or until the patient satisfies discharge criteria. Additional |

| | |analgesia is provided as needed. |

| | |The patient is then transferred to the ambulatory care unit and observed for at least another 30 minutes until |

| | |deemed ready to be discharged home. |

|[pic] |

|00836 |  |Clinical Example (00836) |

| | |The patient is a 4-week-old male born at 28 weeks gestational age. The patient was endotracheally intubated in |

| | |the delivery room with Apgar scores of 2 and 5. The patient's trachea was extubated at 1 week of age after the |

| | |administration of surfactant and indomethacin. A grade 2 intraventricular hemorrhage was diagnosed in week 2. |

| | |At present there are no significant sequelae from the previous problems. The patient is presently gaining |

| | |weight with oral nutritional supplementation. Discharge planning is taking place, but hindered by the presence |

| | |of a large right inguinal hernia. Currently the patient receives calcium supplementation. There are no |

| | |allergies. The patient's weight is currently 2 kg. The heart rate is 140 beats per minute, respiratory rate of |

| | |45 breaths per minute and a systolic blood pressure of 50 mm Hg. Laboratory data includes normal electrolytes |

| | |and a hematocrit of 30%. Aside from the patient's extremely small size and the presence of a large right |

| | |inguinal hernia, the airway appears appropriate and patent, the lung fields are clear, and the heart is |

| | |auscultated revealing normal rate and rhythm with no appreciable murmur. Also noted are multiple ecchymotic |

| | |areas from previous venous access attempts. There is no venous access at present nor are any veins easily |

| | |visible. The parents are not present or available for discussion regarding anesthetic plans. Surgical consent |

| | |was obtained by phone a day earlier. General anesthesia is planned with induction by intravenous technique. A |

| | |caudal block is planned for intraoperative and postoperative pain relief (separately reportable). |

| | |Description of Procedure (00836) |

| | |The patient is transferred from the neonatal intensive care unit and monitored to the operating room. The |

| | |operating room has been preheated to 80°F. The patient is transferred to the operating table and the monitors |

| | |are placed for ECG, pulse oximetry, and blood pressure. A warming mattress and heat lamps are used to keep the |

| | |patient normothermic. A 22-gauge intravenous catheter is placed in the saphenous vein blindly. Anesthesia is |

| | |induced slowly with intravenous agents constantly monitoring the vital signs. A muscle relaxant is |

| | |administered. A volatile anesthetic agent is slowly titrated to effect with careful attention to blood |

| | |pressure. The baby's trachea is intubated with a 2.5-mm endotracheal tube. After determining appropriate |

| | |placement by the presence of carbon dioxide and auscultation of bilateral breath sounds, the endotracheal tube |

| | |is secured. The baby is turned to the left lateral decubitus position and the sacrum is prepared by sterile |

| | |technique. A caudal block is performed with a 22-gauge styletted blunt needle placed in the epidural space at |

| | |the level of the sacrum. After ascertaining correct needle placement, 2 mL of local anesthetic is slowly |

| | |injected. The baby is returned to the supine position and bilateral breath sounds are auscultated. The inspired|

| | |oxygen concentration is decreased as possible by monitoring pulse oximetry to 25% oxygen or less. Surgery is |

| | |performed with continuous monitoring of vital signs, recording all pertinent data on the anesthesia chart. To |

| | |prevent postoperative apnea that is possible in this age group, 10 mg/kg of caffeine is administered by |

| | |intravenous route. At the end of the surgical procedure, the anesthetic agents are discontinued and the muscle |

| | |relaxant is reversed. Upon demonstration of adequate emergence from anesthesia as noted by purposeful movement |

| | |and adequate reversal of muscle relaxation demonstrated by spontaneous flexion of the hips off the bed, the |

| | |endotracheal tube is removed. The patient is observed for stability of vital signs. The patient is transferred |

| | |to the isolette and monitored. An emergency resuscitation kit is prepared specific to the baby's weight and |

| | |includes airway equipment and resuscitative medications. The baby is transported back to the neonatal intensive|

| | |care unit with continuous pulse oximetry and EKG monitor. Vital signs are again taken and a full report is |

| | |given to the nurse and the primary care physician. Analgesic needs are assessed and medication given as |

| | |necessary to achieve patient comfort. |

|[pic] |

|0083T |  |Clinical Example (0083T) |

| | |A 60-year-old female with long history of tobacco use is found to have a 3.5cm peripheral nodule on chest |

| | |x-ray. CT-guided biopsy shows non-small cell cancer. Staging, including CT of mediastinum and upper abdomen and|

| | |positron emission tomography, shows only localized disease (stage T1b, N0, M0). Pre-operative evaluation |

| | |indicated FEV1 < 40% predicted (medically inoperable). Treatment options include limited pulmonary resection |

| | |with risk of being a pulmonary cripple, conventional fractionated radiation which will expose considerable lung|

| | |volume to ionizing radiation, or stereotactic body radiation therapy. The choice of stereotactic body radiation|

| | |therapy is made based on treatment to just the defined lesion while decreasing radiation exposure to normal |

| | |lung. |

| | |Description of Procedure (0083T) |

| | |The patient will be treated with 2000 cGy per fraction for 6 fractions. Treatment is planned using either a |

| | |frame based stereotactic system or imaging-based stereotactic unit to facilitate the precise identification of |

| | |the target(s) (the tumor or area of interest) and may include comparison with, or analysis of, computed |

| | |tomography scans/magnetic resonance imaging/positron emission tomography scans (or other imaging and/or |

| | |functional studies) with or without image fusion. |

| | |The final plan (using work currently described by CPT codes 77301 and 77295) will achieve stereotaxic treatment|

| | |to the target planned treatment volume (PTV) and is usually associated with numerous beams that are arranged to|

| | |deliver a high focal dose to the tumor target. |

| | |Under the direct supervision of the physician, the patient is set up on the treatment table and the |

| | |positioning/immobilization devices are placed. All treatment parameters are verified by the physician. |

| | |Appropriate accounting for patient movement, respiratory motion or other types of motion is verified. With the |

| | |physician in attendance, this is followed by the delivery of the radiation dose for that fraction (which may |

| | |last for an hour or more). The entire treatment process is repeated for each of the 6 fractions. Following each|

| | |treatment, a patient assessment is performed by the physician. |

|[pic] |

|0084T |  |Clinical Example (0084T) |

| | |Following transurethral microwave thermotherapy (TUMT) a 70-year-old male presents to his urologist for an |

| | |evaluation of continuing lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH). It is |

| | |determined the patient is a candidates for a minimally invasive prostatic therapy. Following the minimally |

| | |invasive therapy the patient presents with temporary worsening symptoms (e.g. decreased voided volume, increase|

| | |in post void residual urine, urinary retention). A temporary prostatic urethral stent is placed to manage |

| | |voiding dysfunction during the healing phase. |

| | |Description of Procedure (0084T) |

| | |The patient is prepped and draped for a typical sterile urethral device insertion procedure. |

| | |To achieve the best results with the spanner, the appropriate length device must be selected to accommodate the|

| | |patient's anatomical requirements. The length of the urethra from the bladder neck to the distal side of the |

| | |external sphincter is measured using the surveyor urethral measurement device. Using the length measurement |

| | |from the surveyor, the appropriate size spanner is selected. |

| | |The spanner and insertion tool are prepared for insertion, and inserted into the urethra until the distal tip |

| | |and balloon are positioned in the bladder. The balloon is then inflated, the urethral stent is positioned in |

| | |the prostatic urethra by applying gentle traction and then deployed. The insertion tool is slowly withdrawn |

| | |from the urethra. The spanner's retrieval suture may be trimmed such that the distal end is just inside the |

| | |urethra's meatus. |

| | |After inserting the spanner, the patient should be assessed to assure that the patient is able to void |

| | |adequately prior to discharge from the clinic. This may be accomplished by uroflometry and a bladder ultrasound|

|[pic] |

|0085T |  |Clinical Example (0085T) |

| | |A 44-year-old white male received a heart transplant two weeks ago, for the management of intractable |

| | |congestive cardiac failure. The operation is successful, and he is followed intensively as an outpatient during|

| | |the first postoperative year by a transplant cardiologist who performs serial endomyocardial biopsies. However,|

| | |the transplant cardiologist is concerned about the limitations of endomyocardial biopsy-it is an expensive, |

| | |invasive procedure, and its dependability is limited by subjectivity. There is poor interobserver |

| | |reproducibility amongst the pathologists who read the slides and score the severity of rejection. The |

| | |transplant cardiologist requests that the patient should have a breath test for heart transplant rejection |

| | |performed every two weeks during the first postoperative year, as an objective marker of grade 3 rejection. |

| | |During the course of the year, the transplant cardiologist employs the results of the breath test as an adjunct|

| | |to endomyocardial biopsy, in order to determine whether or not the patient requires a change in |

| | |immunosuppressant therapy. |

| | |Description of Procedure (0085T) |

| | |The patient breathes into a breath collection apparatus for 2.0 min, and the volatile organic compounds (VOCs) |

| | |in 1.0 l alveolar breath are captured on to a sorbent trap. No expiratory effort is required beyond normal |

| | |respiration. A second sample of 1.0 l ambient room air is similarly collected on to a second sorbent trap. |

| | |There are no known risks to this procedure. The collection is supervised by a technician. |

| | |The sorbent traps are sent to the laboratory for analysis by automated thermal desorption with gas |

| | |chromatography and mass spectroscopy (ATD/GC/MS). |

| | |Data are downloaded into a computerized data base. A subtraction chromatogram is constructed, comprising the |

| | |abundance of VOCs in breath minus the abundance of VOCs in room air. The breath methylated alkane contour |

| | |(BMAC) is constructed, a three-dimensional display of markers of oxidative stress. It comprises a three |

| | |dimensional graph of the abundance of C4 to C20 alkanes and monomethylated alkanes in the subtraction |

| | |chromatogram. The BMAC is interpreted by an algorithm derived from a clinical study, which generates the |

| | |probability of grade 3 heart transplant rejection as a value between zero and one. Based on these findings, a |

| | |report is sent to the requesting physician stating the probability of grade 3 heart transplant rejection, and |

| | |the interpretation of the test (positive, negative, or intermediate for rejection). The positive or negative |

| | |predictive value of the test is also provided, if the probability of grade 3 heart transplant rejection is |

| | |greater than or less than 0.5 respectively. |

|[pic] |

|00869 |  |Clinical Example (00869) |

| | |A 42-year-old married male with three children, ages 11, 8, and 3, desires permanent sterilization. He and his |

| | |wife prefer not to use mechanical means of contraception. They have chosen vasectomy for him, preferring to |

| | |avoid general anesthesia necessary for a tubal ligation. He is in excellent health, exercising 45 minutes or so|

| | |five days a week. |

| | |Description of Procedure (00869) |

| | |The patient was taken to the operating room, placed on the table in the supine position, and had the usual |

| | |monitoring devices attached (EKG, non-invasive blood pressure, and pulse oximetry). Supplemental oxygen was |

| | |given via a face mask, to which had been attached an end-tidal CO2 sampling tube. |

| | |The patient was sedated with 2 mg midazolam and 100 mcg fentanyl. His scrotum was prepped, and just prior to |

| | |the surgeon injecting local anesthesia, the patient was given 50 mg of propofol. When the patient stopped |

| | |responding to verbal stimulation, the surgeon injected a local anesthetic into each side of the patient's upper|

| | |scrotum, after having identified the spermatic cord. |

| | |During the procedure, the patient was given an additional 50 mg of propofol. After 20 minutes, the bilateral |

| | |incisions had been closed; and the patient was easily arousable. The monitors were removed, and the patient |

| | |moved himself to the recovery stretcher. His mental status was sufficient to allow him to be taken to the |

| | |second stage recovery area. |

| | |Report was given to the recovery area nurse, and after assuring that the patient was awake and comfortable the |

| | |anesthesiologist gave his pager number to the nurse and left to do his next case. |

|[pic] |

|0086T |  |Clinical Example (0086T) |

| | |A patient arrives in the emergency department with shortness of breath (SOB). The patient is known to have |

| | |chronic lung disease and heart disease. The question is whether the SOB is secondary to lung disease, heart |

| | |failure or a combination of the two. Within 15 minutes and with no risk to the patient, VeriCor can provide an |

| | |accurate measurement of LVEDP which, if normal, virtually excludes heart failure as a cause. If this is |

| | |significantly elevated, it would contribute to the diagnosis of heart failure. Furthermore, the severity of |

| | |heart failure can be assessed and this can help to determine whether or not hospitalization is necessary. |

| | |Description of Procedure (0086T) |

| | |A digital expiratory manometer, a continuous arterial pressure monitor, and a medical grade computer, are |

| | |integrated and controlled by state-of-the-art software and provide a series of prompts on a video screen. A |

| | |tonometric sensor is attached to the patient's wrist with a blood pressure cuff attached to the arm. After an |

| | |8-minute tonometric calibration period is completed, the system is ready for use. For the test, the patient is |

| | |prompted to perform a Valsalva maneuver by blowing into the mouthpiece of the digital manometer to produce an |

| | |expiratory pressure of 20 to 30 mmHg for a minimum of eight seconds. The expiratory pressure and the arterial |

| | |blood pressure measurements are recorded, stored and analyzed. |

| | |The patient is asked to perform a series of three Valsalva maneuvers over a period of 15 minutes. Total testing|

| | |time is approximately 25 minutes. The LVEDP measurements are obtained via the analysis of the changes in the |

| | |contour of the arterial waveform response to the Valsalva maneuver that have been calibrated by simultaneous |

| | |left ventricular catheterization. |

|[pic] |

|0087T |  |Clinical Example (0087T) |

| | |A 34-year-old male and his partner were referred to the in vitro fertilization (IVF) laboratory after two years|

| | |of unprotected sexual activity and no pregnancies. Fresh semen would be collected and the hyaluronic binding |

| | |assay (HBA) would be run in addition to standard sperm count, motility, morphology and other measures to |

| | |diagnose male infertility. The results from this assay in combination with those obtained from other diagnostic|

| | |tests would assist the physician in determining the best course of treatment for the couple. |

| | |Description of Procedure (0087T) |

| | |The assay requires fresh liquefied semen less than three hours old. Semen should be obtained by masturbation, |

| | |preferably following 203 days of abstinence. It should be collected in a sterile collection container and kept |

| | |at room temperature (18-28° C) for 30 minutes to allow it to liquefy. |

| | |Gently mix the sample and pipette a drop, 7-10µL in volume, near to the center of chamber A or B. Place the |

| | |Cell-Vu gridded cover slip over the sample. Incubate the slide for at least 10 and not more than 20 minutes at |

| | |room temperature. Count the total number of motile sperm, both bound and unbound. In the same number of grid |

| | |squares count the number of bound motile sperm. |

| | |Calculate the percent hyaluronan-binding sperm using the equation below: |

| | |%bound = 100x Boundmotile Boundmotile+unboundmotile |

| | |A score of >80% indicates normal binding capacity: A score 60% indicates possible problems with |

| | |binding capacity and a score 14.7. She has Los Angeles Grade A|

| | |esophagitis and no hiatal hernia. The patient is provided a trial of daily full-dose proton pump inhibitor |

| | |therapy. Her symptoms improve but are not completely relieved. Double-dose treatment is instituted with control|

| | |of the symptoms but she is desirous of pursuing other means to allow her to control the disease. The patient is|

| | |counseled regarding the treatment options, including pharmacologic, endoscopic, and surgical. Given the risk |

| | |and benefit of each option, the patient states she is adverse to a surgical procedure. The patient and |

| | |physician choose endoscopic deep intramural injection of a biopolymer into the lower esophageal sphincter for |

| | |treatment of her gastroesophageal reflux disease. |

| | |Description of Procedure |

| | |The procedure is performed on an outpatient basis in an endoscopy unit equipped for fluoroscopy. After informed|

| | |consent is obtained, the patient is placed on an endoscopy gurney. Intravenous access is obtained, conscious |

| | |sedation is administered, and vital signs are monitored. An EGD is performed to confirm the absence of |

| | |pathology that would represent a contraindication to the performance of the proposed procedure. The upper |

| | |endoscope is then positioned in the lower esophagus and the injection catheter introduced through the |

| | |endoscope. The squamocolumnar junction (Z-line) is visualized, the injection needle is advanced, and the mucosa|

| | |punctured 1-2 mm below the Z-line. The biopolymer solution is then injected along the muscle layer under |

| | |fluoroscopic guidance. Multiple discrete injections of 1-2 cc each are performed in a circumferential manner |

| | |until a total of 6-8 cc are implanted. The injection rate is no faster than 1 cc/min to allow for |

| | |polymerization and heat dissipation. The needle remains in place for 1 minute after complete implantation. |

| | |During the procedure, fluoroscopy is used to monitor the injection procedure and confirm intramural implant |

| | |location. Following the last injection, the endoscope is removed and the procedure terminated. Postprocedure |

| | |vital signs are checked and the patient is transferred to the recovery suite. The patient is monitored for |

| | |signs of complications. Prescriptions for pain medication and anti-emetics are provided and the patient is |

| | |discharged with instructions regarding potential delayed complications. |

|[pic] |

|0135T |  |Clinical Example |

| | |A 76-year-old man was presented to his primary care physician complaining of abdominal pain. A computed |

| | |tomography (CT) scan was ordered and a 3.0-cm enhancing solid renal mass in the posterior aspect of the midpole|

| | |of the left kidney was incidentally found. The patient has had previous open-heart surgery and has marginal |

| | |renal function making open total or partial nephrectomy extremely risky. The patient’s urologist refers the |

| | |patient for cryoablation of this renal mass based on his comorbidities. |

| | |Description of Procedure |

| | |On the day of the procedure, after an overnight fast as directed, the patient is admitted to the pre-procedural|

| | |preparation area. The patient is evaluated by anesthesia and the appropriate lines placed. After premedication,|

| | |the patient is transferred to the interventional suite. The patient is placed under successful general |

| | |anesthesia, and all imaging compatible monitors were placed. The patient is placed in the prone position on the|

| | |table and is properly protected. Imaging is performed to target the lesion (separately reportable using |

| | |appropriate modality specific imaging code: 76940, ultrasound; 76362, CT; or 76394, magnetic resonance |

| | |imaging). A set of images are obtained for localization purposes (included in the separately reportable |

| | |modality-specific imaging code: 76940, 76362, or 76394) and for selection of the site for initial cryoprobe |

| | |placement. The physician reviews these initial images and plans a skin entry site and treatment plan. The |

| | |appropriate size cryoprobe(s) (2 mm or 3 mm) are placed in the lesion. The cryoprobe tip locations are |

| | |confirmed and found to be safely positioned. Freezing of the lesion is then begun and monitored continuously to|

| | |ensure complete coverage of the lesion with an appropriate margin, as well as avoidance of injury to other |

| | |organs. After complete freezing of the lesion, the entire tumor is actively thawed. The cryoprobes are |

| | |maintained in place without repositioning and the tumor is frozen a second time. A second active thaw |

| | |sufficient to allow removal of the cryoprobe(s) without tearing of the tissue is performed, then the remainder |

| | |of the tumor thaws passively. If the iceball coverage is judged to be inadequate, the lesion is thawed to allow|

| | |repositioning of the existing cryoprobes or implantation of additional probes. Freezing is continued or probes |

| | |are added until the entire tumor plus any margin receives two complete freeze/thaw cycles. The incision sites |

| | |are cleaned and covered with sterile adhesive dressings. The patient is transported to the recovery room and |

| | |admitted overnight to an observation bed for pain control and monitoring of any significant hemorrhage. If |

| | |stable, he is discharged home the following morning with antibiotics and narcotics. Documentation of the |

| | |procedure is done for the permanent record. Cryoablation outcome and the patient’s status are communicated to |

| | |the patient’s family and copies of reports are sent to the patient’s referring physician. Upon discharge, the |

| | |patient is advised to contact the treating physician for treatment-related issues such as return of symptoms to|

| | |the area, fever, or pain with breathing and scheduled for a follow-up appointment within 7-10 days. |

|[pic] |

|0137T |  |Clinical Example |

| | |A 50-year-old gentleman has a rising prostate specific antigen (PSA). He recently underwent traditional |

| | |transrectal ultrasound with biopsies that revealed two suspicious biopsies suggestive, but not diagnostic, for |

| | |carcinoma. In an effort to more accurately determine if he has prostate cancer and the volume of the disease, |

| | |he is to undergo template-guided saturation biopsies for prostate mapping. |

| | |Description of Procedure |

| | |The patient is taken to the operating suite and given general anesthesia. He is placed in the dorsal lithotomy |

| | |position and prepped and draped. A foley catheter is inserted into the bladder. A transrectal ultrasound |

| | |transducer is placed into the rectum and the prostate is visualized. A midway reference place is determined |

| | |using the stepping function of the biopsy stepper. At the midway reference plane, everything toward the base is|

| | |labeled “proximal” and everything toward the apex is labeled “distal.” Next a coronal reference plane that |

| | |divides the prostate into anterior and posterior zones is chosen, preferably at the junction of the transition |

| | |and the peripheral zones. A brachytherapy grid is then placed against the perineum and rectum. Using |

| | |transrectal ultrasound for needle guidance, a total of 20 to 40 biopsies are taken using the template or grid |

| | |as a guide. Starting at the highest point within the prostate, biopsies are taken moving from the right to left|

| | |until the row is completed. Then, moving down a row, the same sequence is performed until all rows are |

| | |complete. With several deeper sections, a proximal and distal biopsy is taken from the same tract. With each |

| | |biopsy, the urologist states the correct location and coordinates of that specimen. The assistant keeps track |

| | |of the numbers and location of the biopsies to prevent confusion and mislabeling. After completion, the patient|

| | |is taken to the recovery room and is scheduled for follow-up in 2 weeks. |

|[pic] |

|01400 |  |Clinical Example (01400) |

| | |A typical patient is a young adult athlete, male or female, who has sustained an injury to the knee and now has|

| | |a painful and unstable knee, which precludes participation in his/her sport. An MRI reveals a torn anterior |

| | |cruciate ligament and arthroscopic-assisted surgical repair of the torn anterior cruciate ligament is |

| | |scheduled. |

| | |Description of Procedure |

| | |The general anesthetic is begun after assessing the baseline vital functions. An inhalation anesthetic is used |

| | |with a laryngeal mask airway (LMA). The procedure, which includes an open harvest of the patellar tendon graft |

| | |and the arthroscopic preparation of the joint and placement of the graft, proceeds without problem. Vital signs|

| | |are monitored continuously during the procedure. At the end of the procedure, and after the placement of a |

| | |brace on the operated knee, the patient is awakened and taken to the post-anesthesia care unit (PACU). |

|[pic] |

|0140T |  |Clinical Example |

| | |An 18-year-old female athlete with a history of mild intermittent asthma presents by ambulance to the emergency|

| | |department with acute respiratory distress beginning during a track and field competition. She has inspiratory |

| | |and expiratory wheezes, a slightly elevated heart rate with normal heart sounds, and no evidence of heart |

| | |disease. She has an oxygen saturation of 99% on room air. A chest X ray and spirometry are ordered and, after |

| | |providing informed consent, the patient is enrolled in a research study and exhaled breath condensate |

| | |collection is obtained. Therapy is instituted with beta agonists. The chest X ray is normal without evidence of|

| | |hyperinflation or infiltrate. Spirometry reveals truncated inspiratory and expiratory loops without evidence of|

| | |small airway disease. Exhaled breath condensate pH is 7.8 (normal 7.5-8.3). Further history is obtained and |

| | |reveals that she is an A student and has frequent anxiety episodes. The patient improves rapidly in the |

| | |emergency department and is discharged with the diagnosis of suspected vocal cord syndrome. |

| | |Description of Procedure |

| | |The physician, respiratory therapist, or nurse removes a disposable breath condensate collector from its |

| | |package, obtains a chilled metal condenser from a nearby freezer, and places an insulation cover over it. |

| | |Alternatively, an electric exhaled breath cooling (EBC) device for the disposable collector can be used. The |

| | |health care professional has the patient hold the portable device and place the mouthpiece of the EBC collector|

| | |into her mouth (the mouthpiece is identical to a nebulizer mouthpiece). The patient is instructed to breathe in|

| | |and out normally through the mouthpiece for 2 to 10 minutes. Ambient air (optionally supplemented with oxygen) |

| | |is inhaled through a one-way valve while exhaled air is directed through the condensation chamber. The health |

| | |care professional uses a specially designed syringe-style plunger to remove the EBC from the condenser. |

| | |Approximately 400 microliters of EBC are obtained and placed in a micro centrifuge tube, deaerated with Argon |

| | |gas (bubbling inexpensive Argon through the sample by means of a pipette), and the pH measured with a glass pH |

| | |microelectrode after appropriate calibration. The sample is stored for subsequent research involving other |

| | |biomarkers in EBC, such as cytokines and cysteinyl-leukotrienes. |

| | |Other applications include incorporating the collector into the exhalation limb of a ventilator circuit for |

| | |either one collection and assay or for continuous minute-by-minute EBC pH monitoring for hours or days. |

| | |Collection systems other than the one described can also be employed, although the technique described is the |

| | |most common method employed in the last 2 years in the United States and the technique employed in the |

| | |NIH-sponsored multi-centered asthma studies. |

|[pic] |

|0141T |  |Clinical Example (0141T) |

| | |A 23-year-old man with Type I diabetes mellitus one year status post kidney transplant, presents with stable |

| | |kidney graft function, but poor control of diabetes and secondary complications, including retinopathy and |

| | |neuropathy. Pancreatic islet cells are transplanted percutaneously through the portal vein. |

| | |Description of Procedure (0141T) |

| | |The transplant physician/surgeon ensures that the islet product is properly labeled, that it is the correct |

| | |islet product for the patient, and the final crossmatch and blood type are checked. Intravenous |

| | |immunosuppression is administered and monitored. The transplant surgeon/physician begins by confirming proper |

| | |location of the tip of the infusion catheter and reviews fluoroscopic portography. Next, the portal pressure is|

| | |measured and recorded by the transplant surgeon/physician. If the portal pressure is less than 20 mm Hg, and no|

| | |abnormalities are noted on the fluoroscopic portography, the transplant surgeon/physician adds heparin to the |

| | |islet infusion bag and connects it to the portal venous catheter using a standard intravenous infusion set. The|

| | |IV bag containing the islets is suspended during the infusion. To reduce clumping and risk of portal vein |

| | |thrombosis the IV bag containing the islets in suspension is manually rocked. The islets are infused |

| | |intraportally, over a period of up 90 minutes, using gravity drainage. Portal venous pressure is monitored and |

| | |recorded after 5 ml (packed volume) of tissue is infused, and after every subsequent 2.5-5.0 ml of tissue |

| | |infused (up to a total of 10 ml of tissue). Islet infusion is halted if the portal pressure change from pre- to|

| | |post-infusion exceeds 14-16 mm Hg; it is restarted only if the pressure drops below 18 mm Hg. If the pressure |

| | |remains elevated, infusion is stopped. Throughout the infusion, the patients vital signs and oxygenation are |

| | |monitored every 15 minutes to diagnose possible intolerability of the islet infusion . The transplant |

| | |surgeon/physician also uses these monitoring data to diagnose possible technical complications of the portal |

| | |venous access, such as pneumo- or hemo-thorax, intra-abdominal bleeding from the liver, and other complications|

| | |from the interventional procedure, apart from infusion related complications. During the islet infusion the |

| | |transplant surgeon/physician also monitors and documents blood glucose values to guide insulin therapy. The |

| | |islets produce insulin immediately after infusion, there is also free insulin being infused due to release of |

| | |insulin from damaged islets. Changes in the patients insulin dosages or requirements for intravenous glucose |

| | |are based on serial blood glucose measurements obtained in the radiology suite using finger-stick values. The |

| | |transplant surgeon/physician also manages immunotherapy infusion, antibiotic infusion and pain medication |

| | |during the procedure. After completion of the islet infusion and after a final rinse of the infusion bag, the |

| | |closing portal pressure is obtained and recorded by the transplant surgeon/physician. A completion portogram is|

| | |obtained by the interventional radiologist and he/she removes the portal catheter and embolizes the portal vein|

| | |to prevent bleeding and augment hemostasis. Post-operatively, the transplant surgeon/physician observes the |

| | |patient in the recovery room. The insulin drip or glucose infusion is adjusted to maintain strict blood glucose|

| | |control between 85 and 130 mg% based on serial one-hour glucose measurements. After discharge from the recovery|

| | |room, the patient is transferred to the transplant unit, which is associated with an inpatient general clinical|

| | |research center (GCRC) within the meaning of NIH definitions. In-hospital work includes hematologic assessment,|

| | |liver function testing, general chemistries including amylase, and serial blood glucose monitoring. After |

| | |discharge, the transplant surgeon/physician conducts metabolic monitoring at regular intervals, including close|

| | |monitoring of insulin requirements, C-peptide levels, oral glucose tolerance testing (OGTT), and hematological |

| | |studies |

|[pic] |

|0142T |  |Clinical Example (0142T) |

| | |A 23-year-old man with Type I diabetes mellitus one year status post kidney transplant, presents with stable |

| | |kidney graft function, but poor control of diabetes and secondary complications, including retinopathy and |

| | |neuropathy. At laparotomy, pancreatic islet cells are transplanted through the portal vein. |

| | |Description of Procedure (0142T) |

| | |The transplant surgeon ensures that the islet product is properly labeled, that it is the correct islet product|

| | |for the patient, and the final crossmatch and blood type are checked. Intravenous immunosuppression is |

| | |administered and monitored. Antibiotics are administered. Under general anesthesia, an upper mid-line incision |

| | |is performed. Dissection carried through the linea alba. Soft tissue perfusion is assessed and hemostasis is |

| | |obtained. The peritoneum is carefully entered. The abdomen is manually explored by inspection and palpation. |

| | |Self-retaining retractors and their attachments are placed. The omentum is mobilized and brought up through the|

| | |incision. An omental vein is dissected out and encircled with suture. The vein is open and a 5 french feeding |

| | |tube is inserted. The portal pressure is measured and recorded. If the portal pressure is less than 20 mm Hg, |

| | |heparin is added to the islet infusion bag and it is connected to the portal venous catheter using a standard |

| | |intravenous infusion set. The IV bag containing the islets are suspended during the infusion. To reduce |

| | |clumping and risk of portal vein thrombosis the IV bag containing the islets in suspension is manually rocked. |

| | |The islets are infused intraportally, over a period of up 90 minutes, using gravity drainage. Portal venous |

| | |pressure is monitored and recorded after 5 ml (packed volume) of tissue is infused, and after every subsequent |

| | |2.5-5.0 ml of tissue infused (up to a total of 10 ml of tissue). Islet infusion is halted if the portal |

| | |pressure change from pre- to post-infusion exceeds 14-16 mm Hg; it is restarted only if the pressure drops |

| | |below 18 mm Hg. If the pressure remains elevated, infusion is stopped. Throughout the infusion, the patients |

| | |vital signs and oxygenation are monitored every 15 minutes to diagnose possible intolerability of the islet |

| | |infusion . During the islet infusion the blood glucose values are monitored to guide insulin therapy. The |

| | |islets produce insulin immediately after infusion, there is also free insulin being infused due to release of |

| | |insulin from damaged islets. Changes in the patients insulin dosages or requirements for intravenous glucose |

| | |are based on serial blood glucose measurements. After completion of the islet infusion and after a final rinse |

| | |of the infusion bag, the closing portal pressure is obtained and recorded. A completion portogram may be |

| | |obtained. The infusion catheter is removed and the omental vein ligated. The midline fascia is re-approximated |

| | |with suture. The skin edges and subcutaneous tissues are irrigated and closed in layers and a clean dressing |

| | |applied. Post-operatively, the patient is observed for several hours in the recovery room; an insulin drip is |

| | |initiated and adjusted to maintain strict blood glucose control between 85 and 130 mg percent, and serial one |

| | |hour glucose measurements are ordered and reviewed. After discharge from the recovery room, the patient is |

| | |transferred to the transplant unit, which is associated with an inpatient general clinical research center |

| | |(GCRC) within the meaning of NIH definitions. In-hospital work includes hematologic assessment, liver function |

| | |testing, general chemistries including amylase, and serial blood glucose monitoring. After discharge, the |

| | |transplant surgeon conducts metabolic monitoring at regular intervals, including close monitoring of insulin |

| | |requirements, C-peptide levels, oral glucose tolerance testing (OGTT), and hematological studies |

|[pic] |

|0143T |  |Clinical Example (0143T) |

| | |A 23-year-old man with Type I diabetes mellitus one year status post kidney transplant, presents with stable |

| | |kidney graft function, but poor control of diabetes and secondary complications, including retinopathy and |

| | |neuropathy. At laparoscopy, pancreatic islet cells are transplanted through the portal vein. |

| | |Description of Procedure (0143T) |

| | |The transplant surgeon ensures that the islet product is properly labeled, that it is the correct islet product|

| | |for the patient, and the final crossmatch and blood type are checked. Intravenous immunosuppression is |

| | |administered and monitored. Antibiotics are administered. Under general anesthesia, surgical laparoscopy is |

| | |performed. An umbilical incision is made, and peritoneum is grasped with sutures on the fascia. The peritoneum |

| | |is opened under direct vision. A Hassan blunt trocar is inserted. Gas flow is initiated to distend the abdomen,|

| | |and the laparoscope is introduced. Gas flow and intra-abdominal pressure are carefully monitored so as not to |

| | |impair ventilation or venous return. Two additional trocar ports are placed in roughly a diamond pattern on the|

| | |anterior abdominal wall above the umbilicus. The viscera are inspected and the abdomen visually explored to |

| | |exclude pathology. Pneumoperitoneum is maintained at 15 mm Hg throughout the procedure. Access to the port vein|

| | |is accomplished by isolating either the right gastroepiploic vein intracorporeally or a small intestine vein |

| | |branch after withdrawing the selected loop of bowel through the umbilical port. In either situation a 5 french |

| | |catheter is inserted for both portal pressure measurements and islet infusion. Veins used for infusion are |

| | |secured with ligatures following the removal of the catheter. If the portal pressure is less than 20 mm Hg, and|

| | |no abnormalities are noted, the islet infusion bag is connected with the portal vein catheter using a standard |

| | |intravenous infusion set. The islets are infused intraportally, over a period of 60-90 minutes, using gravity. |

| | |The transplant surgeon actively monitors the portal vein pressure. Islet cell transplantation is halted if the |

| | |portal pressure exceeds 22 mm Hg; it is restarted only if the pressure drops below 18 mm Hg. If the pressure |

| | |remains elevated, infusion is stopped. Throughout the infusion, the patients oxygenation is monitored to make |

| | |sure that the islets do not embolize into the lung through intrapulmonary shunts. Also, the hemodynamics are |

| | |monitored carefully to be certain that no systemic response occurs. During the procedure the transplant surgeon|

| | |also actively manages hemodynamics, blood glucose interpretation and insulin therapy, immunotherapy infusion, |

| | |antibiotic infusion and pain medication. After completion of the islet infusion and after a final rinse, the |

| | |closing portal pressure is obtained and recorded. Meticulous hemostasis is maintained, and the peritoneal |

| | |cavity is irrigated. The trocars are removed under direct vision to assure no abdominal wall vascular injury or|

| | |hemorrhage. The abdominal gas is evacuated, and the trocar sites are closed with multiple sutures. |

| | |Post-operatively, the patient is observed for several hours in the recovery room; an insulin drip is initiated |

| | |and adjusted to maintain strict blood glucose control between 85 and 130 mg percent, and serial one hour |

| | |glucose measurements are ordered and reviewed. After discharge from the recovery room, the patient is |

| | |transferred to the transplant unit, which is associated with an inpatient general clinical research center |

| | |(GCRC) within the meaning of NIH definitions. In-hospital work includes hematologic assessment, liver function |

| | |testing, general chemistries including amylase, and serial blood glucose monitoring. After discharge, the |

| | |transplant surgeon conducts metabolic monitoring at regular intervals, including close monitoring of insulin |

| | |requirements, C-peptide levels, oral glucose tolerance testing (OGTT), and hematological studies. |

|[pic] |

|0153T |  |Clinical Example (0153T) |

| | |A 71-year-old male has been diagnosed with a 7.3-cm abdominal aortic aneurysm. He has chosen to have the |

| | |aneurysm treated using an endovascular repair. An implantable wireless physiologic sensor is placed during |

| | |surgery. |

| | |Description of Procedure (0153T) |

| | |The physician reviews the computed tomographic imaging results to ensure the availability of a sufficient |

| | |thrombus-free space within aneurysm sac to allow safe placement of implantable wireless physiologic sensor |

| | |(IWPS). The indications, risks and benefits of placement of the IWPS are discussed with the patient and family.|

| | |A review of the operating room is performed to ensure that all components are present and ready in the |

| | |operating room. Once the main body of the endograft has been deployed the sensor placement begins. The IWPS |

| | |catheter is prepared by flushing the guidewire lumen. The technologists are supervised to position fluoroscopy |

| | |unit appropriately. The physician manipulates the guidewire/catheter system to lie external to the main body of|

| | |endograft. The delivery system is tracked over a guidewire from the contralateral access site in the groin and |

| | |the sensor positioned at the top of the aneurysmal sac using fluoroscopic imaging. Multiple projections are |

| | |used, as required, to ensure exact placement of the sensor. The delivery system is retracted, while maintaining|

| | |position of the sensor on the tether wire. The delivery system is replaced with a 14 French sheath/dilator |

| | |system. The sensor is calibrated, using an antenna and the system, and the first pre-exclusion measurement is |

| | |taken. The stent graft placement procedure is completed, including all limbs/extensions and ballooning to |

| | |achieve a seal of the site of the endovascular aortic repair. (Note: this is a part of endograft deployment.) |

| | |The sensor is released from the tether wire and the second post exclusion measurement is obtained. |

|[pic] |

|0154T |  |Clinical Example (0154T) |

| | |A 71-year-old male underwent endovascular AAA repair with implantation of a wireless physiologic sensor one |

| | |year ago. He is referred by the physician responsible for postoperative graft surveillance to undergo |

| | |collection and analysis of aneurysm sac physiologic data. |

| | |Description of Procedure (0154T) |

| | |The patient is greeted and a gown is provided. The patient is educated with information related to the |

| | |procedure and verbal informed consent is obtained. The patients blood pressure is taken and is then prepped and|

| | |positioned. The IWPS monitoring equipment is prepared and the examination is begun. The antenna of the wireless|

| | |pressure sensor is placed over the patients abdomen to measure the pressure of the AAA sac to ensure that there|

| | |is no evidence of an endoleak as indicated by an elevated pressure in the sac. Once the antenna is properly |

| | |positioned on the patients abdomen, the technologist records and prints the pressure tracing. The preliminary |

| | |data is collated. Following the completion of this examination by the technologist, the physician reviews the |

| | |requisition and the previous studies. The pressures and pressure tracing are analyzed. These current pressures |

| | |and pressure tracing are analyzed for comparison to the previous measurements to ensure that there has not been|

| | |a significant increase in sac pressure that would warrant further diagnostic studies or intervention. The |

| | |results are considered in light of systemic (arm) blood pressure. A complete written or electronic report is |

| | |completed and filed. |

|[pic] |

|0155T |  |Clinical Example (0155T) |

| | |A 44-year-old woman (height: 5 ft-6 in; weight 300 lbs; BMI 49 kg/m2) presents with a history of Type II |

| | |diabetes and hypertension. A recent sleep study showed severe, obstructive sleep apnea for which she was placed|

| | |on CPAP. Her gastroesophageal reflux is controlled with an H2-blocker. Her mobility is restricted due to severe|

| | |arthritis of her lower back and knees. Family and diet history confirm morbid obesity began at age nine. The |

| | |patient underwent multiple weight-loss programs, losing up to 50 pounds three times. However, the weight loss |

| | |was never maintained for more than six months and each weight regain was more than what was originally lost. |

| | |Weight loss programs utilized included very low calorie diets, a popular commercial program, exercise, appetite|

| | |suppressants, and meal replacements. The patient has passed the pre-surgical screening algorithm. At operation,|

| | |she undergoes a laparoscopic implantation of gastric stimulation electrodes. |

| | |Description of Procedure (0155T) |

| | |Surgical laparoscopy is performed under general anesthesia. The abdomen is entered through the umbilicus using |

| | |standard techniques and pneumoperitoneum is established. A laparoscope is introduced with survey of the upper |

| | |abdominal organs. Three trocar ports are placed in the anterior abdominal wall above the umbilicus. The liver |

| | |is retracted, and the stomach is visualized. The pes anserinus and lesser curvature are exposed. A paper ruler |

| | |is placed along the lesser curvature and the entrance and exit points for the stimulator leads are measured and|

| | |marked. Intra-operative gastroscopy may also be simultaneously performed, by a separate physician, to monitor |

| | |for possible mucosal penetration during electrode insertion. An electrode is implanted in the gastric wall by |

| | |passing a needle-tipped lead for 3.5 cm through the muscle of the gastric wall along each measured tract. Each |

| | |implanted lead is checked for possible gastric mucosal penetration before removal of the guide needle. Sutures |

| | |are used to secure the leads in the gastric wall. |

| | |After both leads are secured, they are brought out the left upper abdominal port for connection to a |

| | |neurostimulation generator. The laparoscope and retractor are removed and the pneumoperitoneum decompressed. |

| | |The gastric neurostimulator is implanted in a pocket based on the rectus fascia in the left upper abdomen. The |

| | |electrodes are tested for proper impedance and the leads are then connected to the neurostimulator pulse |

| | |generator. The generator is anchored in the pocket with sutures. (Report implantation of the gastric |

| | |stimulation generator with 64590.) The ports are closed with sutures and the stimulator pocket is closed in |

| | |layers. A postoperative X-ray of the stomach is taken to record the location of the leads and electrodes in the|

| | |event of possible malfunction. |

|[pic] |

|0156T |  |Clinical Example (0156T) |

| | |A patient in whom an Implantable Gastric Stimulation (IGS) system was implanted 9 months earlier has failed to |

| | |sustain the steady weight loss experienced following initiation of IGS and returns for evaluation. |

| | |Interrogation of the gastric neurostimulation device reveals high impedance values for both electrodes on |

| | |serial testing, suggesting lead malfunction. An X-ray of the abdomen shows a discontinuity in one lead and a |

| | |change in position of the second lead relative to the original post-operative X-ray. A laparoscopic replacement|

| | |of the leads is scheduled. |

| | |Description of Procedure (0156T) |

| | |Surgical laparoscopy is performed under general anesthesia. The abdomen is entered through the umbilicus using |

| | |standard techniques and pneumoperitoneum is established. A laparoscope is introduced with survey of the upper |

| | |abdominal organs. Three trocar ports are placed in the anterior abdominal wall above the umbilicus. The liver |

| | |is retracted, and the stomach is visualized. The leads are traced back to the entry site and the tract is |

| | |opened. The broken lead is identified and the attached electrode is removed from the gastric wall. The |

| | |displaced second electrode is also removed and both electrodes with their attached lead wires are removed from |

| | |the peritoneal space through the exit port. A new set of leads is introduced into the peritoneal space and the |

| | |electrodes are both implanted along the lesser curvature. Intra-operative gastroscopy may also be |

| | |simultaneously performed, by a separate physician, to monitor for possible mucosal penetration. When implanted,|

| | |both leads are tested for impedance before final anchoring to the gastric wall. After decompression of the |

| | |pneumoperitioneum, the distal end of each lead is attached to the neurostimulator device. This requires the |

| | |stimulator device pocket to be opened in order to disconnect the broken leads and reconnect the newly implanted|

| | |leads. (If the gastric stimulation generator needs to be removed or revised, report with 64595.) All wounds are|

| | |closed in layers. A postoperative X-ray of the stomach is made. |

|[pic] |

|0157T |  |Clinical Example (0157T) |

| | |A 44-year-old man (height: 5 ft-11 in; weight 390 lbs; BMI 55 kg/m2) presents with a history of Type II |

| | |diabetes, hypertension, Gastroesophageal Reflux Disease, and arthritis. The patient underwent multiple |

| | |weight-loss programs, losing up to 70 pounds three times. However, the weight loss was never maintained for |

| | |more than six months and each weight regain was more than what was originally lost. Weight loss programs |

| | |utilized included very low calorie diets, a popular commercial program, exercise, appetite suppressants, and |

| | |meal replacements. The patient has passed the pre-surgical screening algorithm. Due to prior upper abdominal |

| | |surgery, a laparotomy for implantation of gastric stimulation electrodes is scheduled. |

| | |Description of Procedure (0157T) |

| | |Under general anesthesia, a midline incision is made, starting at the xiphoid process and extending |

| | |approximately 6 cm to 8 cm in length. The incision is down to the linea alba. A pocket to accommodate the |

| | |neurostimulator pulse generator is constructed immediately anterior to the left anterior rectus fascia, using |

| | |sharp dissection. The linea alba is then incised to enter the peritoneal cavity. The overhanging liver is |

| | |gently retracted to expose the lesser curve of the stomach. A paper ruler is placed along the lesser curvature |

| | |and the entrance and exit points for the stimulator leads are measured and marked. Intra-operative gastroscopy |

| | |may also be simultaneously performed, by a separate physician, to monitor for possible mucosal penetration. An |

| | |electrode is implanted in the gastric wall by passing a needle-tipped lead for 3.5 cm through the muscle of the|

| | |gastric wall along each measured tract. Each implanted lead is checked for possible gastric mucosal penetration|

| | |before removal of the guide needle. Sutures are used to secure the leads in the gastric wall. |

| | |The lead wires are curled gently within the abdominal cavity and brought out through a separate stab wound into|

| | |the previously constructed IGS pocket. Intraoperative testing shows normal impedance values for each electrode.|

| | |The leads are then attached to the neurostimulator pulse generator, and the generator is secured within the |

| | |pocket with sutures. (Report implantation of the gastric stimulation generator with 64590.) The pocket is |

| | |closed with a running absorbable suture and the abdomen is closed with appropriate sutures. A running |

| | |subcuticular plastic closure is used under the skin. A postoperative check film of the stomach is made. |

|[pic] |

|0158T |  |Clinical Example (0158T) |

| | |A patient who had laparotomy for implantation of an IGS 12 months ago returns for an annual checkup. |

| | |Interrogation of the gastric neurostimulation device shows abnormally high impedance of both leads. X-ray of |

| | |the stomach shows a suspicious angulation of one of the leads compatible with a kinked area and break in the |

| | |lead. A laparotomy is done for replacement of the two broken leads and reconnection to the implanted electrodes|

| | |and the pulse generator. |

| | |Description of Procedure (0158T) |

| | |After induction of endotracheal general anesthesia, a laparotomy is performed in the upper midline through the |

| | |linea alba into the peritoneal space. After careful retraction of the liver, the lesser curvature is exposed |

| | |and the kinked lead is identified. It is disconnected from the wall of the abdomen as well as from the |

| | |neurostimulator pulse generator and replaced with a new lead. Intra-operative gastroscopy may also be |

| | |simultaneously performed, by a separate physician, to monitor for possible mucosal penetration.This requires |

| | |the stimulator device pocket to be opened in order to disconnect the broken leads and reconnect the newly |

| | |implanted leads. (If the gastric stimulation generator needs to be removed or revised, report with 64595.) The |

| | |second lead is replaced in the same manner. Intraoperative testing shows normal impedance values for each |

| | |electrode. The wounds are closed in layers. A postoperative check film is made of the stomach. |

|[pic] |

|0159T |  |Clinical Example (0159T) |

| | |A 60-year-old female is referred to the radiology department complaining of a lump at the two oclock position |

| | |in her left breast, which is corroborated by her referring physician. She had a screening mammogram 1 year ago.|

| | |Description of Procedure (0159T) |

| | |A diagnostic contrast-enhanced magnetic resonance scan (coded separately) is performed on the breast to include|

| | |any suspected tumor sites. |

| | |Once the data has been acquired, the software analyzes the data from the multiple time points and if tumors are|

| | |present, the tumors are colorized based on the resulting data. The software assigns a color to each pixel that |

| | |exhibits enhancement based on the administration of the contrast agent. A preponderance of red indicates |

| | |malignancy, green indicates highly suspicious tissue, and blue indicates tissue of benign growth. |

| | |The service includes the time for the clinical staff (magnetic resonance imaging [MRI] technologists) to |

| | |initiate the pharmacokinetic analysis and electronically transmit the MRI dataset through the picture archiving|

| | |and communications system to the viewing workstation utilized by the radiologist for review. The physician |

| | |reviews the MRI of the breast scans and then re-evaluates any computer-aided detection marks before making a |

| | |final assessment and dictating a report. |

|[pic] |

|0160T |  |Clinical Example (0160T) |

| | |The patient is a 34-year-old female who presents with a clinical diagnosis consistent with DSM-IV defined major|

| | |depressive disorder. Repetitive transcranial magnetic stimulation is prescribed. She has no unstable medical |

| | |conditions, and has no contraindications to repetitive transcranial magnetic stimulation (rTMS). |

| | |Description of Procedure (0160T) |

| | |Dose determination and targeting are performed at the initial assessment and at clinically appropriate points |

| | |periodically during a course of rTMS therapy. With each dose determination and targeting session a medical |

| | |appraisal (reported separately as E/M) is made to determine any relevant medical history that may be expected |

| | |to influence the patients risk profile with regard to the use of rTMS, or to have led to an alteration in the |

| | |patients previously determined dose level. |

| | |The patient is seated comfortably in the treatment chair and the physician applies a headset to the patient |

| | |which will assist in locating both the site over the primary motor cortex where the motor threshold (MT) will |

| | |be determined and the location over the prefrontal cortex where the magnetic stimulation will be delivered. |

| | |Next, the patient is provided with ear plugs and her head is placed in the headrest and the headset is adjusted|

| | |for patient head size and comfort. Prior to placement of the electromagnetic coil on the patients head, a |

| | |component is attached to the face of the coil which assists the physician in measuring coil proximity to the |

| | |scalp, improves the comfort during the procedure and provides system confirmation of the appropriate output |

| | |magnetic field strength. Patient-specific information that has been entered in the rTMS therapy system in |

| | |advance of the treatment session is verified with the patient and the electromagnetic coil is then placed on |

| | |the patients head over the motor strip area above the ear on the same hemisphere as where the treatment |

| | |stimulation will be delivered. For determination of the motor threshold (MT), the rTMS system is set to a pulse|

| | |rate of less than 1 Hz. Operationally, the MT value is defined as the lowest level of system output power which|

| | |produces a visible movement in the contra-lateral thumb or next most proximate digit, as observed by the |

| | |evaluating physician. The physician moves the coil across the surface of the scalp overlaying the area of motor|

| | |cortex in a systematic grid pattern, to identify the optimal MT location, adjusting the stimulator output in a |

| | |gradual fashion until the optimal location on the motor strip that controls the movement of the thumb or finger|

| | |is found. This location is marked on the headset for future use since the same headset is ordinarily used |

| | |throughout a course of therapy. The stimulator output power is now titrated to determine the exact output power|

| | |that is sufficient to induce a motor response, but in no excess. This process is repeated in a standardized |

| | |manner four times with the final value computed by the system by finding the 50% probability power level of the|

| | |known probability distribution that bestfits the physicians observations of the thumb movement. The output |

| | |power level determined by this process is called the MT value. This value is saved in the rTMS therapy system |

| | |and rechecked periodically throughout a course of therapy on subsequent treatment days as needed based on the |

| | |medical determination of the treating physician. The physician then measures 5 cm anterior on an oblique |

| | |saggital arc ending up over the prefrontal cortex which will be the site of therapeutic stimulation. This |

| | |position is also marked on the headset to future use. The coil is positioned on the patients head by combining |

| | |this location information with proximity sensor feedback to determine the coil resting position. The coil is |

| | |then fixed to remain in good contact with the patients head for the duration of treatment. This process |

| | |typically takes up to one hour for the first MT determination, and may take 30 to 45 minutes on repeat |

| | |determinations. After MT is determined, the treatment is ready to begin. |

|[pic] |

|0161T |  |Clinical Example (0161T) |

| | |The patient is a 34-year-old female who presents with a clinical diagnosis consistent with DSM-IV defined major|

| | |depressive disorder. She has failed to receive benefit from an adequate trial of antidepressant |

| | |pharmacotherapy. She has no unstable medical conditions, and has no contraindications to repetitive |

| | |transcranial magnetic stimulation (rTMS). |

| | |Description of Procedure (0161T) |

| | |Once the headset is in place on the patients head, the MT value is determined and the coil is in the treatment |

| | |position, then the treatment can begin. The prescribed treatment parameters are selected by the physician and |

| | |stored in the system. A typical treatment will consist of 10 Hz stimulation at an intensity of 120% of the MT |

| | |value. At this frequency and intensity, the stimulation is typically delivered in 4-second bursts beginning 30 |

| | |seconds apart. A total of 75, 4 second bursts are delivered to the patient to total 3000 stimulations per |

| | |treatment session. A typical treatment session takes about 45 minutes. During the treatment session, the |

| | |patient must be closely monitored at all times to ensure good coil-to-head contact. If this is lost due to |

| | |patient motion or other factors, the system provides an alarm to the physician, and the coil must be |

| | |repositioned before continuing treatment to facilitate the most robust outcomes possible. The user must monitor|

| | |the system continually and respond to these and any other alarm conditions indicated by the system. In |

| | |addition, the physician must monitor the patients clinical status for comfort and tolerability and, if |

| | |necessary adjust coil position and potentially, customize the stimulation parameters to mitigate discomfort. |

| | |Finally, although the risk is extremely low (400s. The LVAD was then weaned with initial hemodynamic stability. However,|

| | |the pulmonary artery and right ventricle began to dilate with increasing left-sided failure. It appeared as if |

| | |the inflow cannula was obstructing the mitral valve as the TEE revealed good ventricular contractility despite |

| | |the worsening hemodynamics. Nitric oxide therapy was instituted while complete LVAD support was resumed. An |

| | |attempt was made to wean the patient from the device once again with 20 ppm of nitric oxide support. |

| | |Unfortunately, the right side failed again. Therefore, the ascending aorta and the right atrium was cannulated |

| | |and the patient was placed on cardiopulmonary bypass. |

| | |After achieving full flow, the LVAD outflow graft was divided with a vascular stapling device and the suture |

| | |line oversewn with a 4-0 Prolene suture. The inflow cannula was then removed from the apex of the left |

| | |ventricle and the pursestring sutures secured. The apex was inspected for hemostasis and then started weaning |

| | |the patient from cardiopulmonary bypass. This time, the patient weaned easily from bypass with excellent |

| | |hemodynamics. Transesophageal echocardiography revealed good biventricular function. Protamine was given to |

| | |reverse anticoagulation and the patient decannulated. The chest was irrigated once again with warm saline and |

| | |then closed after a final inspection for hemostasis. Stainless steel wires were employed to approximate the |

| | |sternum, and absorbable sutures were used to close the pectoralis fascia, the subcutaneous tissue, and the |

| | |skin. Three chest drains were left in the chest, a #36 French anterior mediastinal and #32 French left and |

| | |right pleural tubes. Temporary right atrial and right ventricular pacing wires were also placed prior to |

| | |sternal closure. The patient tolerated the procedure well and was transferred to the cardiothoracic ICU in |

| | |stable condition. |

|[pic] |

|33979 |  |Clinical Example (33979) |

| | |A 56-year-old man diagnosed with previous heart transplant, ischemic cardiomyopathy, and diabetes mellitus was |

| | |admitted to the hospital with worsening heart failure. He had a history of subacute bacterial endocarditis, |

| | |multiple silent myocardial infarctions, atrial fibrillation, and coronary artery bypass x 3. He was first |

| | |hospitalized for congestive heart failure two years prior to admission, rehospitalized a year later and three |

| | |months after that. At the last hospitalization, the patient developed acute tubular necrosis requiring |

| | |dialysis. After admission, the patient was managed medically with inotropic support and diuretics. His |

| | |condition worsened and it was decided that he required a LVAD implant. Transesopha- geal echocardiography |

| | |showed a severely hypokinetic left ventricle. A large left atrial thrombus obstructed the pulmonary veins. |

| | |There was minimal pericardial effusion, mildly depressed right ventricular function. Pulmonary arterial |

| | |pressure was 75/30 mm Hg. Gross findings were minimal adhesions and a small amount of pericardial effusion. A |

| | |large white thrombus was observed in the left atrium. The left ventricular lateral and posteroinferior wall |

| | |showed contraction after initiation of cardiopulmonary bypass. Vein grafts to D1 and RI were patent as well as |

| | |left internal mammary arterty-to-left anterior descending artery. |

| | |Description of Procedure (33979) |

| | |Under general endotracheal anesthesia, in the supine position, the patient was prepped and draped in standard |

| | |aseptic fashion. The previous midline incision was re-entered. The device pocket was created with |

| | |electrocautery. The inferior phrenic vessels on the diaphragm were identified and ligated. The driveline egress|

| | |site was created in the right upper abdomen. The LVAD was brought onto the field and placed into the pocket. |

| | |The driveline was tunneled out from the right upper quadrant incision. Preparation for cardiopulmonary bypass |

| | |(CPB) included ACT-guided heparinization, cannulation of the aorta (3-0 prolene purse string, Sarns 8.0 mm), |

| | |and cannulation of the superior vena cava (3-0 Prolene purse string, 28 DLP) and inferior vena cava (3-0 |

| | |Prolene purse string, 28 DLP). A Bentley cardioplegia needle was secured in the ascending aorta with a 4-0 |

| | |Prolene. An apical LV vent was placed and the patient was cooled to 32 degrees C. The patient's pressure was |

| | |temporarily reduced to 50 mm Hg. The aortic cross clamp was applied, and 4:1 blood cardioplegia, 1000 ml, was |

| | |given antegrade. The left atriotomy was re-opened and the left atrium inspected with findings described above. |

| | |A large thrombus was removed, and no residual thrombus confirmed remained. The atriotomy was closed with |

| | |running 3-0 Prolene. The patient was de-aired in standard fashion, and the atriotomy was tied shut. The aortic |

| | |pressure was temporarily reduced to 50 mm Hg. The aortic cross clamp was removed, and the patient was |

| | |ventilated and de-aired once again. The apex was cored and the left ventricle and tract was cleared of |

| | |thrombus. The inflow cuff was attached to the apex of the LV using pledgeted 2-0 Tevdek sutures in a mattress |

| | |fashion. The cuff was attached to the LVAD and secured with #2 Tevdek tie as well as two umbilical tapes. |

| | |A partial occluding clamp was placed on the greater curvature of the ascending aorta. The outflow graft length |

| | |was measured and the graft was sewn to an eliptico-longitudinal aortotomy using semi-continuous running 3-0 |

| | |Prolene buttressed with a Teflon felt strip washer. The pressure decreased to 50 mm Hg, aortic root suction |

| | |applied and the clamp released. The device was allowed to fill with blood and the outflow graft was |

| | |subsequently attached. A de-airing hole was made in the outflow graft, and the device was slowly de-aired. |

| | |The patient was weaned from cardiopulmonary bypass with levophed, milrinone, dobutamine, and pitressin. LVAD |

| | |flows were 5.5 to 7 L/min. After protamine administration and decannulation, hemostasis was satisfactory. Two |

| | |right ventricular and two right atrial pacing wires were placed, a #36 anterior mediastinal, #32 left pleural |

| | |chest tubes were placed. Two large JP drains were placed in the abdominal pocket. The sternum was closed with 7|

| | |wires, the abdominal fascia with #2 Prolene, and the skin and subcutaneous tissue closed in layers of 0, 2-0, |

| | |and 4-0 Vicryl. The patient was subsequently transported to the open heart recovery room in guarded condition. |

|[pic] |

|33980 |  |Clinical Example (33980) |

| | |A 35-year-old man with a history of hypertension was admitted, complaining of weakness, sore throat, and |

| | |diarrhea, with one week on antibiotics for dental abscess. Echocardiogram showed severely decreased LV/RV with |

| | |global hypokinesis. Diagnosis was consistent with viral myocarditis. The patient developed cardiogenic shock |

| | |and was taken to the operating room for placement of an intracorporeal LVAD. Postoperatively, the patient was |

| | |transferred to the ICU. The patient was extubated on postop day no. 10. The patient developed atrial flutter |

| | |that was thought to be secondary to ongoing myocarditis treated with Ibutiride. He continued to be consistently|

| | |febrile despite antibiotic treatment with Vancomycin/Ceftriaxone/Erythromycin. The patient was evaluated by an |

| | |otolaryngologist for hoarseness and was noted to have vocal cord paralysis. The patient was evaluated for |

| | |possible cardiac recovery. The LVAD was set at fixed rate and the patient underwent a right heart |

| | |catheterization, which revealed normal hemodynamics. The patient underwent an additional right heart |

| | |catheterization with normal hemodynamics prior to cardiopulmonary exercise. While in the exercise lab, the |

| | |patient experienced a vagal episode with decreased blood pressure and decreased LVAD flows. The exercise test |

| | |was postponed. The patient was rescheduled and underwent cardiopulmonary exercise with a peak VO2 of 13.8 and |

| | |normal ejection fraction. The decision was made that the patient had recovered and the device could be |

| | |explanted. Eight days later, the patient was taken to the operating room for removal of the TCI device. |

| | |Description of Procedure (33980) |

| | |Under general endotracheal anesthesia in the supine position, the patient was prepped and draped in standard |

| | |aseptic fashion. Median sternotomy was completed carefully and the LVAD pocket opened. The pericardial space |

| | |contained moderate adhesions. The heart was evaluated by transesophageal echocardiography, with an ejection |

| | |fraction estimated as 65% without inotropes. No left ventricular thrombus or purulent material was found in the|

| | |LVAD pocket. Some serous material in the pocket was cultured. The heart was carefully dissected and a |

| | |pericardial well was created with 2-0 silk. Preparation for cardiopulmonary bypass (CPB) included ACT-guided |

| | |heparinization. The LVAD outflow graft was cannulated (3-0 Prolene purse string sutures, Sarns 6.5mm). |

| | |Cannulation of the right atrium (3-0 Prolene purse string sutures, 36/51) was completed. Intraoperatively the |

| | |patient had decreased blood pressure after aprotinin administration requiring epinephrine, levophed, and |

| | |pitressin. In addition, he had increased bleeding requiring multiple transfusions of blood products. |

| | |Cardiopulmonary bypass was initiated and the dissection of the heart completed. The patient remained at 36 |

| | |degrees C. The inflow to the LVAD was freed and separated from the LVAD. The driveline was dissected free and |

| | |the device was removed from the field. The inflow cuff was removed. The cored hole at the apex was closed with |

| | |double 2-0 Prolene purse string sutures and 3-0 Prolene mattress-type sutures buttressed with Dacron graft |

| | |materials. When the purse string suture was tied down, de-airing maneuver was completed. |

| | |The patient was weaned from CPB with levophed and pitression. After protamine and decannulation, the outflow |

| | |graft was stapled close to the aorta and the stump oversewn using 4-0 Prolene running suture. Hemostasis was |

| | |unsatisfactory even with a large amount of protamine administration, requiring blood product transfusion. |

| | |Satisfactory hemostasis was obtained after a lengthy and meticulous hemostatic procedure. Two right ventricular|

| | |and two right atrial pacing wires were placed. #36 (anterior mediastinal) and #32 (left pleural) chest tubes |

| | |were placed. A large Jackson-Pratt drain was placed in the abdominal pocket. Sternum was closed with wire (6), |

| | |and the skin closed in layers with 0, 3-0 and 4-0 Dexon. The patient was transferred to the ICU and |

| | |subsequently extubated and transferred to the CCU. He continued to recover and was transferred to the floor |

| | |where he continued to recover. |

|[pic] |

|34800 |  |Clinical Example (34800) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction has a 5.8 cm aortic aneurysm. Imaging studies indicate that the aneurysm is infrarenal |

| | |with an adequate neck to allow successful deployment of an endovascular prosthesis. There is also adequate |

| | |normal aorta below the aneurysm to allow use of a tube graft. The iliac artery anatomy should accommodate |

| | |passage of the device. |

| | |Description of Procedure (34800) |

| | |The device and typically large introducer are threaded onto the guidewire and advanced to the edge of the |

| | |artery. An arteriotomy is fashioned and the introducer is pushed into the artery. The device is then carefully |

| | |advanced through the iliac arteries, into the aorta, and positioned such that the proximal edge is just below |

| | |the renal artery origins and above the beginning of the aneurysm. Its position is confirmed exactly by |

| | |fluoroscopy, often with injections of contrast. If a selective second catheter has been placed to mark the |

| | |lower renal artery, it is drawn back into the iliac, and the main endovascular device is deployed under |

| | |exacting fluoroscopic guidance. Fine adjustments in position are made during the deployment to assure accurate |

| | |positioning just below the renal artery origins. In some patients the mean arterial pressure is transiently |

| | |reduced by the anesthesiologist to decrease the chance that pressure from flowing blood will push the endograft|

| | |distally during deployment. After deployment, the arterial pressure is normalized. The introducer portion of |

| | |the main device is removed over the guidewire, leaving the endograft in position. Some devices require balloon |

| | |dilatation at the proximal and distal anastomoses to help assure proper seating and hemostatic seal with the |

| | |arterial wall. If this is the case, a large diameter compliant balloon is advanced over the wire to the |

| | |proximal anastomosis, and under fluoroscopic guidance the balloon is positioned and inflated. This same balloon|

| | |may be pulled back and used to seat the distal anastomosis. |

| | |Once the complete endograft is in place, a pigtail catheter or multi-sidehole catheter is repositioned over one|

| | |of the guidewires, and placed just above the renal arteries for a final angiographic evaluation. An aortogram |

| | |is performed and immediately evaluated for graft position, patency of appropriate branches (renals and |

| | |hypogastrics), presence or absence of endoleaks, and patency of lumbar or inferior mesenteric arteries that may|

| | |contribute to persistent endoleaks. Removal of the catheters and guidewires is performed. Arteriotomy site and |

| | |skin closure is also performed. |

|[pic] |

|34802 |  |Clinical Example (34802) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. aortic aneurysm. Imaging studies indicate that the aneurysm is infrarenal |

| | |in nature with an adequate neck of normal aorta below the renal artery origins for deployment of an |

| | |endovascular prosthesis. Distally the aneurysm extends to the end of the aorta, indicating that a bifurcated |

| | |prosthesis will be required. Iliac arteries are of appropriate diameter and length to provide landing zones for|

| | |the iliac limbs of the prosthesis. The iliac artery anatomy should accommodate passage of the device. |

| | |Description of Procedure (34802) |

| | |The procedure begins by loading the endovascular device and its introduction mechanism onto the guidewire and |

| | |advancing it to the edge of the artery. A large arteriotomy is made, and the introducer is pushed in. This |

| | |large introducer sheath often fills the entire lumen of the femoral artery. The device is carefully advanced |

| | |through the iliac arteries and positioned such that the proximal edge is just below the renal artery origins |

| | |and above the beginning of the aneurysm. Its position is confirmed exactly by fluoroscopy, often with |

| | |injections of contrast. If a selective second catheter has been placed to mark the lower renal artery, it is |

| | |drawn back into the iliac, and the main endovascular device is deployed under exacting fluoroscopic guidance. |

| | |Fine adjustments in position are made during the deployment to assure accurate positioning just below the renal|

| | |artery origins. In some patients the mean arterial pressure is transiently reduced by the anesthesiologist to |

| | |decrease the chance that pressure from flowing blood will push the endograft distally during deployment. After |

| | |deployment the arterial pressure is normalized. The introducer portion of the main device is removed over the |

| | |guidewire, leaving the endograft in position. Some devices require balloon dilatation at the proximal and |

| | |distal anastomoses to help assure proper seating and hemostatic seal with the arterial wall (not a separately |

| | |billable service). If this is the case, a large diameter compliant balloon is advanced over the wire to the |

| | |proximal anastomosis, and under fluoroscopic guidance the balloon is positioned and inflated. This same balloon|

| | |may be pulled back and used to seat the iliac anastomosis by using an incomplete inflation (since the iliac |

| | |diameter is smaller than the aorta). In other cases, a balloon better matched to the iliac diameter is |

| | |required, entailing an exchange of balloons over the guidewire. |

| | |The guidewire on this initial ipsilateral side is left in position within the endograft, and attention is |

| | |turned to the contralateral side for placement of the docking limb. The guidewire on this side has been left in|

| | |position within the iliac artery. Using fluoroscopic guidance, this guidewire is advanced into the docking port|

| | |of the short iliac limb of the main prosthesis. This frequently is a difficult and time-consuming maneuver, |

| | |since the aneurysm may be large and may divert the catheter or guidewire away from the intended target. If it |

| | |is not possible to pass the wire from the contralateral groin into the appropriate position, access may be |

| | |obtained by using the catheter from the ipsilateral groin. With appropriate manipulation this may be hooked |

| | |over the flow divider of the aortic prosthesis, allowing passage of the guidewire down the short contralateral |

| | |iliac limb, through the docking port, and down the native contralateral iliac artery. This guidewire may then |

| | |be grasped by passing a snare device upward from the contralateral groin and pulling the guidewire out through |

| | |the arteriotomy. Having achieved this "over the horn" guidewire configuration, a catheter is passed back up the|

| | |wire, into the contralateral limb docking port, and past the flow divider. If this maneuver is used, the |

| | |selective catheter code for the ipsilateral side is changed from 36200 for placement of the catheter into the |

| | |aorta to 36245 for first order selective catheterization of the contralateral common iliac artery. If this |

| | |maneuver is unsuccessful, the contralateral port may also be accessed by means of an axillary or brachial |

| | |artery puncture. If an arm approach is used, a third access code would also be reported in addition to the one |

| | |or two femoral catheterization codes. (In this case, code 36245 would probably be the appropriate code, for |

| | |first order selective catheterization of the contralateral common iliac artery). This allows passage of a |

| | |guidewire from above, maneuvering it into the contralateral port, and then snaring the wire from the |

| | |contralateral groin. |

| | |Once a guidewire has been successfully advanced from the contralateral groin into the contralateral docking |

| | |port of the aortic prosthesis, the contralateral docking limb is placed. A sheath is usually passed over the |

| | |wire. The contralateral limb is advanced through the sheath into docking position, and the exact position of |

| | |the limb is determined by fluoroscopy. The proximal end must be firmly seated within the docking port of the |

| | |main prosthesis while the distal end must be located within a normal diameter segment of iliac artery, usually |

| | |proximal to the iliac bifurcation. Once correct position is confirmed, the sheath is pulled back, and the limb |

| | |is deployed. Accurate deployment is checked with fluoroscopy, using contrast injection. For some devices, the |

| | |proximal and distal ends of this iliac limb are secured in position and fully opened by dilation using |

| | |appropriately sized balloons. |

| | |Once the complete endograft is in place, a pigtail catheter or multi-sidehole catheter is repositioned over one|

| | |of the guidewires, and placed just above the renal arteries for a final angiographic evaluation. An aortogram |

| | |is performed and immediately evaluated for graft position, patency of appropriate branches (renals and |

| | |hypogastrics), presence or absence of endoleaks, and patency of lumbar or inferior mesenteric arteries that may|

| | |contribute to persistent endoleaks. If the graft is in good position and free of endoleaks, the intra-service |

| | |portion of 34802 is complete. Removal of the catheters and guidewires is included in the catheter introduction |

| | |codes (36200-36248) and the arteriotomy and skin closure is included in 34812-34820. |

|[pic] |

|34803 |  |Clinical Example (34803) |

| | |A 67-year-old male with coronary artery disease status post myocardial infarction (MI) and chronic obstructive |

| | |pulmonary disease (COPD) was found to have a 5.8 cm diameter abdominal aortic aneurysm (AAA) by abdominal exam |

| | |and subsequent ultrasound. Risks and benefits of open surgical repair, endovascular repair, and watchful |

| | |waiting are discussed with the patient, and he opts for repair. History, physical examination, and |

| | |perioperative risk evaluation including cardiac workup are performed to determine the patient's suitability for|

| | |surgery. Imaging studies (typically a combination of computed tomography [CT] scan, magnetic resonance imaging |

| | |[MRI], and/or angiography) indicate that the aneurysm is infrarenal in nature with an adequate neck of normal |

| | |diameter aorta below the renal artery origins to allow successful deployment of endovascular prosthesis. |

| | |Description of Procedure (34803) |

| | |After each groin is accessed by open femoral or iliac artery exposure or percutaneously and catheters and/or |

| | |sheaths are positioned into the aorta from each side, the physician performs an aortogram to reconfirm anatomy |

| | |of the aorta and iliac arteries to confirm previously planned endorepair. (Note: Code 75952 includes all |

| | |imaging work associated with endovascular repair of infrarenal abdominal aortic aneurysm or dissection.) A |

| | |final examination is conducted of endovascular components for correct models, sizing, etc. Next, soft J-wires |

| | |are exchanged for superstiff exchange wires. Reconfirming that the appropriate device has been chosen, the |

| | |physician unpackages the main-body component and prepares the device for insertion. The patient's blood is then|

| | |anticoagulated with IV heparin. Then, the main-body component is loaded onto the ipsilateral superstiff wire |

| | |and advanced to the femoral artery. The tip of the main device is introduced into arteriotomy. The physician |

| | |opens the proximal vascular clamp and advances the tip of the device into the artery, using rubber constrictors|

| | |to limit blood loss as necessary. Under fluoroscopic guidance, the main-body device is advanced through the |

| | |iliac arteries, and then into the aorta. The physician pushes the device through AAA carefully so the proximal |

| | |edge lies below the renal arteries. The arteriography is repeated as needed to confirm the renal origin |

| | |locations. Deployment is begun. Adjustments are made to align the top of the graft just below the renal |

| | |origins. The main-body device is deployed with constant attention to exact positioning, watching both the renal|

| | |arteries proximally and checking distally to determine that the position above the aortic bifurcation is |

| | |correct. The main-body device is deployed to the point of opening the contralateral, docking port. The |

| | |physician next cannulates the contralateral, docking port using a selective catheter/guidewire combination, and|

| | |advances the catheter into the main body of the graft to the level of the proximal anastomosis. Contrast |

| | |material is injected and an image of the graft is taken to confirm placement of the catheter within the graft. |

| | |Aortic angiography is performed to confirm position of the proximal anastomosis, and any final adjustments |

| | |needed are made to position of the proximal anastomosis at the level of the renals. Once this final position is|

| | |confirmed, the suprarenal fixation portion of the main-body component is deployed. The contralateral superstiff|

| | |wire is advanced into the suprarenal aorta. Through a contralateral sheath, angiography of the contralateral |

| | |iliac bifurcation is performed to roadmap the position for the distal anastomosis. Once the appropriate length |

| | |and diameter of the contralateral limb is confirmed, the physician unpackages the limb and prepares the device |

| | |to be introduced. Then the contralateral limb is loaded onto the contralateral superstiff wire and advanced to |

| | |the femoral artery. The contralateral limb device is advanced through the arteriotomy, and under fluoroscopy is|

| | |advanced through the iliac artery into docking position. Next, the physician confirms the appropriate overlap |

| | |of the contralateral limb with the main body device, and confirms the appropriate position of the distal |

| | |anastomosis above the internal iliac origin. Then the contralateral docking limb is deployed. Afterward, he/she|

| | |finishes deployment of the main-body component by deploying of the ipsilateral, docking port. The proximal |

| | |portion of the delivery device is recaptured above the suprarenal fixation portion of the device, and the |

| | |delivery device is removed from the main-body component and from the patient. Angiography is performed through |

| | |the sheath to confirm position of ipsilateral common iliac bifurcation. Then the physician confirms the |

| | |appropriate length and diameter of the ipsilateral limb and opens and prepares the device for insertion into |

| | |the patient. The ipsilateral limb device is loaded onto superstiff wire, advanced to the ipsilateral femoral |

| | |artery, and introduced through an arteriotomy. The physician observes fluoroscopically, as the ipsilateral limb|

| | |is advanced through the iliac arteries into docking position. He or she then confirms the appropriate overlap |

| | |of the limb with the main-body device, and the appropriate position of the distal anastomosis above the |

| | |internal iliac origin. He/she then deploys the ipsilateral limb. The introducer devices are removed from the |

| | |bilateral iliac limbs, using fluoroscopic guidance to prevent disruption of the graft position. The physician |

| | |uses angioplasty on all 5 anastomoses to seat the graft, and angioplasty of any or all graft components as |

| | |needed for complete expansion. The physician repositions the flush catheter to the level of the proximal |

| | |anastomosis, and performs the completion arteriogram. Any areas of Type I endoleak or incomplete graft opening |

| | |are re-ballooned as needed. If needed, stents are deployed within the body of the prosthesis to seal endoleaks |

| | |or treat kinks or areas of incomplete opening. The physician performs the final completion arteriogram and |

| | |completion pressure measurements. Finally, he/she removes catheters/wires/sheaths using fluoroscopic |

| | |guidance.The arteriotomies are closed appropriately for the type of arteriotomy used. |

|[pic] |

|34804 |  |Clinical Example (34804) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. Imaging studies indicate that the aneurysm is |

| | |infrarenal with an adequate neck to allow successful deployment of an endovascular prosthesis. Distally the |

| | |aneurysm extends to the end of the aorta, indicating that a bifurcated prosthesis will be required. Iliac |

| | |arteries are of appropriate diameter and length to provide landing zones for the iliac limbs of the prosthesis.|

| | |The iliac artery anatomy should accommodate passage of the device. |

| | |Description of Procedure (34804) |

| | |This procedure commences when the endovascular device and its introducing mechanism are brought onto the |

| | |surgical field. Deployment of a unibody bifurcated prosthesis differs from the modular design in that the first|

| | |steps include passage of the special contralateral iliac limb guidewire into the aorta and capture of this wire|

| | |by a snare advanced through the arteries from the opposite groin. Once completed, this technically demanding |

| | |step allows the contralateral graft limb to be pulled downward from the aorta into that opposite iliac artery. |

| | |Once this step is completed, the delivery sheath is loaded onto the guidewire and advanced to the edge of the |

| | |femoral artery. This sheath is very large in diameter and typically requires incision of up to half of the |

| | |arterial circumference to allow entry. The device is advanced slowly through the femoral and iliac arteries |

| | |into the aorta. It is carefully positioned such that the proximal edge is just below the renal artery origins |

| | |and above the beginning of the aneurysm. Exact position is confirmed by fluoroscopy, using injections of |

| | |contrast. If a selective second catheter has been placed to mark the lower renal artery, it is drawn back into |

| | |the iliac, and the main endovascular device is deployed under fluoroscopic guidance. Fine adjustments in |

| | |position are made during the deployment to assure accurate positioning just below the renal artery origins. In |

| | |some patients the mean arterial pressure is transiently reduced by the anesthesiologist to decrease the chance |

| | |that pressure from flowing blood will push the endograft distally during deployment. After deployment the |

| | |arterial pressure is normalized. The introducer portion of the main device is removed over the guidewire, |

| | |leaving the endograft in position. Some devices require balloon dilatation at the aortic and iliac attachment |

| | |sites to help assure proper seating and hemostatic seal. If this is the case, a large diameter compliant |

| | |balloon is advanced over the wire to the proximal anastomosis, and under fluoroscopic guidance the balloon is |

| | |positioned and inflated. This same balloon may be pulled back and used to seat the iliac anastomosis by using |

| | |an incomplete inflation (since the iliac diameter is smaller than the aorta). In other cases, a balloon better |

| | |matched to the iliac diameter is required, entailing an exchange of balloons over the guidewire. |

| | |The next step is deployment of the contralateral iliac limb. The leading guidewire for this limb has already |

| | |been snared and exits the opposite femoral artery. This wire is carefully retracted, leading the second iliac |

| | |limb across the aortic bifurcation into the appropriate common iliac artery. Further manipulations are done to |

| | |bring the contralateral limb into correct position, and then this limb is deployed. This second iliac limb is |

| | |typically dilated with a compliant balloon (all balloon dilations within the body of the device are included in|

| | |the work of this code). |

| | |When the complete endograft is in place, a pigtail catheter or multi-sidehole catheter is repositioned over one|

| | |of the guidewires, and placed just above the renal arteries for a final angiographic evaluation. An aortogram |

| | |is performed and immediately evaluated for graft position, patency of appropriate branches (renals and |

| | |hypogastrics), presence or absence of endoleaks, and patency of lumbar or inferior mesenteric arteries that may|

| | |contribute to persistent endoleaks. If the graft is in good position and free of endoleaks, the intra-service |

| | |portion of 34802 is complete. Removal of the catheters and guidewires is included in the catheter introduction |

| | |codes (36200-36248) and the arteriotomy and skin closure is included in the femoral artery exposure codes |

| | |34812-34820. |

|[pic] |

|34805 |  |Clinical Example (34805) |

| | |A 67-year-old male with coronary artery disease, status post myocardial infarction and chronic obstructive |

| | |pulmonary disease was found to have a 5.8 cm diameter abdominal aortic aneurysm (AAA) by abdominal exam and |

| | |subsequent ultrasound. Risks and benefits of open surgical repair, endovascular repair, and watchful waiting |

| | |are discussed with the patient, and he opts for repair. History, physical examination, and perioperative risk |

| | |evaluation including cardiac workup are performed to determine the patient's suitability for surgery. Imaging |

| | |studies (typically a combination of CT scan, MRI, and/or angiography) indicate that the aneurysm is infrarenal |

| | |in nature with an adequate neck of normal diameter aorta below the renal artery origins to allow successful |

| | |deployment of endovascular prosthesis. Distally the aneurysm extends to the very end of the aorta. One of the |

| | |patient's common iliac arteries is completely occluded, and an aortouniiliac (AUI) endograft is the appropriate|

| | |choice of prosthesis. |

| | |Description of Procedure (34805) |

| | |A road-mapping arteriogram is performed with specific attention to the renal artery origins. The endovascular |

| | |device is examined to confirm it is the correct model, diameter, length, etc, for the procedure. The carrier |

| | |and contained endograft is prepared by flushing the ports and ensuring that the flow valves are in the correct |

| | |position. Next, the carrier/endograft is moved into place adjacent to the arterial introduction site. The |

| | |patient is anticoagulated with IV heparin. The carrier/endograft is backloaded on a super-stiff wire, and the |

| | |tip of the carrier/endograft is introduced into the arteriotomy site. The proximal vascular clamp is opened and|

| | |the front of the carrier/endograft is advanced into the artery. The rubber constrictors are manipulated and |

| | |adjusted to limit blood loss. Under fluoroscopic guidance, the carrier/endograft is carefully directed through |

| | |the external iliac artery. Next, the carrier/endograft is advanced into the common iliac artery, into the |

| | |aorta, and through the aneurysm so that the tip lies above the renal artery origins. Repeat arteriography is |

| | |performed to confirm the renal origin location. Deployment is begun by slowly backing the carrier away from the|

| | |endograft. Adjustments are made to align the top edge of the endograft just below the renal origins. The |

| | |remainder of the endograft is gently deployed with constant attention to the exact position of the device. |

| | |Final position adjustments to the device are made. The carrier is "wiggled" free of the endograft to ensure |

| | |that the carrier can be removed without malpositioning the endograft device. The carrier is removed. |

| | |Balloon angioplasty is performed at the proximal end of the endograft to complete expansion and seating of the |

| | |device. A smaller balloon is used to complete the expansion and seating of the iliac end of the device. Stents |

| | |are deployed within the body of the endograft device to maintain expansion. |

| | |Completion arteriogram is performed to ensure proper positioning of the endograft device, patency of the major |

| | |branches, and to rule out endoleaks. Finally, completion pressure measurement is taken. |

|[pic] |

|34808 |  |Clinical Example (34808) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. Imaging studies indicate an adequate proximal |

| | |aortic neck to allow deployment of an endovascular prosthesis. Distally there is an appropriate landing zone in|

| | |the aorta to allow placement of a tube graft. The right iliac artery anatomy will accommodate passage of the |

| | |main device. However, there is diffuse, severe arterial occlusive disease involving the entire left common and |

| | |external iliac artery. Thus, it has been decided that the left common iliac will be occluded using endovascular|

| | |technique, and a right-to-left femoral-femoral bypass graft will be placed to reperfuse the left leg. |

| | |Description of Procedure (34808) |

| | |Placement of the iliac occluder device and its introducer onto the guidewire is performed. The device is then |

| | |advanced under fluoroscopic guidance to the exact location where the occlusion is to be performed. Fine |

| | |adjustments under fluoroscopic guidance are made as necessary. The device is deployed and appropriate position |

| | |is confirmed by hand injection of contrast. If required to achieve complete arterial occlusion, additional |

| | |embolization materials may be placed, and this work is included within the work description of this code. The |

| | |device introducer is removed. |

|[pic] |

|34812 |  |Clinical Example (34812) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. Imaging studies indicate an adequate proximal |

| | |aortic neck to allow deployment of an endovascular prosthesis. Distally there is an appropriate landing zone in|

| | |the aorta to allow placement of a tube graft. The right iliac artery anatomy will accommodate passage of the |

| | |main device. |

| | |Description of Procedure (34812) |

| | |A skin incision is made in the inguinal region. The subcutaneous tissue is dissected until the common femoral |

| | |artery is located. Care is taken to avoid injury to the femoral nerve and vein that lie in close proximity. The|

| | |common, superficial, and deep femoral arteries are dissected and captured in vessel loops. The distal external |

| | |iliac artery is typically included in the dissection. This exposure is accomplished by retraction and/or |

| | |division of the inguinal ligament. The extra exposure facilitates introduction of the very large diameter |

| | |sheath required for endovascular AAA repair. It also serves to apply countertraction and temporarily reduce |

| | |tortuosity of the iliac arteries as the sheath is advanced. Hemostasis in the groin is achieved by ligation or |

| | |electrocautery of small branch arteries and veins. Intravenous heparin is administered before the arteries are |

| | |clamped. A transverse arteriotomy is made in the anterior surface of the common femoral or distal-most external|

| | |iliac artery for introduction of the guidewires and sheaths. |

| | |Intra-service work of 34812 resumes after deployment of the device has been completed and all sheaths and |

| | |guidewires have been removed. The arteriotomy is closed with very fine (eg, 6-0 polypropylene) sutures. |

| | |Hemostasis is achieved, the wound is irrigated, and the soft tissue is reapproximated in several layers. Skin |

| | |closure is performed with staples or sutures. |

|[pic] |

|34813 |  |Clinical Example (34813) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. Imaging studies indicate an adequate proximal |

| | |aortic neck to allow deployment of an endovascular prosthesis. Distally there is an appropriate landing zone in|

| | |the aorta to allow placement of a tube graft. The right iliac artery anatomy will accommodate passage of the |

| | |main device. However, there is diffuse, severe arterial occlusive disease involving the entire left common and |

| | |external iliac artery. Thus, it has been decided that the left common iliac will be occluded using endovascular|

| | |technique, and a right-to-left femoral-femoral bypass graft will be placed to reperfuse the left leg. |

| | |Description of Procedure (34813) |

| | |This procedure involves creation of an arching, curved subcutaneous tunnel from one femoral artery to the |

| | |other. A specially designed curved, blunt-nosed tunneling device is used for this purpose. Care is taken not to|

| | |"button-hole" the skin or enter the abdominal cavity. A synthetic conduit is chosen and pulled gently through |

| | |the tunnel using care to avoid twisting or kinking. Intravenous heparin anticoagulant is administered and the |

| | |femoral arteries are clamped with vascular hemostats. An appropriate arteriotomy is fashioned in the common |

| | |femoral and an anastomosis is completed with fine polypropylene sutures. The graft is cut to appropriate length|

| | |and a similar arteriotomy and anastomosis are performed on the opposite side. Vascular clamps are removed and |

| | |hemostasis is obtained. The technical adequacy of the reconstruction is typically checked with handheld |

| | |Doppler. The intra-service work of 34813 is complete at this point. Irrigation and closure of the wounds is |

| | |included in the primary code 34812-50, and not reported separately. |

|[pic] |

|34820 |  |Clinical Example (34820) |

| | |A 67-year-old woman with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. Imaging studies indicate an adequate proximal |

| | |aortic neck to allow deployment of an endovascular prosthesis. Distally there is an appropriate landing zone in|

| | |the aorta to allow placement of a tube graft. Bilateral distal external iliac and common femoral arteries are |

| | |too small in diameter to accommodate passage of the endovascular device. The decision has been made to perform |

| | |surgical exposure of a more proximal segment of iliac artery, where the diameter is larger, to provide a |

| | |suitable entry site for placement of the device. |

| | |Description of Procedure (34820) |

| | |A skin incision is made in the lower abdomen or retroperitoneum. The tissue is dissected deep into the pelvis |

| | |until the iliac artery is located. Care is taken to avoid injury to the nerves, veins, and ureter that lie in |

| | |close proximity. The arteries are dissected and isolated in vessel loops. Hemostasis is achieved by ligation or|

| | |electrocautery. Intravenous heparin is administered before the arteries are clamped. A transverse arteriotomy |

| | |is made in the anterior surface of the iliac artery for introduction of the guidewires and sheaths. |

| | |The intra-service work of 34820 is interrupted until placement of the endovascular device has been completed. |

| | |Once the device is successfully deployed, 34820 resumes with closure of the arteriotomy using fine vascular |

| | |suture, achievement of hemostasis, wound irrigation, and soft tissue reapproximation. Skin is closed with |

| | |sutures or staples. |

|[pic] |

|34825 |  |Clinical Example (34825) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, underwent endovascular repair of a 5.8 cm diameter abdominal aortic aneurysm (AAA). A |

| | |distal anastomotic endoleak is discovered by follow-up CT scan, and its exact nature is confirmed with |

| | |angiography (separately reportable) during post-operative follow-up. A distal endovascular extension will be |

| | |placed to correct the endoleak. (For radiological supervision and interpretation use 75953). |

| | |Description of Procedure (34825) |

| | |This procedure typically begins by passing an adequately large diameter sheath along the guidewire. The |

| | |endovascular extension prosthesis is then advanced over the guidewire within the sheath. The device is |

| | |carefully advanced through the iliac arteries and positioned such that the proximal and distal edges bridge the|

| | |endoleak. Position is confirmed exactly by fluoroscopy, often with injections of contrast. Fine adjustments in |

| | |position are made as needed. When in exactly the right position the extension cuff is deployed. Some devices |

| | |require balloon dilatation to help assure proper seating and hemostatic seal (included in service). If this is |

| | |the case, a large diameter compliant balloon is advanced over the wire, and under fluoroscopic guidance the |

| | |balloon is positioned and inflated. An injection is performed to determine whether the endoleak has been |

| | |sealed. |

|[pic] |

|34826 |  |Clinical Example (34826) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, underwent endovascular repair of a 5.8cm diameter abdominal aortic aneurysm (AAA). An |

| | |endoleak is discovered by follow-up CT scan one year after the procedure, and angiography (separately |

| | |reportable) confirms leaks from one iliac anastomosis as well as from the proximal anastomosis. Endovascular |

| | |extensions will be placed to correct endoleaks in both vessels. |

| | |Description of Procedure (34826) |

| | |This procedure typically begins by passing an adequately large diameter sheath along the guidewire. The |

| | |endovascular extension prosthesis is then advanced over the guidewire within the sheath. The device is |

| | |carefully positioned such that the proximal and distal edges bridge the endoleak. Position is confirmed exactly|

| | |by fluoroscopy, often with injections of contrast. Fine adjustments in position are made to assure exact |

| | |positioning. The extension cuff is deployed. Some devices require balloon dilatation to help assure proper |

| | |seating and hemostatic seal. If this is the case, a large diameter compliant balloon is advanced over the wire,|

| | |and under fluoroscopic guidance the balloon is positioned and inflated. An injection is performed to determine |

| | |whether the endoleak has been sealed. |

|[pic] |

|34830 |  |Clinical Example (34830) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction has a 5.8 cm. infrarenal aortic aneurysm. He undergoes attempted endovascular repair, but|

| | |after the procedure has been underway for 5 hours it is determined that the endoprosthesis cannot be completed |

| | |successfully. The main body of the device is lodged in the distal infrarenal aorta. |

| | |Description of Procedure (34830) |

| | |This procedure includes dissection of the abdominal contents and exposure of the aorta. Proximal and distal |

| | |exposure of the aorta above and below the aneurysm are accomplished. This exposure is typically more extensive |

| | |than during routine elective AAA repair due to malpositioned or traumatized vessels. Intravenous heparin is |

| | |administered for anticoagulation, and the blood flow in the aneurysm is stopped by application of large |

| | |vascular hemostats. The aneurysm is opened, bleeding lumbar arteries are suture ligated, and thrombus is |

| | |removed. Any lodged pieces of endograft are removed. The proximal anastomosis of the prosthesis is sutured to |

| | |normal, healthy, untraumatized aorta above the aneurysm. The proximal clamp is removed and the anastomosis |

| | |tested for hemostasis. Additional sutures are placed as required. The distal anastomosis is carried out in a |

| | |similar manner at the distal-most infrarenal aorta. Following completion of all anastomoses, the vascular |

| | |clamps are removed and blood flow is restored. Anticoagulation is reversed and hemostasis achieved. All wounds |

| | |are irrigated and closed in layers. |

|[pic] |

|34831 |  |Clinical Example (34831) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. He undergoes attempted endovascular repair, |

| | |but after the procedure has been underway for 5 hours it is determined that the endoprosthesis cannot be |

| | |completed successfully. The main body of the device is lodged in the distal infrarenal aorta. |

| | |Description of Procedure (34831) |

| | |This procedure includes dissection of the abdominal contents and exposure of the aorta. Proximal and distal |

| | |exposure of the aorta above and below the aneurysm are accomplished. This exposure is typically more extensive |

| | |than during routine elective AAA repair due to malpositioned or traumatized vessels. Intravenous heparin is |

| | |administered for anticoagulation, and the blood flow in the aneurysm is stopped by application of large |

| | |vascular hemostats. The aneurysm is opened, bleeding lumbar arteries are suture ligated, and thrombus is |

| | |removed. Any lodged pieces of endograft are removed. The proximal anastomosis of a bifurcated prosthesis is |

| | |sutured to normal, healthy, untraumatized aorta above the aneurysm. The proximal clamp is removed and the |

| | |anastomosis tested for hemostasis. Additional sutures are placed as required. The distal anastomoses are |

| | |carried out in a similar manner to the iliac arteries. Following completion of all anastomoses, the vascular |

| | |clamps are removed and blood flow is restored. Anticoagulation is reversed and hemostasis achieved. All wounds |

| | |are irrigated and closed in layers. |

|[pic] |

|34832 |  |Clinical Example (34832) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. infrarenal aortic aneurysm. He undergoes attempted endovascular repair, |

| | |but after the procedure has been underway for five hours it is determined that the endoprosthesis cannot be |

| | |completed successfully. The main body of the device is lodged in the distal infrarenal aorta. |

| | |Description of Procedure (34832) |

| | |This procedure includes dissection of the abdominal contents and exposure of the aorta. Proximal and distal |

| | |exposure of the aorta above and below the aneurysm are accomplished. This exposure is typically more extensive |

| | |than during routine elective AAA repair due to malpositioned or traumatized vessels. Intravenous heparin is |

| | |administered for anticoagulation, and the blood flow in the aneurysm is stopped by application of large |

| | |vascular hemostats. The aneurysm is opened, bleeding lumbar arteries are suture ligated, and thrombus is |

| | |removed. Any lodged pieces of endograft are removed. The proximal anastomosis of a bifurcated prosthesis is |

| | |sutured to normal, healthy, untraumatized aorta above the aneurysm. The proximal clamp is removed and the |

| | |anastomosis tested for hemostasis. Additional sutures are placed as required. Since the distal common iliac |

| | |arteries or external iliacs are involved with the aneurysm or have been traumatized during the endovascular |

| | |procedure, the prosthetic limbs are tunneled through the pelvis with anastomoses performed at the femoral |

| | |artery level. Following completion of all anastomoses, the vascular clamps are removed and blood flow is |

| | |restored. Anticoagulation is reversed and hemostasis achieved. All wounds are irrigated and closed in layers. |

|[pic] |

|34833 |  |Clinical Example |

| | |A 65-year-old female smoker with hypertension, chronic obstructive pulmonary disease (COPD), and previous |

| | |myocardial infarction (MI) has a 7-cm infrarenal aortic aneurysm. Her iliac arteries are very small in caliber |

| | |and heavily calcified. Placement of an iliac conduit will be required to enable endovascular aortic aneurysm |

| | |repair. |

| | |Description of Procedure |

| | |Every patient requires individualized assessment and surgical approach, and every surgeon has his or her own |

| | |“best” method to accomplish an operation. Realizing that, a typical case may include the following steps. |

| | |A skin incision is made. Access to the iliac artery is achieved via a transabdominal or retroperitoneal |

| | |approach. All soft tissue, bowels, ureters, and veins are carefully mobilized as the iliac artery is |

| | |approached. The artery is cleared for 5 to 6 cm, and vessel loops are passed around the vessel proximally and |

| | |distally. Once adequate exposure is achieved and intravenous heparin anticoagulation is administered, proximal |

| | |and distal vascular clamps are applied. A longitudinal arteriotomy is made. The conduit (a large-diameter |

| | |tubular segment of synthetic bypass graft) is brought onto the field, tailored to the appropriate size, and an |

| | |anastomosis of conduit to the iliac artery is sutured with fine polypropylene. The conduit is clamped and |

| | |vascular clamps are removed from the iliac artery. The suture line is checked for hemostasis and additional |

| | |sutures are applied as required. |

| | |Endovascular repair (separately reportable) is undertaken with the prostheses introduced through the newly |

| | |formed conduit. |

| | |Once endovascular repair is complete, closure of the conduit is achieved in one of two ways. The unattached |

| | |distal end of the conduit may be sewn to the more distal external iliac artery, thereby leaving the conduit in |

| | |place as a common channel to external iliac bypass graft. Alternatively, the conduit can be transected close to|

| | |the iliac artery and oversewn with a polypropylene suture. Hemostasis is achieved. The wound is irrigated and |

| | |closed in layers. |

|[pic] |

|34834 |  |Clinical Example |

| | |A 65-year-old female smoker with hypertension, COPD, and previous MI has a 7-cm infrarenal aortic aneurysm. Her|

| | |iliac arteries are tortuous. Exposure of the brachial artery is performed to insert a guide to enable |

| | |endovascular aortic aneurysm repair. |

| | |Description of Procedure |

| | |Every patient requires individualized assessment and surgical approach, and every surgeon has his or her own |

| | |“best” method to accomplish an operation. Realizing that, a typical case may include the following steps. |

| | |A skin incision is made. Access to the brachial artery is achieved via an upper arm incision. All soft tissue, |

| | |nerves, and veins are carefully mobilized as the brachial artery is approached. The artery is cleared for 5 to |

| | |6 cm, and soft vessel loops are passed around the artery proximally and distally. Once adequate exposure is |

| | |achieved and intravenous heparin anticoagulation administered, proximal and distal vascular clamps are applied |

| | |and removed as required for subsequent introduction of wires, sheaths, and catheters. |

| | |The endovascular procedure is performed (and separately reported). |

| | |Upon completion of the endovascular procedure, vascular clamps are reapplied. The large hole in the brachial |

| | |artery is irrigated, the edges are trimmed as needed, and it is closed with fine polypropylene sutures. The |

| | |suture line is checked for hemostasis and additional sutures are applied as required. The wound is irrigated |

| | |and closed in layers. |

|[pic] |

|34900 |  |Clinical Example (34900) |

| | |A 67-year-old male with coronary artery disease status post MI plus chronic obstructive pulmonary disease has a|

| | |5-cm-diameter iliac artery aneurysm. Imaging studies indicate the aneurysm is suitable for endovascular repair.|

| | |Description of Service (34900) |

| | |This procedure begins after achieving arterial exposure (eg, 34812) and after initial catheter and guidewire |

| | |placements (typically reported by codes 36200, 36245-36248). These services are separately reportable and |

| | |subject to multiple procedure payment reduction rules. |

| | |The endovascular device is loaded onto the guidewire and advanced into the patient. Depending on the device |

| | |chosen, this may or may not be done through a large introducer sheath. The device is carefully manipulated |

| | |through adjacent arteries toward the deployment target. It is carefully positioned such that the proximal edge |

| | |lies in normal-caliber vessel proximal to the beginning of the aneurysm. Position is confirmed exactly by |

| | |fluoroscopy, often with injection of contrast. The device is then deployed under exacting fluoroscopic |

| | |guidance. Fine adjustments in position are made during the deployment to assure accurate deployment. In some |

| | |patients the mean arterial pressure is transiently reduced by the anesthesiologist to decrease the chance that |

| | |pressure from flowing blood will push the endograft distally during deployment. After deployment the arterial |

| | |pressure is normalized. The introducer portion of the main device is removed over the guidewire, leaving the |

| | |endograft in position. |

| | |Some devices require balloon dilatation at the proximal and distal landing zones to help assure proper seating |

| | |and hemostatic seal with the arterial wall. If this is the case, a large-diameter balloon is advanced over the |

| | |wire, and using fluoroscopic guidance the balloon is positioned and inflated. This same balloon may be |

| | |repositioned to fully expand and seat the remainder of the endoprosthesis. |

| | |Once the complete endograft is in place, a pigtail catheter or multi-sidehole catheter is repositioned over one|

| | |of the guidewires, and placed just above the proximal endograft for a final angiographic evaluation. If the |

| | |graft is in good position and free of endoleaks, the catheters and guidewires are removed. |

| | |Closure of the arteriotomy(s) and arterial exposure site(s) is included in the work of the exposure codes. |

|[pic] |

|35301 |  |Clinical Example (35301) |

| | |A 75-year-old male with a history of a left cerebral hemisphere transient ischaemic attack is diagnosed with an|

| | |85% stenosis of this left carotid artery and a 60% stenosis of his right internal carotoid artery upon invasive|

| | |vascular evaluation. Appropriate invasive monitoring is done with the insertion of an arterial line. A catheter|

| | |and sequential compression devices are applied. After appropriate positioning of the patient, he undergoes a |

| | |standard left carotid endarterectomy utilizing cerebral perfusion precautions. The patient becomes hypertensive|

| | |in the recovery room and receives oral pharmacologic management for 24 hours. The postoperative course is |

| | |uneventful and he is discharged from the hospital on the third postoperative day. |

| | |Description of Procedure (35301) |

| | |The neck is incised along the anterior border of the sternocleidomastoid muscle, and the soft tissue is |

| | |dissected away from the carotid sheath. The common carotid, internal carotid, and external carotid arteries are|

| | |exposed, mobilized, and encircled, with care taken not to injure the vagus or hypoglossal nerves. Systemic |

| | |anticoagulation is administered, the arteries are clamped, and the common carotid artery is opened |

| | |longitudinally. This incision is carried across the bifurcation, onto the internal carotid artery, and beyond |

| | |the terminus of the obstructive plaque. Intraoperative electroencephalography recording is sometimes used in |

| | |this portion of the operation to follow brain function during blood flow interruption. A shunt may be inserted |

| | |for cerebral perfusion if required. |

| | |Using magnification loupes, the surgeon dissects the plaque from the common, external, and internal carotid |

| | |arteries. The endarterectomy site is inspected carefully, searching for residual remnants of plaque, which are |

| | |removed. Fine sutures are used to tack down any distal shelf at the endpoint of the endarterectomy in the |

| | |internal carotid. When the surgeon is confident that no loose segments of plaque remain within the vessel, the |

| | |arteriotomy is closed. Often a diamond-shaped synthetic or venous patch is incorporated in this arterial suture|

| | |line to increase the diameter of the artery. If a shunt has been used, it is removed just prior to completion |

| | |of the arterial closure. Vascular clamps are released with reinitiation of blood flow, and hemostasis of the |

| | |suture line is achieved. The incision is closed in three layers. |

|[pic] |

|35302 |  |Clinical Example (35302) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has an irregular bulky plaque causing a critical |

| | |stenosis of his superficial femoral artery. Because of the size and location of this plaque, he is felt not to |

| | |be a candidate for percutaneous intervention. A thromboendarterectomy is performed. |

| | |Description of Procedure (35302) |

| | |Initial dissection: The skin is incised overlying the superficial femoral artery, and the soft tissue is |

| | |dissected until the artery is located. The artery is circumferentially dissected and mobilized with a soft |

| | |rubber loop for control. The dissection is extended proximally and distally to gain appropriate starting and |

| | |endpoints. |

| | |Vein harvest for patch graft, if performed: Attention is shifted to the vein harvest, which is usually |

| | |predetermined and previously prepped. The skin is incised through the soft tissue to find the vein. The vein is|

| | |carefully dissected out with all of the side branches, tied, and divided. The original operative site is |

| | |checked to ensure that a sufficient length of vein is exposed. The vein is clamped and the segment excised for |

| | |use as a patch graft. The transected ends of the vein that remain in the patient are ligated. The harvested |

| | |segment of the vein is opened and examined on the back table to ensure suitability. The vein is cropped to the |

| | |shape required to serve as a patch, and preserved in heparinized saline until time for use. |

| | |Endarterectomy: Intravenous anticoagulant is administered and vascular clamps are applied to the artery. The |

| | |artery is incised and the arteriotomy carried across the length of the vessel to be treated. The internal |

| | |pathology of the artery is assessed to ensure that the endarterectomy will be effective. The endarterectomy is |

| | |performed by careful excision of the plaque, intima, and most of the media, leaving the adventitia. The |

| | |endarterectomy site is irrigated with heparinized saline and is inspected carefully to ensure that all loose |

| | |plaque fragments have been removed. The patch graft is used, if necessary, and the arteriotomy is closed. |

| | |Before closing the suture line, all vessels are flushed to remove all air and debris, and the suture line is |

| | |completed. The vascular clamps are released and the site is assessed for leaks. Additional sutures are applied |

| | |as needed. The anticoagulant reversal agent is administered with close observation. The wound is irrigated with|

| | |sterile saline and electrocautery or suture ligation is used to achieve final hemostasis. The wound is closed |

| | |in multiple layers, with special attention paid to the reoperative site. The skin is closed. A handheld Doppler|

| | |assessment is oftentimes used to ensure adequate blood flow to the foot prior to leaving the operating room. |

| | |Closure of vein harvest, if performed: At the vein harvest site, electrocautery or suture ligation is used to |

| | |achieve final hemostasis. The wound is copiously irrigated with sterile saline. The harvest site is closed in |

| | |layers. |

|[pic] |

|35303 |  |Clinical Example (35303) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking and an ischemic foot ulcer has an irregular bulky|

| | |plaque causing a critical stenosis of his popliteal artery. Because of the size and location of this plaque, he|

| | |is felt not to be a candidate for percutaneous intervention. A thromboendarterectomy is performed. |

| | |Description of Procedure (35303) |

| | |Initial dissection: The skin is incised overlying the popliteal artery, and the soft tissue is dissected until |

| | |the artery is located. The artery is circumferentially dissected and mobilized with a soft rubber loop for |

| | |control. The dissection is extended proximally and distally to gain appropriate starting and endpoints. |

| | |Vein harvest, if performed: Attention is shifted to the vein harvest, which is usually predetermined and |

| | |previously prepped. The skin is incised through the soft tissue to find the vein. The vein is carefully |

| | |dissected out with all of the side branches, tied, and divided. The original operative site is checked to |

| | |ensure that a sufficient length of vein is exposed. The vein is clamped and the segment excised for use as a |

| | |patch graft. The transected ends of the vein that remain in the patient are ligated. The harvested segment of |

| | |the vein is opened and examined on the back table to ensure suitability. The vein is cropped to the shape |

| | |required to serve as a patch, and preserved in heparinized saline until time for use. |

| | |Intraservice work for endarterectomy: Intravenous anticoagulant is administered and vascular clamps are applied|

| | |to the artery. The artery is incised and the arteriotomy carried across the length of the vessel to be treated.|

| | |The internal pathology of the artery is assessed to ensure that the endarterectomy will be effective. The |

| | |endarterectomy is performed by careful excision of the plaque, intima, and most of the media, leaving the |

| | |adventitia. The endarterectomy site is irrigated with heparinized saline and is inspected carefully to ensure |

| | |that all loose plaque fragments have been removed. The arteriotomy closure is begun, using the patch graft at |

| | |this point if deemed necessary. |

| | |Prior to completing the arteriotomy closure, all vessels are flushed to remove all air and debris. The suture |

| | |line is completed. The vascular clamps are released and the site is assessed for leaks. Additional sutures are |

| | |applied as needed. The anticoagulant reversal agent is administered with close observation. The wound is |

| | |irrigated with sterile saline and electrocautery or suture ligation is used to achieve final hemostasis. The |

| | |wound is closed in multiple layers, with special attention paid to the reoperative site. The skin is closed. A |

| | |handheld Doppler assessment is oftentimes used to ensure adequate blood flow to the foot prior to leaving the |

| | |operating room. |

| | |Vein harvest site closure: At the vein harvest site, electrocautery or suture ligation is used to achieve final|

| | |hemostasis. The wound is copiously irrigated with sterile saline. The harvest site is closed in layers. |

|[pic] |

|35304 |  |Clinical Example (35304) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking and an ischemic foot ulcer has an irregular bulky|

| | |plaque causing a critical stenosis of his tibioperoneal trunk artery. Because of the size and location of this |

| | |plaque, he is felt not to be a candidate for percutaneous intervention. A thromboendarterectomy is performed. |

| | |Description of Procedure (35304) |

| | |Initial dissection: The skin is incised overlying the tibioperoneal trunk artery, and the soft tissue is |

| | |dissected until the artery is located. The artery is circumferentially dissected and mobilized and encircled |

| | |with a soft rubber loop for control. The dissection is extended proximally and distally to gain appropriate |

| | |starting and endpoints. |

| | |Vein harvest, if performed: Attention is shifted to the vein harvest, which is usually predetermined and |

| | |previously prepped. The skin is incised through the soft tissue to find the vein. The vein is carefully |

| | |dissected out with all of the side branches, tied, and divided. The original operative site is checked to |

| | |ensure that a sufficient length of vein is exposed. The vein is clamped and the segment excised for use as a |

| | |patch graft. The transected ends of the vein that remain in the patient are ligated. The harvested segment of |

| | |the vein is opened and examined on the back table to ensure suitability. The vein is cropped to the shape |

| | |required to serve as a patch, and preserved in heparinized saline until time for use. |

| | |Endarterectomy: Intravenous anticoagulant is administered and vascular clamps are applied to the artery. The |

| | |artery is incised and the arteriotomy carried across the length of the vessel to be treated. The internal |

| | |pathology of the artery is assessed to ensure that the endarterectomy will be effective. The endarterectomy is |

| | |performed by careful excision of the plaque, intima, and most of the media, leaving the adventitia. The |

| | |endarterectomy site is irrigated with heparinized saline and is inspected carefully to ensure that all loose |

| | |plaque fragments have been removed. At this point, if a patch graft is deemed necessary it is included in the |

| | |arteriotomy closure. |

| | |Prior to finishing the arteriotomy closure, all vessels are flushed to remove all air and debris. The suture |

| | |line is completed. The vascular clamps are released and the site is assessed for leaks. Additional sutures are |

| | |applied as needed. The anticoagulant reversal agent is administered with close observation. The wound is |

| | |irrigated with sterile saline and electrocautery or suture ligation is used to achieve final hemostasis. The |

| | |wound is closed in multiple layers, with special attention paid to the reoperative site. The skin is closed. A |

| | |handheld Doppler assessment is oftentimes used to ensure adequate blood flow to the foot prior to leaving the |

| | |operating room. |

| | |Vein harvest site closure: If a vein has been harvested, that site also needs closure. Electrocautery or suture|

| | |ligation is used to achieve final hemostasis, with copious irrigation using sterile saline. A layered closure |

| | |of the harvest site is performed. |

|[pic] |

|35305 |  |Clinical Example (35305) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking and an ischemic foot ulcer has an irregular bulky|

| | |plaque causing a critical stenosis of his anterior tibial artery. Because of the size and location of this |

| | |plaque, he is felt not to be a candidate for percutaneous intervention. A thromboendarterectomy is performed. |

| | |Description of Procedure (35305) |

| | |Initial dissection: The skin is incised overlying the anterior tibial, posterior tibial, or peroneal artery, |

| | |and the soft tissue is dissected until the artery is located. The artery is circumferentially dissected, |

| | |mobilized and encircled with a soft rubber loop for control. The dissection is extended proximally and distally|

| | |to gain appropriate starting and endpoints. |

| | |Vein harvest, if performed: Attention is shifted to the vein harvest, which is usually predetermined and |

| | |previously prepped. The skin is incised through the soft tissue to find the vein. The vein is carefully |

| | |dissected out with all of the side branches, tied, and divided. The original operative site is checked to |

| | |ensure that a sufficient length of vein is exposed. The vein is clamped and the segment excised for use as a |

| | |patch graft. The transected ends of the vein that remain in the patient are ligated. The harvested segment of |

| | |the vein is opened and examined on the back table to ensure suitability. The vein is cropped to the shape |

| | |required to serve as a patch, and preserved in heparinized saline until time for use. |

| | |Endarterectomy: Intravenous anticoagulant is administered and vascular clamps are applied to the artery. The |

| | |artery is incised and the arteriotomy carried across the length of the vessel to be treated. The internal |

| | |pathology of the artery is assessed to ensure that the endarterectomy will be effective. The endarterectomy is |

| | |performed by careful excision of the plaque, intima, and most of the media, leaving the adventitia. The |

| | |endarterectomy site is irrigated with heparinized saline and is inspected carefully to ensure that all loose |

| | |plaque fragments have been removed. A patch graft is applied at this point if deemed necessary. |

| | |Prior to completing the arteriotomy closure, all vessels are flushed to remove all air and debris, and the |

| | |suture line is completed. The vascular clamps are released and the site is assessed for leaks. Additional |

| | |sutures are applied as needed to achieve hemostatis. The anticoagulant reversal agent is administered with |

| | |close observation. The wound is copiously irrigated with sterile saline and electrocautery or suture ligation |

| | |is used to achieve final hemostasis. The wound is closed in multiple layers, and the skin is closed. A handheld|

| | |Doppler assessment is oftentimes used to ensure adequate blood flow to the foot prior to leaving the operating |

| | |room. |

| | |Vein harvest site closure: If a vein has been harvested this site is also closed. Electrocautery or suture |

| | |ligation is used to achieve final hemostasis, copious irrigation using sterile saline. The harvest site is |

| | |closed in layers. |

|[pic] |

|35306 |  |Clinical Example (35306) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking and an ischemic foot ulcer has an irregular bulky|

| | |plaque causing a critical stenosis of his anterior tibial and peroneal arteries. Because of the size and |

| | |location of this plaque, he is felt not to be a candidate for percutaneous intervention, and anterior tibial |

| | |endarterectomy has been performed. The Doppler blood flow signals in his foot have not improved. A |

| | |thromboendarterectomy of the peroneal artery is performed. |

| | |Description of Procedure (35306) |

| | |Initial dissection: The skin is incised overlying the additional tibial artery, and the soft tissue is |

| | |dissected until the artery is located. The artery is circumferentially dissected, mobilized, and encircled with|

| | |a soft rubber loop for control. The dissection is extended proximally and distally to gain appropriate starting|

| | |and endpoints. |

| | |Vein harvest, if performed: Attention is shifted to the vein harvest, which is usually predetermined and |

| | |previously prepped. The skin is incised through the soft tissue to find the vein. The vein is carefully |

| | |dissected out with all of the side branches, tied, and divided. The original operative site is checked to |

| | |ensure that a sufficient length of vein is exposed. The vein is clamped and the segment excised for use as a |

| | |patch graft. The transected ends of the vein that remain in the patient are ligated. The harvested segment of |

| | |the vein is opened and examined on the back table to ensure suitability. The vein is cropped to the shape |

| | |required to serve as a patch, and preserved in heparinized saline until time for use. |

| | |Endarterectomy: Intravenous anticoagulant is administered and vascular clamps are applied to the artery. The |

| | |artery is incised and the arteriotomy carried across the length of the vessel to be treated. The internal |

| | |pathology of the artery is assessed to ensure that the endarterectomy will be effective. The endarterectomy is |

| | |performed by careful excision of the plaque, intima, and most of the media, leaving the adventitia. The |

| | |endarterectomy site is irrigated with heparinized saline and is inspected carefully to ensure that all loose |

| | |plaque fragments have been removed. Arteriotomy closure is begun, employin the patch graft at this point, if |

| | |deemed necessary. |

| | |Prior to finishing the arteriotomy closure, all vessels are flushed to remove all air and debris. The suture |

| | |line is completed. The vascular clamps are released and the site is assessed for leaks. Additional sutures are |

| | |applied as needed. The anticoagulant reversal agent is administered with close observation. The wound is |

| | |irrigated with sterile saline and electrocautery or suture ligation is used to achieve final hemostasis. The |

| | |wound is closed in multiple layers, with special attention paid to the reoperative site. The skin is closed. A |

| | |handheld Doppler assessment is oftentimes used to ensure adequate blood flow to the foot prior to leaving the |

| | |operating room. |

| | |Vein harvest site closure: If a vein patch has been harvested, closure is performed. Electrocautery or suture |

| | |ligation is used to achieve final hemostasis, with copious irrigation using sterile saline and layered closure |

| | |of the site. |

|[pic] |

|35500 |  |A 68-year-old man presented with nonhealing gangrene of the base of toes 3 and 4 of the right foot. This |

| | |patient was admitted for planned lowerextremity revascularization for limb salvage. Because of the advanced |

| | |peripheral vascular disease and the potential for poor wound healing, the goal was to use minimal incision |

| | |sites in performing this operation. A right femoraldorsalis pedis in situ saphenous vein bypass was performed |

| | |with angioscopy for venous valve lysis, identification of side branch ligation, and visualization of distal |

| | |anastomosis and distal dorsalis pedis artery. |

|[pic] |

|35501 |  |Clinical Example (35501) |

| | |A 68-year-old cigarette-smoking, hyperlipidemic, hypertensive, diabetic female underwent carotid artery |

| | |stenting for a critical stenosis of the carotid bifurcation 2 years ago. Subsequently, she developed early |

| | |recurrent stenosis on three separate occasions, each requiring percutaneous retreatment. She returns 3 months |

| | |after the most recent intervention with yet another critically severe stenosis and hemispheric transient |

| | |ischemic attacks. She is deemed not a candidate for further percutaneous intervention. A bypass graft using |

| | |vein conduit is recommended. It will extend from her proximal cervical common carotid artery to the distal |

| | |extracranial internal carotid artery beyond the region of multiply recurrent stenosis. |

| | |Description of Procedure (35501) |

| | |Initial dissection: Incise the skin from posterior to the ear lobe along the anterior border of the |

| | |sternocleidomastoid muscle to the clavicle. Divide the platysma muscle. Dissect through the soft tissue until |

| | |the carotid sheath is located. Dissect the jugular vein away from the carotid artery. Divide the facial vein |

| | |and suture ligate it. Locate and avoid the vagus nerve. Identify the common carotid artery at the base of the |

| | |neck. Circumferentially dissect the artery and pass a soft rubber loop around it for control. Extend the |

| | |dissection distally to expose the bifurcation, proximal external, and internal carotid artery (ICA). Mobilize |

| | |and avoid the cranial nerves X and XII as needed to reach a normal segment of the ICA. Divide the digastric |

| | |muscle as needed to reach a normal segment of the ICA. Sublux the jaw, if needed, to reach a normal segment of |

| | |the ICA. Pass loops around each artery for control. Identify the superior thyroid artery, dissect it free, and |

| | |pass fine rubber loop around it for the control vein. |

| | |Shift attention to the vein harvest site, which is usually predetermined and previously prepped. Incise the |

| | |skin over the vein. Dissect through soft tissue to find the vein. Carefully dissect out a vein, tying and |

| | |dividing all side branches. Check original operative site to ensure that a sufficient length of vein is |

| | |exposed. Clamp the vein and excise the segment to be used for bypass. Ligate the transected ends of the vein |

| | |that remain in the patient. Examine the removed segment of the vein on the back table to ensure suitability. |

| | |Prepare the vein by gentle distension and suture any leaks with monofilament. Preserve the vein in heparinized |

| | |saline until time for use. |

| | |Perform a final check to ensure that there is sufficient proximal and distal arterial control beyond the |

| | |stented region. Administer anticoagulant and wait for the effect. Apply a vascular clamp to the ICA beyond the |

| | |diseased/stented area. Apply the vascular clamp to the external carotid artery. Apply a vascular clamp to the |

| | |common carotid artery (CCA) proximal to diseased/stented area. |

| | |Incise the CCA proximal to the stented/stenotic portion and carry the arteriotomy across the length of vessel |

| | |to a normal portion of the distal ICA. Remove the old stents, using wire-cutters if necessary. Place vein |

| | |conduit on a soft plastic shunt and insert the proximal end of the shunt into the CCA after opening the clamp. |

| | |Declamp the CCA around the shunt. Test the shunt to ensure arterial inflow. Open the distal ICA clamp and |

| | |insert the distal end of the shunt. Backbleed as needed to remove all air from the shunt. Reestablish blood |

| | |flow to the brain by opening the shunt. |

| | |Transect the CCA and prepare the proximal normal segment for proximal anastomosis. Perform a proximal |

| | |anastomosis of the vein conduit to the CCA with a fine suture. Irrigate the site with heparinized saline, |

| | |inspecting it carefully to remove all loose plaque fragments. Test the anastomosis for leaks and apply any |

| | |additional sutures as needed to achieve hemostasis. |

| | |Prepare the distal internal carotid for anastomosis, transecting the ICA at a segment of normal artery. Trim |

| | |the vein to the appropriate length. Perform a distal anastomosis of the vein conduit to the ICA with a fine |

| | |suture. Before closing the suture line, flush all vessels to remove air and debris. Complete the suture line. |

| | |Remove the vascular clamps and check for leaks. Apply additional sutures as needed to seal all leaks. |

| | |Administer the anticoagulant reversal agent and wait for it to take effect. Irrigate the wound copiously with |

| | |sterile saline. Use electrocautery or suture ligation to achieve final hemostasis. Close the subcutaneous |

| | |tissue and the skin in multiple layers paying special attention to the skin edges. Close te vein harvest site |

| | |in a similar manner. |

|[pic] |

|35506 |  |Clinical Example (35506) |

| | |A 70-year-old female with classic subclavian steal symptoms is found to have a complete occlusion of the left |

| | |subclavian artery at its origin. Blood flow in the left vertebral artery is retrograde, filling the distal |

| | |subclavian and thereby perfusing the arm. Prior attempts to recanalize the subclavian origin by interventional |

| | |techniques have been unsuccessful. A carotid-subclavian bypass graft is performed using a vein conduit. |

| | |Description of Procedure (35506) |

| | |Incise the skin of the neck overlying the common carotid artery. Dissect the soft tissue to expose the carotid |

| | |artery, avoiding injury to the multiple nearby nerves and veins. Clear the soft tissue from a 6-cm section of |

| | |the carotid artery Pass soft rubber loops around the artery for control. |

| | |Incise the skin overlying the subclavian artery. (This may be an extension of the carotid incision.) Dissect |

| | |the soft tissue from around the subclavian artery, avoiding nerve/vein injury. Pass soft rubber loops around |

| | |the artery for control. Create a plane from the exposed carotid artery to the subclavian target site. |

| | |Harvest the vein conduit. Incise the skin of the thigh/calf over the saphenous vein. Dissect the soft tissue to|

| | |identify the saphenous vein. Clear the soft tissue from around the saphenous vein for adequate length. Ligate |

| | |and divide all of the saphenous vein branches. Ligate and divide the ends of the saphenous vein and remove the |

| | |vein from the lower extremity. Test the saphenous vein conduit for leaks and repair the leaks with vascular |

| | |suture. |

| | |Perform the proximal anastomosis. Anticoagulate the patient with intravenous heparin. Apply vascular clamps to |

| | |the proximal anastomosis site on the carotid artery. Carefully perform the arteriotomy. Perform 90% of the |

| | |anastomosis (vein conduit to carotid artery) with fine vascular sutures. Open the clamps briefly to flush the |

| | |system, and therefore, remove the air and debris from the anastomosis segment. Complete the anastomosis and |

| | |remove the arterial clamps. Apply any additional sutures as needed to control hemorrhage. Pass the vein conduit|

| | |through the appropriate plane to the subclavian artery with care to avoid any twists/kinks. |

| | |Perform the distal anastomosis. Stretch the vein to full length. Apply vascular clamps to the subclavian artery|

| | |with care to avoid any nerves, veins, etc. Carefully perform the subclavian arteriotomy. Cut the vein conduit |

| | |to exactly match the length and size of the arteriotomy. Perform 90% of the vein-to-subclavian artery |

| | |anastomosis with fine vascular sutures. Open the clamps briefly to flush out any air and debris. Complete the |

| | |anastomosis. Remove the vascular clamps. Apply any additional sutures as required to achieve hemostasis. Listen|

| | |with the Doppler and palpate the distal pulses to assure bypass patency. Irrigate all three of the incisions. |

| | |Achieve wound hemostasis. Close all three of the incisions in multiple layers. Recheck the pulses to assure |

| | |patency before applying the sterile dressings. |

|[pic] |

|35509 |  |Clinical Example (35509) |

| | |A 68-year-old cigarette-smoking, hyperlipidemic, hypertensive, diabetic female complains of right hemispheric |

| | |transient ischemic attacks and a severe sense of lightheadedness. Diagnostic evaluation reveals a complete |

| | |occlusion of her innominate artery. The right internal carotid artery is patent, fed by retrograde flow in the |

| | |external carotid. Blood flow in the patient's right vertebral artery is retrograde, supplying her right |

| | |subclavian artery distribution. The left common carotid artery is widely patent. A left-to-right |

| | |carotid-carotid bypass graft is performed using vein conduit. |

| | |Description of Procedure (35509) |

| | |Incise the skin from the ear lobe to the clavicle along the anterior border of the sternocleidomastoid muscle. |

| | |Divide the platysma muscle. Dissect through the soft tissues until the carotid sheath is located. Dissect the |

| | |jugular vein away from carotid artery. Divide the facial vein and suture-ligate the divided ends. Locate and |

| | |avoid the vagus nerve. Identify the common carotid artery. Circumferentially dissect the common carotid artery |

| | |(CCA) and pass a soft rubber loop around the vessel for control. Dissect and expose the carotid bifurcation, |

| | |including distal common carotid, proximal external carotid, and internal carotid end points. Pass loops around |

| | |each artery for control. |

| | |All of the above steps are repeated. Create a tunnel from one side of neck to the other, usually |

| | |retropharyngeal. |

| | |Perform the vein harvest. Shift attention to the vein harvest site, which is usually predetermined and |

| | |previously prepped. Incise the skin over the vein. Dissect through the soft tissue to find the vein. Carefully |

| | |dissect out the vein, tying and dividing all of the side branches. Check the original operative site to ensure |

| | |that a sufficient length of vein is exposed. Clamp the vein and excise the segment to be used for bypass. |

| | |Ligate the transected ends of the vein that remain in the patient. Examine the removed segment of the vein on |

| | |the back table to ensure suitability. Prepare the vein by gentle distension and suture any leaks with |

| | |monofilament. Preserve the vein in heparinized saline until time for use. |

| | |Perform the proximal anastomosis. Administer heparin or other intravenous anticoagulant agent and wait for the |

| | |effect. Apply vascular clamps to the inflow CCA. Incise the CCA to create a longitudinal arteriotomy. Bevel the|

| | |vein conduit to match the length of arteriotomy. Perform a proximal anastomosis in an end-of-vein to a |

| | |side-of-artery fashion. Prior to completion of the anastomosis, remove the clamps briefly to flush out air and |

| | |debris. Finish the last stitches of the anastomosis. Remove the clamps and examine for any leaks. Apply any |

| | |additional sutures as needed to seal all remaining leaks. |

| | |Pass the vein graft through the tunnel to the opposite side of the neck. Check the vein to ensure that there |

| | |are no kinks. Transiently open the clamp to check for adequate inflow of blood. |

| | |Perform the distal anastomosis. Place vascular clamps on the common carotid, internal carotid, and external |

| | |carotid arteries. Perform the longitudinal arteriotomy. Trim the vein graft to the appropriate length and bevel|

| | |the end to match the arteriotomy length. Place the shunt from the vein graft into the internal carotid artery, |

| | |if required. Perform the anastomosis using fine suture. Flush out all air and debris before completing the |

| | |anastomosis. Remove the shunt. Complete the anastomosis. Remove all of the clamps and test for any leaks. Apply|

| | |any additional sutures as needed to stop the remaining leaks. Administer the anticoagulant reversal agent and |

| | |wait for effect. |

| | |Now, close all incisions. Irrigate all three of the incisions copiously with sterile saline. Use electrocautery|

| | |or suture ligation to achieve final hemostasis. Close all of the neck incisions in multiple layers, paying |

| | |special attention to the skin edges. At the vein harvest site, use electrocautery or suture ligation to achieve|

| | |final hemostasis. Irrigate the wound copiously with sterile saline. Close the subcutaneous tissue and skin at |

| | |the vein harvest site. |

|[pic] |

|35510 |  |Clinical Example (35510) |

| | |A left-handed 70-year-old female smoker presents with disabling left upper extremity pain when she tries to |

| | |perform routine activities. She also has extreme cold intolerance of the hand. Noninvasive studies confirm |

| | |diminished blood pressure and flow to the hand and digits. The arteriogram reveals occlusion of the axillary |

| | |artery with reconstitution of the brachial artery. A carotid-brachial bypass is performed using autogenous vein|

| | |conduit. |

| | |Description of Procedure (35510) |

| | |An incision is made in the skin of the neck overlying the common carotid artery. Dissection of soft tissue is |

| | |carried out to expose the carotid artery, avoiding injury to multiple nearby nerves and veins. Soft tissue is |

| | |cleared from the carotid artery for 6 cm in length. Soft rubber loops are passed around the carotid artery for |

| | |control. Distal dissection of the skin overlying the brachial artery is carried out. The soft tissue around the|

| | |brachial artery is dissected, avoiding injury to nearby nerves and veins. Soft rubber loops are passed around |

| | |the brachial artery for control. A tunnel is created from the exposed carotid artery through the axilla, down |

| | |the arm, and to the brachial target site. |

| | |Next, a vein conduit is harvested. This is begun with an incision in the skin of the thigh or calf over the |

| | |saphenous vein. Soft tissue is dissected to identify the saphenous vein. The soft tissue is cleared from around|

| | |the saphenous vein for an adequate length. All saphenous vein branches are then ligated and divided. The ends |

| | |of the saphenous vein are ligated, divided, and removed from the lower extremity. The saphenous vein conduit is|

| | |then tested for leaks. Any leaks are repaired with vascular suture. |

| | |Next, the proximal anastomosis is performed. This is initiated by first anticoagulating the patient with IV |

| | |heparin. Vascular clamps are applied to the proximal anastomosis site on the carotid artery. Arteriotomy is |

| | |carried out. The anastomosis of the vein conduit to the carotid artery is performed with fine vascular sutures.|

| | |The clamps are then opened transiently to flush the system, and remove air and debris. The anastomosis is |

| | |completed and the arterial clamps are removed. Additional sutures are applied to control hemorrhage, as needed.|

| | |Next, the vein conduit is passed through the tunnel to the brachial artery, taking care to avoid twists or |

| | |kinks. |

| | |The distal anastomosis is performed by first stretching the vein to full length. Brachial arteriotomy is |

| | |carried out. The vein conduit is cut to match the length and size of the arteriotomy. The anastomosis of the |

| | |vein conduit to the brachial artery is performed with fine vascular sutures. The clamps are opened briefly to |

| | |flush out air and debris. The anastomosis is completed and the vascular clamps are removed. Additional sutures |

| | |are applied as required to achieve hemostasis. The physician then listens with Doppler and palpates the distal |

| | |pulses to assure bypass patency. |

| | |All three incisions are irrigated and wound hemostasis is achieved. The three incisions are closed in multiple |

| | |layers. Pulses are rechecked to assure patency prior to application of sterile dressings. |

|[pic] |

|35512 |  |Clinical Example (35512) |

| | |A left-handed 70-year-old female smoker presents with disabling left upper extremity pain when she tries to |

| | |perform routine activities. She also has extreme cold intolerance of the hand. Noninvasive studies confirm |

| | |diminished blood pressure and flow to the hand and digits. The arteriogram reveals occlusion of the axillary |

| | |and proximal brachial artery with reconstitution of the distal brachial just proximal to the elbow. A |

| | |subclavian-brachial bypass is performed using autogenous vein conduit. |

| | |Description of Procedure (35512) |

| | |Proximal dissection is begun by incising the skin above the clavicle overlying the subclavian artery. Soft |

| | |tissue is dissected to expose the subclavian artery, avoiding injury to multiple nearby nerves. The soft tissue|

| | |is cleared from the subclavian artery for 4 cm in length. Soft rubber loops are passed around the artery for |

| | |control. |

| | |Next, distal dissection is carried out by incising the skin overlying the distal brachial artery just proximal |

| | |to the elbow. The soft tissue is dissected from around the artery, avoiding injury to nearby nerves and veins. |

| | |Soft rubber loops are passed around the brachial artery for control. A tunnel is created under the clavicle, |

| | |through the axilla, and down the arm, to the exposed brachial artery. |

| | |Next, the vein conduit is harvested beginning with an incision in the skin of the thigh or calf over the |

| | |saphenous vein. Dissection is carried out to identify the saphenous vein. The soft tissue is cleared from |

| | |around the saphenous vein for adequate length. All saphenous vein branches are ligated and divided. The ends of|

| | |the saphenous vein are ligated, divided, and removed from the lower extremity. The saphenous vein conduit is |

| | |then tested for leaks. Any leaks present are repaired with vascular sutures. |

| | |Next, the proximal anastomosis is carried out by first anticoagulating the patient with IV heparin. Vascular |

| | |clamps are applied to the proximal anastomosis site on the subclavian artery. A subclavian arteriotomy is |

| | |carried out. The vein conduit is sutured to the subclavian artery with fine vascular sutures. The system is |

| | |then flushed to removed air and debris. The clamps are removed to test the anastomosis. Additional sutures are |

| | |applied as needed to control hemorrhage. The vein conduit is passed through the tunnel to the brachial artery |

| | |with care to avoid twists or kinks. |

| | |Following this, the distal anastomosis is carried out. This is begun by stretching the vein to full length. |

| | |Occluding clamps are applied to the brachial artery anastomosis site. A brachial arteriotomy is carried out. |

| | |The vein conduit is cut to match the length and size of the arteriotomy. Anastomosis of the vein conduit to the|

| | |brachial artery is performed mostly with fine vascular sutures. The clamps are opened briefly to flush out air |

| | |and debris. The anastomosis is then completed. The vascular clamps are removed. Additional sutures are applied |

| | |to the anastomosis as needed to achieve hemostasis. The physician then listens with Doppler and palpates the |

| | |distal pulses to assure bypass patency. The subclavian, brachial, and vein donor site incisions are irrigated. |

| | |All three incisions are closed in multiple layers. Pulses are rechecked to assure patency prior to application |

| | |of sterile dressings. |

|[pic] |

|35522 |  |Clinical Example (35522) |

| | |A left-handed 70-year-old female smoker presents with disabling left upper extremity pain when she tries to |

| | |perform routine activities. She also has extreme cold intolerance of the hand. Noninvasive studies confirm |

| | |diminished blood pressure and flow to the hand and digits. An arteriogram reveals occlusion of the distal |

| | |axillary and proximal brachial arteries with reconstitution of the brachial artery proximal to elbow. An |

| | |axillary-brachial bypass is performed using autogenous vein conduit. |

| | |Description of Procedure (35522) |

| | |Proximal dissection is carried out by making an incision in the skin of the chest wall just below the clavicle,|

| | |overlying the axillary artery. The soft tissue around the axillary artery is dissected, avoiding injury to |

| | |multiple nearby nerves and veins. The soft tissue is cleared from the axillary artery for 4 cm in length. Soft |

| | |rubber loops are passed around the axillary artery for control. |

| | |Next, a distal dissection is carried out. An incision is made in the skin overlying the distal brachial artery |

| | |just proximal to the elbow. The soft tissue is dissected from around the brachial artery, avoiding injury to |

| | |nearby nerves and veins. Soft rubber loops are passed around the brachial artery for control. A tunnel is then |

| | |created from the exposed axillary artery through the axilla and down the arm to the brachial target site. |

| | |Next, the vein conduit is harvested. This is carried out by making an incision in the skin of the thigh or calf|

| | |over the saphenous vein. The soft tissue is dissected to identify the saphenous vein. The soft tissue is |

| | |cleared from around the saphenous vein for adequate length. All saphenous vein branches are ligated and |

| | |divided. The ends of the saphenous vein are ligated, divided and removed from the lower extremity. The |

| | |saphenous vein conduit is tested for leaks. Any leaks are repaired with vascular sutures. |

| | |Next, the proximal anastomosis is performed by first anticoagulating the patient with IV heparin. Vascular |

| | |clamps are applied to the proximal anastomosis site on the axillary artery. An arteriotomy is carried out. The |

| | |anastomosis of the vein conduit to the axillary artery is performed mostly with fine vascular sutures. The |

| | |clamps are opened transiently to flush the system, removing air and debris. The anastomosis is completed and |

| | |arterial clamps are removed. Additional sutures are applied as needed to control hemorrhage. The vein conduit |

| | |is passed through the tunnel to the brachial artery with care to avoid twists or kinks. |

| | |Next, the distal anastomosis is performed by first stretching the vein to full length. A brachial arteriotomy |

| | |is carried out. The vein conduit is cut to match the length and size of the arteriotomy. The anastomosis of the|

| | |vein conduit to the brachial artery is performed mostly with fine vascular sutures. The clamps are opened |

| | |briefly to flush out air and debris. The anastomosis is completed, and the vascular clamps are removed. |

| | |Additional sutures are applied as required to achieve hemostasis. The physician listens with Doppler and |

| | |palpates the distal pulses to assure bypass patency. The three incisions are irrigated and wound hemostasis is |

| | |achieved. All three incisions are closed in multiple layers. The pulses are rechecked to assure patency prior |

| | |to application of sterile dressings. |

|[pic] |

|35525 |  |Clinical Example (35525) |

| | |A left-handed 70-year-old female smoker presents with disabling left upper extremity pain when she tries to |

| | |perform routine activities. She also has extreme cold intolerance of the hand. Noninvasive studies confirm |

| | |diminished blood pressure and flow to the hand and digits. Arteriogram reveals occlusion of the brachial artery|

| | |with reconstitution of the distal brachial just beyond the elbow. Brachial-brachial bypass is performed using |

| | |autogenous vein conduit. |

| | |Description of Procedure (35525) |

| | |Proximal dissection is begun by making an incision in the skin of the upper arm overlying the proximal brachial|

| | |artery. Soft tissue is dissected to expose the brachial artery, avoiding injury to multiple nearby nerves and |

| | |veins. The soft tissue is cleared from the brachial artery for 6 cm in length. Soft rubber loops are passed |

| | |around the artery for control. |

| | |Next, a distal dissection is carried out. An incision is made in the skin overlying the distal brachial artery.|

| | |The soft tissue is dissected from around the brachial artery, avoiding injury to the nearby nerves and veins. |

| | |Soft rubber loops are passed around the brachial artery for control. A tunnel is created from the proximal to |

| | |distal brachial dissection sites. |

| | |Next, the vein conduit is harvested by making an incision in the skin of the thigh or calf over the saphenous |

| | |vein. The soft tissue is dissected to identify the saphenous vein. The soft tissue is cleared from around the |

| | |saphenous vein for adequate length. All saphenous vein branches are ligated and divided. The ends of the |

| | |saphenous vein are ligated, divided and remove from the lower extremity. The saphenous vein conduit is tested |

| | |for leaks. Any leaks are repaired with vascular sutures. |

| | |Next, a proximal anastomosis is carried out by first anticoagulating the patient with IV heparin. Vascular |

| | |clamps are applied to the proximal anastomosis site on the brachial artery. An arteriotomy is performed. |

| | |Anastomosis of the vein conduit to the brachial artery is performed mostly with fine vascular sutures. The |

| | |clamps are opened transiently to flush the system, removing air and debris. The anastomosis is completed, and |

| | |the arterial clamps are removed. Additional sutures are applied as needed to control hemorrhage. The vein |

| | |conduit is passed through the tunnel to the brachial artery with care to avoid twists or kinks. |

| | |Next, the distal anastomosis is carried out by first stretching the vein to full length. A brachial arteriotomy|

| | |is performed. The vein conduit is cut to match the length and size of the arteriotomy. Anastomosis of the vein |

| | |conduit to the brachial artery is performed mostly with fine vascular sutures. The clamps are opened to flush |

| | |out air and debris. The anastomosis is completed and the vascular clamps are removed. Additional sutures are |

| | |applied as required to achieve hemostasis. The physician listens with Doppler and palpates the distal pulses to|

| | |assure bypass patency. All three incisions are irrigated and wound hemostasis is achieved. The three incisions |

| | |are closed in multiple layers. The pulses are rechecked to assure patency prior to application of sterile |

| | |dressings. |

|[pic] |

|35537 |  |Clinical Example (35537) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has an irregular bulky plaque causing a critical |

| | |stenosis at his aortoiliac bifurcation. Because of the size and location of this plaque, he is felt not to be a|

| | |candidate for percutaneous intervention. An aortoiliac bypass graft is performed using a vein graft. |

| | |Description of Procedure (35537) |

| | |Incise the skin of the abdomen or the retroperitoneum. Dissect through the scarred soft tissue and lyse all |

| | |adhesions until the infrarenal aorta is identified. Insert and adjust the mechanical retractors to keep the |

| | |viscera out of the operative field. Circumferentially dissect the aorta and pass a soft rubber loop around it |

| | |for control. Extend the dissection distally to gain access to a normal section of the iliac artery. |

| | |Attention shifts to the vein harvest site, which is usually predetermined and previously prepped. Incise the |

| | |skin over the vein. Dissect through the soft tissue to find the vein. Carefully dissect out the vein, tying and|

| | |dividing all of the side branches. Check the original operative site to ensure that a sufficient length of vein|

| | |is exposed. Clamp the vein and excise the segment to be used. Ligate the transected ends of the vein that |

| | |remain in patient. Examine the removed segment of the vein on the back table to ensure suitability. Gently |

| | |distend the vein with heparinized saline to test for leaks. Repair all of the leaks with very fine vascular |

| | |sutures. Examine the caliber of the vein to ensure a size match with the aorta. In almost all cases the |

| | |saphenous vein will need to be transected and sewn longitudinally or in a spiral manner to make a paneled graft|

| | |that has a diameter that matches the aorta. Preserve the vein in heparinized saline until it is needed. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant agent and wait for it to take |

| | |effect. Apply the vascular clamps to a section of the normal aorta below the renal artery origins. Apply the |

| | |vascular clamp to the iliac artery along a normal segment of the artery. Trim the end/edges of the aorta as |

| | |required to perform a proximal anastomosis. Bring the vein conduit onto the field and bevel it as required for |

| | |the conduit. Perform a proximal anastomosis with appropriately sized vascular sutures. Open the clamps and test|

| | |for hemostasis. Apply any additional sutures as required to achieve hemostasis. |

| | |Perform the distal anastomosis. Trim the iliac artery as required to freshen up the end for the anastomosis. |

| | |Trim the length of the vein as required for an accurate fit. Bevel the vein end as required to match the iliac |

| | |artery. Suture the distal anastomosis between the vein and the iliac artery. Prior to closing the suture line, |

| | |flush all of the vessels to remove any remaining air and debris. Complete the suture line. Remove the vascular |

| | |clamps and check for leaks. Apply any additional sutures as needed to seal all of the leaks. Check for adequate|

| | |flow through the new graft into the iliac artery and the lower extremity. Revise the anastomosis as required if|

| | |the flow is inadequate. Administer the anticoagulant reversal agent and wait for it to take effect. Irrigate |

| | |the abdomen copiously with sterile saline.Use electrocautery or suture ligation to achieve final hemostasis. |

| | |Close the abdomen in multiple layers. Irrigate the subcutaneous tissue. Close the skin. |

| | |Close the vein harvest sites. At the vein harvest sites, use electrocautery or suture ligation to achieve final|

| | |hemostasis. Irrigate the wound copiously with sterile saline. Close the subcutaneous tissue. Close the skin. |

|[pic] |

|35538 |  |Clinical Example (35538) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking and an ischemic foot ulcer has an irregular bulky|

| | |plaque causing a critical stenosis just proximal to his aortoiliac bifurcation. Because of the size and |

| | |location of this plaque, he is felt not to be a candidate for percutaneous intervention. An aortobi-iliac |

| | |bypass graft is performed using a vein graft. |

| | |Description of Procedure (35538) |

| | |Incise the skin of the abdomen or the retroperitoneum. Dissect through the scarred soft tissue and lyse the |

| | |adhesions until the infrarenal aorta is identified. Insert and adjust the mechanical retractors to keep the |

| | |viscera out of the operative field. Circumferentially dissect the aorta and pass a soft rubber loop around it |

| | |for control. Extend the dissection distally to gain access to the normal sections of both of the iliac |

| | |arteries. |

| | |Perform the vein harvest. The attention is then shifted to the vein harvest site, which is usually |

| | |predetermined and previously prepped. Incise the skin over the vein. Dissect through the soft tissue to find |

| | |the vein. Carefully dissect out the vein, tying and dividing all of the side branches. Check the original |

| | |operative site to ensure that a sufficient length of vein is exposed. Clamp the vein and excise the segment to |

| | |be used. Ligate the transected ends of the vein that remain in the patient. Examine the removed segment of the |

| | |vein on the back table to ensure suitability. Gently distend the vein with heparinized saline to test for |

| | |leaks. Repair all of the leaks with very fine vascular sutures. Examine the caliber of the vein to ensure a |

| | |size match with the aorta. In almost all of the cases the saphenous vein will need to be transected and sewn |

| | |longitudinally or in a spiral manner to make a paneled graft that has a diameter that matches the aorta. |

| | |Preserve the vein in heparinized saline until it is needed for the anastomosis. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant and wait for it to take effect. |

| | |Apply the vascular clamps to a section of normal aorta below the renal artery origins. Apply the vascular |

| | |clamps to both of the iliac arteries along the normal segments. Trim the end/edges of the aorta as required to |

| | |perform a proximal anastomosis. Bring the vein conduit onto the field and bevel it as required for the conduit.|

| | |Perform the proximal anastomosis with appropriately sized vascular sutures. Open the clamps and test the artery|

| | |for hemostasis. Apply any additional sutures as required to achieve hemostasis. |

| | |Perform the first distal anastomosis. Trim the first iliac artery as required to freshen up the end for |

| | |anastomosis. Trim the length of the vein as required for an accurate fit. Bevel the vein end as required to |

| | |match the iliac artery. Suture the distal anastomosis between the vein and the iliac artery. Before closing the|

| | |suture line, flush all of the vessels to remove any remaining air and debris. Complete the suture line. Remove |

| | |the vascular clamps and check for any leaks and apply additional sutures as needed to seal these. Check the new|

| | |graft for adequate flow through the iliac artery and lower extremity. Revise as required if the flow is |

| | |inadequate. |

| | |Perform the venovenostomy. Determine the location on the first aortoiliac segment where the second leg should |

| | |be sewn. Clamp above and below this spot on the vein conduit. Perform a large venotomy. Bevel the next piece of|

| | |vein to match the venotomy. Perform the anastomosis between the second leg of the bypass and the original leg. |

| | |Remove the clamps, test for any leaks, and apply additional sutures as required to achieve hemostasis. |

| | |Perform the second distal anastomosis. Examine and freshen up the ends of the contralateral iliac artery at the|

| | |site for the second anastomosis. Cut the vein conduit to the appropriate length and bevel it to match the end |

| | |of iliac artery. Perform an end-of-vein to end-of-iliac anastomosis. Open the clamps briefly before completing |

| | |the anastomosis to remove all air and debris. Complete the anastomotic suture line. Remove the clamps and test |

| | |for any leaks. Apply additional sutures as needed to achieve hemostasis. Check the blood flow to both of the |

| | |legs, and revise as required to achieve good flow. Administer the anticoagulant reversal agent and wait for it |

| | |to take effect. Irrigate the abdomen copiously with sterile saline. Use electrocautery or suture ligation to |

| | |achieve final hemostasis. Close the abdomen in multiple layers. Irrigate the subcutaneous tissue. Close the |

| | |skin. |

| | |Close the vein harvest sites. At the vein harvest sites, use electrocautery or suture ligation to achieve final|

| | |hemostasis. Irrigate the wound copiously with sterile saline. Close the subcutaneous tissue. Close the skin. |

|[pic] |

|35539 |  |Clinical Example (35539) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has undergone removal of an infected synthetic |

| | |aortoiliac graft. His past medical history is notable for a prior above-knee amputation on the right side. His |

| | |remaining left lower extremity is found to be severely ischemic. An aortofemoral bypass graft is performed |

| | |using a vein conduit. |

| | |Description of Procedure (35539) |

| | |Incise the skin in the groin. Dissect through the subcutaneous fat and the soft tissue to find the common, |

| | |superficial, and deep femoral arteries. Carefully dissect each of these arteries free of the connective tissue |

| | |and encircle them with a loop. Incise the skin of the abdomen or the retroperitoneum. Dissect through the |

| | |scarred soft tissue and lyse the adhesions until the infrarenal aorta is identified. Insert and adjust the |

| | |mechanical retractors to keep the viscera out of the operative field. Circumferentially dissect the aorta and |

| | |pass a soft rubber loop around it for control. Extend the dissection distally to create a tunnel from the |

| | |abdomen to the groin incision. |

| | |Attention shifts to the vein harvest sites, which are usually predetermined and previously prepped. Incise the |

| | |skin over the vein. Dissect through the soft tissue to find the vein. Carefully dissect out the vein, tying and|

| | |dividing all of the side branches. Check the original operative site to ensure that a sufficient length of vein|

| | |is exposed. Clamp the vein and excise the segment to be used. Ligate the transected ends of the vein that |

| | |remain in the patient. Examine the removed segment of vein on the back table to ensure suitability. Gently |

| | |distend the vein with a heparinized saline solution to test for leaks. Repair all of the leaks with very fine |

| | |vascular sutures. Examine the caliber of the vein to ensure a size match with the aorta. In almost all cases, |

| | |the saphenous vein will need to be transected and sewn longitudinally or in a spiral manner to make a paneled |

| | |graft that has a diameter that matches the aorta. Perform as many vein harvests as are needed to acquire a |

| | |sufficient vein conduit. Preserve the vein in a heparinized saline solution until needed. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant agent and wait for it to take |

| | |effect. Apply the vascular clamps to a section of normal aorta below the renal artery origins. Apply the |

| | |vascular clamp to the iliac arteries. Trim the end/edges of the aorta as required to perform a proximal |

| | |anastomosis. Suture ligate the common iliac arteries to stop any backbleeding. Bring the vein conduit onto the |

| | |field and bevel it as required for the conduit. Perform a proximal anastomosis with appropriately-sized |

| | |vascular sutures. Open the clamps and test for hemostasis. Apply additional sutures as required to achieve |

| | |hemostasis. Pass the distal end of the vein through the tunnel to the groin. Briefly open the clamp to check |

| | |for adequate blood flow and ensure that there are no kinks in the vein. |

| | |Perform the distal anastomosis. Place the vascular clamps on the common, superficial, and deep femoral |

| | |arteries. Perform an arteriotomy in the common femoral artery for distal anastomosis. Trim the length of vein |

| | |as required for an accurate fit. Bevel the vein end as required to match the femoral arteriotomy. Suture the |

| | |distal anastomosis between the vein and the femoral artery. Before closing the suture line, flush all of the |

| | |vessels to remove any remaining air and debris. Complete the suture line. Remove the vascular clamps and check |

| | |for any leaks, applying additional sutures as needed to seal all of the leaks. Check for adequate flow through |

| | |the new graft into the femoral artery and the lower extremity. Revise the anastomosis as required if the flow |

| | |is inadequate. Administer the anticoagulant reversal agent and wait for it to take effect. Irrigate the abdomen|

| | |copiously with sterile saline. Use electrocautery or suture ligation to achieve final hemostasis. Close the |

| | |abdomen in multiple layers. Irrigate the subcutaneous tissue. Close the skin. |

| | |Close the femoral site. At the femoral anastomosis site, use electrocautery or suture ligation to achieve |

| | |hemostasis. Irrigate the wound copiously with sterile saline. Close the subcutaneous tissue. Close the skin. |

| | |Close all of the vein harvest sites. Irrigate the wounds. Achieve hemostasis with sutures and electrocautery as|

| | |needed. Close the subcutaneous tissue with interrupted sutures. Perform the final check for hemostasis. Close |

| | |the skin. Repeat these steps for all of the vein harvest sites. |

|[pic] |

|35540 |  |Clinical Example (35540) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has undergone the removal of an infected |

| | |synthetic aortobi-iliac graft. His lower extremities are found to be severely ischemic. An aortobifemoral |

| | |bypass graft is performed using a vein conduit. |

| | |Description of Procedure (35540) |

| | |Incise the skin of both groins. Dissect through the subcutaneous fat and the soft tissue to find the common, |

| | |superficial, and deep femoral arteries bilaterally. Carefully dissect each of these arteries free of the |

| | |connective tissue and encircle them with a loop. Incise the skin of the abdomen or the retroperitoneum. Dissect|

| | |through the scarred soft tissue and lyse the adhesions until the infrarenal aorta is identified. Insert and |

| | |adjust the mechanical retractors to keep the viscera out of the operative field. Circumferentially dissect the |

| | |aorta and pass a soft rubber loop around it for control. Extend the dissection distally to create bilateral |

| | |tunnels from the abdomen to the groin. |

| | |Perform the vein harvest. The attention shifts to the vein harvest site, which is usually predetermined and |

| | |previously prepped. Incise the skin over the vein. Dissect through the soft tissue to find the vein. Carefully |

| | |dissect out the vein, tying and dividing all of the side branches. Check the original operative site to ensure |

| | |that a sufficient length of vein is exposed. Clamp the vein and excise the segment to be used. Ligate the |

| | |transected ends of the vein that remain in the patient. Examine the removed segment of the vein on the back |

| | |table to ensure its suitability for use in the graft. Gently distend the vein with a heparinized saline |

| | |solution to test for leaks. Repair all leaks with very fine vascular sutures. Examine the caliber of the vein |

| | |to ensure a size match with the aorta. In almost all of the cases, the saphenous vein will need to be |

| | |transected and sewn longitudinally or in a spiral manner to make a paneled graft that has a diameter that |

| | |matches the aorta. Preserve the vein in a heparinized saline solution until needed for use in the anastomisis. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant agent and wait for it to take |

| | |effect. Apply the vascular clamps to a section of normal aorta below the renal artery origins. Apply the |

| | |vascular clamp to the iliac arteries. Trim the end/edges of the aorta as required to perform a proximal |

| | |anastomosis. Suture ligate the common iliac arteries to stop any backbleeding. Bring the vein conduit onto the |

| | |field and bevel it as required for the conduit. Perform the proximal anastomosis with appropriately sized |

| | |vascular sutures. Open the clamps and test for hemostasis, applying additional sutures as required to achieve |

| | |hemostasis. Pass the distal end of the vein through the tunnel to one groin. Briefly open the clamp to check |

| | |the blood flow, ensuring that there are no kinks in the vein. |

| | |Perform the first distal anastomosis. Place the vascular clamps on the common, superficial, and deep femoral |

| | |arteries. Perform the arteriotomy in the common femoral artery for the distal anastomosis. Trim the length of |

| | |the vein as required for an accurate fit. Bevel the vein end as required to match the femoral arteriotomy. |

| | |Suture the distal anastomosis between the vein and the femoral artery. Prior to closing the suture line, flush |

| | |all of the vessels to remove any remaining air and debris. Complete the suture line. Remove the vascular clamps|

| | |and check for leaks, applying additional sutures as needed to seal all remaining leaks. Check for adequate flow|

| | |through the new graft into the femoral artery and the lower extremity, revising as required if the flow is |

| | |inadequate. |

| | |Perform the venovenostomy. Determine the location on the first aortofemoral segment where the second leg should|

| | |be sewn. Clamp above and below this spot on the vein conduit. Perform the large venotomy. Bevel the next piece |

| | |of the vein to match the venotomy. Perform the anastomosis between the second leg of the bypass and the |

| | |original leg using fine sutures. Remove the clamps and test for leaks, applying additional sutures as required |

| | |to achieve hemostasis. Pass this second femoral limb through the tunnel to the opposite groin. Open the clamp |

| | |briefly to test the blood flow and to ensure that no kinks are in the vein conduit. |

| | |Perform the second distal anastomosis. Place the vascular clamps on the common, superficial, and deep femoral |

| | |arteries. Perform an arteriotomy in the common femoral artery for distal anastomosis. Trim the length of the |

| | |vein as required for an accurate fit. Bevel the vein end as required to match the femoral arteriotomy. Suture |

| | |the distal anastomosis between the vein and femoral artery. Briefly open the clamps to blow out all air and |

| | |debris. Finish the suture line. Remove the clamps and examine for any suture line leaks, applying additional |

| | |sutures as needed to achieve hemostasis. Check the blood flow to both legs, revising as required to achieve |

| | |good flow. Administer the anticoagulant reversal agent and wait for it to take effect. Irrigate the abdomen |

| | |copiously with sterile saline. Use electrocautery or suture ligation to achieve final hemostasis. Close the |

| | |abdomen in multiple layers. Irrigate the subcutaneous tissue. Close the skin of the abdomen. Close both groins.|

| | |Irrigate both groins copiously with sterile saline and achieve final hemostasis. Close both of the incisions in|

| | |multiple layers. Close the skin. |

| | |Close the vein harvest sites. At all of the vein harvest sites, use electrocautery or suture ligation to |

| | |achieve final hemostasis. Irrigate the wound copiously with sterile saline. Close the subcutaneous tissue. |

| | |Close the skin. |

|[pic] |

|35572 |  |Clinical Example (35572) |

| | |A 70-year-old male has comorbidities including tobacco abuse, COPD, CAD, and MI, and he is status post |

| | |revascularization surgeries including CABG using autogenous vein, bilateral lower extremity bypass grafts using|

| | |autogenous vein, and a synthetic femoral-femoral bypass graft, the latter as treatment for an occluded left |

| | |iliac artery. He returned to medical attention with complaints of fever, chills, malaise, and a small skin pore|

| | |in his left groin that is releasing purulent drainage. Diagnostic workup revealed infection of the |

| | |femoral-femoral graft, requiring surgical removal and extensive debridement. As a result he has severe left leg|

| | |ischemia, and a new graft must be placed to save his leg. Extensive duplex vein search reveals that he has no |

| | |remaining autogenous superficial vein suitable for conduit on either lower or upper extremity. Synthetic |

| | |revascularization is contraindicated due to open groin wounds and significant local infection. Femoral-femoral |

| | |bypass using vein conduit is recommended (separately reportable as CPT code 35558). Autogenous femoropopliteal |

| | |vein is harvested for use as conduit. |

| | |Description of Procedure (35572) |

| | |Intra-service work begins with the skin incision. An incision is extended from the groin along the anterior |

| | |aspect of the thigh. Soft tissue is dissected with electrocautery. The lateral border of the sartorius muscle |

| | |is identified and reflected medially to expose the adductor canal. The femoral vein (FV) is identified next to |

| | |the femoral artery. The branches of the FV are carefully doubly ligated and divided without injuring the vein |

| | |wall. The dissection is continued distally as the vein and artery travel deep in the thigh. The adductor hiatus|

| | |is opened by dividing the tendinous insertion of the adductor magnus muscle. The dissection is usually tedious |

| | |in the distal adductor canal region where there are often multiple large branches that must be carefully |

| | |ligated, and where the vein is usually in very close apposition to the artery and the aponeurosis of the |

| | |adductor magnus. At the upper end of the popliteal space the name of the deep vein becomes the popliteal vein. |

| | |Initial dissection of the popliteal vein follows the same incision and planes as the femoral did, but a |

| | |separate incision is required to harvest the most distant segment of popliteal vein. When the vein is |

| | |completely exposed, it is ligated proximally and distally, and divided. The vein segment is removed from the |

| | |thigh and measured to determine that adequate length has been obtained. Vein valves are disrupted using a |

| | |valvulotome. Flow through the new conduit is tested by injection of heparinized saline. Any missed branches or |

| | |rents in the conduit are repaired under loupe magnification using very fine suture. |

| | |Once the conduit is proven adequate, it is used in the bypass procedure. |

| | |After completion of the bypass, the vein harvest site is irrigated copiously, and hemostasis is achieved with |

| | |electrocautery and suture ligation as required. The harvest site wound is closed in multiple layers. Drains are|

| | |inserted as required. |

|[pic] |

|35600 |  |Clinical Example (35600) |

| | |A 58-year-old man presented to the emergency room with unstable angina. His past medical history included a |

| | |five-vessel coronary bypass eight years prior to his admission. Four of his bypass grafts were created using |

| | |saphenous veins removed from his left leg. His entire right saphenous system had been removed because of severe|

| | |varicosities. The patient had been involved in an automobile accident as a teenager with extensive deep vein |

| | |thrombosis of right leg which ultimately led to the varicosities and venous insufficiency. In his initial CABG |

| | |operation, the left internal mammary artery was used as a bypass conduit to his left anterior descending |

| | |coronary artery. |

| | |Description of Procedure |

| | |Once the patient was stabilized, he underwent cardiac catheterization. Three of the four saphenous vein bypass |

| | |grafts were occluded. The left internal mammary artery was patent and filled the left anterior descending |

| | |coronary artery nicely. The fourth saphenous vein graft was diffusely diseased and had a severe stenosis with |

| | |an unstable ulcerated plaque in its midportion. This bypass graft led to the right coronary artery which was |

| | |relatively large. The right coronary system filled a large system via collaterals. There was no antegrade |

| | |arterial inflow to the circumflex system because of the patient's native disease. |

| | |The patient was felt to be a candidate for reoperative coronary bypass surgery. At the time of his procedure, |

| | |the right internal mammary was removed and used as a free graft to revascularize the circumflex system. His |

| | |left radial artery was removed for use as a bypass conduit. The radial artery was used as a free graft to the |

| | |right coronary system. There were two separate distal sites that the radial artery was used to revascularize |

| | |using a sequential technique. |

|[pic] |

|35601 |  |Clinical Example (35601) |

| | |A 68-year-old cigarette-smoking hyperlipidemic, hypertensive, diabetic female underwent carotid artery stenting|

| | |for a critical stenosis of the carotid bifurcation 2 years ago. Subsequently, she developed early recurrent |

| | |stenosis on three separate occasions, each requiring percutaneous retreatment. She returns 3 months after the |

| | |most recent intervention with yet another critically severe stenosis and hemispheric transient ischemic |

| | |attacks. She is deemed not to be a candidate for further percutaneous intervention. A bypass graft using a |

| | |synthetic conduit is recommended. The graft will extend from her proximal cervical common carotid artery to the|

| | |distal extracranial internal carotid artery beyond the region of her multiply recurrent stenosis. |

| | |Description of Procedure (35601) |

| | |Incise the skin from the posterior to the ear lobe along the anterior border of the sternocleidomastoid muscle |

| | |to the clavicle. Divide the platysma muscle. Dissect through the soft tissue until the carotid sheath is |

| | |located. Dissect the jugular vein away from the carotid artery. Divide the facial vein and suture ligate. |

| | |Locate and avoid the vagus nerve. Identify the common carotid artery at the base of the neck. Circumferentially|

| | |dissect the common carotid artery and pass a soft rubber loop around it for control. Extend the dissection |

| | |distally to expose the bifurcation, the proximal external, and the internal carotid arteries. Mobilize and |

| | |avoid cranial nerves X and XII as needed to reach a normal distal segment of the internal carotid artery (ICA) |

| | |beyond the stent. Divide the digastric muscle as needed to reach a normal segment of the ICA. Dislocate the |

| | |jaw, if needed, to reach a normal segment of the ICA. Pass loops around the internal and external carotid |

| | |arteries for control. Identify the superior thyroid artery, dissect it free, and pass a fine rubber loop around|

| | |it for control. |

| | |Make a final check to ensure that there is sufficient proximal and distal arterial control beyond the stented |

| | |segment. Administer the anticoagulant agent and wait for it to take effect. Apply the vascular clamp to the ICA|

| | |beyond the stented area. Apply the vascular clamp to the external carotid artery. Apply the vascular clamp to |

| | |the common carotid artery (CCA) proximal to the stented area. Incise the CCA proximal to the stented/stenotic |

| | |portion and carry the arteriotomy across the length of the vessel to a normal portion of the distal ICA. Remove|

| | |the old stents, using wire-cutters if necessary. Place the synthetic conduit on the soft plastic shunt and |

| | |insert the proximal end of the shunt into the CCA after opening the clamp. Reclamp the CCA around the shunt. |

| | |Test the shunt to ensure that there is adequate arterial inflow. Open the distal ICA clamp and insert the |

| | |shunt. Backbleed the artery as needed to remove all air from the shunt. Reestablish bloodflow to the brain by |

| | |opening the shunt. Transect the CCA and prepare the proximal normal segment for a proximal anastomosis. Perform|

| | |a proximal anastomosis of synthetic conduit to the CCA with fine vascular sutures. Irrigate the anastomosed |

| | |segment with a heparinized saline solution, inspecting carefully to remove all of the loose plaque fragments. |

| | |Test the anastomosis for leaks, applying additional sutures as needed to achieve hemostasis. Prepare the distal|

| | |internal carotid for an anastomosis, transecting the ICA at a segment of normal artery. Trim the synthetic |

| | |conduit to an appropriate length. Perform a distal anastomosis of synthetic conduit to the ICA with fine |

| | |vascular sutures. Prior to closing the suture line, flush all of the vessels to remove air and debris. Complete|

| | |the suture line. Remove the vascular clamps and check for leaks. Apply additional sutures as needed to seal all|

| | |leaks. Administer the anticoagulant reversal agent and wait for it to take effect. Irrigate the wound copiously|

| | |with sterile saline. Use electrocautery or suture ligation to a! |

| | |chieve f |

| | |inal hemostasis. Close the subcutaneous layer and skin in multiple layers, paying special attention to the skin|

| | |edges. |

|[pic] |

|35637 |  |Clinical Example (35637) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has ischemic rest pain and a nonhealing ulcer on |

| | |his left foot. His past medical history is notable for a prior above-knee amputation on the right side. His |

| | |remaining left lower extremity is found to be severely ischemic by physical exam and noninvasive studies. |

| | |Diagnostic studies reveal dense calcified plaque and near occlusion of the infrarenal aorta and proximal left |

| | |common iliac artery. The distal left common iliac and external iliac have only minimal atherosclerotic plaque. |

| | |The right common iliac and external iliac are occluded. An aortoiliac bypass graft using synthetic conduit is |

| | |performed. |

| | |Description of Procedure (35637) |

| | |Incise the skin of the abdomen or the retroperitoneum. Dissect through the soft tissue until the infrarenal |

| | |aorta is identified. Insert and adjust the mechanical retractors to keep the viscera out of the operative |

| | |field. Circumferentially dissect the aorta and pass a soft rubber loop around it for control. Extend the |

| | |dissection distally to gain access to a normal section of the iliac artery. Now that the percutaneous |

| | |intervention is common, this is typically deep in the pelvis. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant agent and wait for it to take |

| | |effect. Apply the vascular clamps to a section of normal aorta below the renal artery origins. Apply the |

| | |vascular clamp to the iliac artery along a normal segment of the artery. Trim the end/edges of the aorta as |

| | |required to perform a proximal anastomosis. Bring the synthetic conduit onto the field and bevel it as required|

| | |to match the arteriotomy. Perform a proximal anastomosis with an appropriately sized vascular suture. Open the |

| | |clamps and test for hemostasis. Apply any additional sutures as required to achieve hemostasis. |

| | |Perform the distal anastomosis. Trim the iliac artery as required to freshen up the end for anastomosis. Trim |

| | |the length of the synthetic conduit as required for an accurate fit. Bevel the synthetic conduit end as |

| | |required to match the iliac artery. Suture the distal anastomosis between the end of the synthetic conduit and |

| | |the iliac artery. Prior to closing the suture line, flush all of the vessels to remove any air and debris. |

| | |Complete the suture line. Remove the vascular clamps and check for possible leaks. Apply any additional sutures|

| | |as needed to seal all of the leaks. Check for an adequate blood flow through the new graft into the iliac |

| | |artery and the lower extremity. Revise the anastomosis as required if the blood flow is inadequate. Administer |

| | |the anticoagulant reversal agent and wait for it to take effect. Irrigate the abdomen copiously with sterile |

| | |saline. Use electrocautery or suture ligation to achieve final hemostasis. Close the abdomen in multiple |

| | |layers. Irrigate the subcutaneous tissue. Close the skin. |

|[pic] |

|35638 |  |Clinical Example (35638) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking has ischemic chest pain and bilateral nonhealing |

| | |foot ulcers. His lower extremities are found to be severely ischemic. Diagnostic studies reveal dense calcified|

| | |plaque and near occlusion of the infrarenal aorta and both proximal common iliac arteries. The distal common |

| | |iliacs and both external iliacs are widely patent. An aortobiiliac bypass graft using a synthetic conduit is |

| | |performed. |

| | |Description of Procedure (35638) |

| | |Incise the skin of the abdomen or the retroperitoneum. Dissect through the soft tissue until the infrarenal |

| | |aorta is identified. Insert and adjust the mechanical retractors to keep the viscera out of the operative |

| | |field. Circumferentially dissect the aorta and pass a soft rubber loop around it for control. Extend the |

| | |dissection distally to gain access to the normal sections of both of the iliac arteries. |

| | |Perform the proximal anastomosis. Administer the intravenous anticoagulant and wait for it to take effect. |

| | |Apply the vascular clamps to a section of normal aorta below the renal artery origins. Apply the vascular clamp|

| | |to both of the iliac arteries along normal segments. Trim the end/edges of the aorta as required to perform a |

| | |proximal anastomosis. Bring the bifurcated synthetic conduit onto the field and bevel it as required for the |

| | |conduit. Perform a proximal anastomosis with the appropriately sized vascular sutures. Open the clamps and test|

| | |for hemostasis, applying additional sutures as required to achieve hemostasis. |

| | |Perform the first distal anastomosis. Trim the first iliac artery as required to freshen up the end for |

| | |anastomosis. Trim the length of the synthetic conduit as required for an accurate fit. Bevel the conduit end as|

| | |required to match the iliac artery. Suture the distal anastomosis between the synthetic conduit and the iliac |

| | |artery. Prior to closing the suture line, flush all of the vessels to remove any remaining air and debris. |

| | |Complete the suture line. Remove the vascular clamps and check for leaks, applying additional sutures as needed|

| | |to seal all leaks. Check for adequate flow through the new graft into the iliac artery and the lower extremity.|

| | |Revise as required if flow is inadequate. |

| | |Perform the second distal anastomosis. Examine and freshen up the ends of the contralateral iliac at the site |

| | |for the second anastomosis. Cut the second limb of the bifurcated conduit to the appropriate length and bevel |

| | |it to match the iliac artery. Perform the end-of-synthetic conduit to end-of-iliac anastomosis. Open the clamps|

| | |briefly before completing the anastomosis to remove all remaining air and debris. Complete the anastomotic |

| | |suture line. Remove the clamps and test the graft for leaks, applying additional sutures as needed to achieve |

| | |hemostasis. Check the blood flow to both legs, revising as required to achieve hemostasis. Administer the |

| | |anticoagulant reversal agent and wait for it to take effect. Irrigate the abdomen copiously with sterile |

| | |saline. Use electrocautery or suture ligation to achieve final hemostasis. Close the abdomen in multiple |

| | |layers. Irrigate the subcutaneous tissue. Close the skin. |

|[pic] |

|35646 |  |Clinical Example (35646) |

| | |A 75-year-old patient with coronary artery disease and emphysema presents with ischemic rest pain in both legs |

| | |and dry gangrene of one toe. Physical examination reveals the absence of femoral pulses and very ischemic lower|

| | |extremities. An arteriogram identifies occlusion of the distal aorta and both common iliac arteries. The |

| | |situation is discussed in detail with patient and family. Placement of an aorto-bifemoral bypass graft is |

| | |recommended because the disease has advanced beyond the point where angioplasty is an option. Alternatives |

| | |include primary amputation, an obviously undesirable choice. Following completion of a thorough pre-operative |

| | |evaluation, an aorto-bifemoral bypass is performed. |

| | |Description of Procedure (35646) |

| | |A laparotomy is performed under general anesthesia. Following a routine abdominal exploration, the small bowel |

| | |is mobilized toward the patient's right side. The retroperi-toneum is incised, and the aorta is exposed along |

| | |its entire length from just beyond the renal artery origins to the aortic bifurcation. Complete circumferential|

| | |dissection of the proximal aorta is performed in order to place a vascular cross clamp. The proximal common |

| | |iliac arteries are exposed in a similar manner, care being taken to avoid injury to the ureters. The |

| | |retroperitoneum is elevated over the iliac arteries in the pelvis on both sides to create tunnels for the graft|

| | |limbs. |

| | |Attention is directed to the groins where incisions are performed over the common femoral arteries. The soft |

| | |tissue is dissected until the femoral arteries are encountered. The distal common femoral and proximal |

| | |superficial and profunda femoral arteries are dissected and isolated bilaterally in a region long enough to |

| | |achieve vascular control and perform the graft anastomoses. |

| | |A tunnel is completed between the femoral regions on each side and the abdominal cavity. This often requires |

| | |ligation of multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administered for |

| | |anticoagulation. A bifurcated synthetic graft is passed onto the surgical field. Proximal and distal vascular |

| | |control of the aorta is obtained, and cross clamps are placed. An anastomosis is performed between the aorta |

| | |and the proximal end of the bifurcated graft. Clamps are removed, and extra sutures are placed as required to |

| | |achieve anastomotic hemostasis. |

| | |One graft limb is passed through each tunnel between abdomen and groins. The graft is checked to make sure |

| | |there are no kinks or twists. Starting on either side first, vascular clamps are placed at the femoral |

| | |bifurcation, and an arteriotomy is performed. The graft limb is cut to appropriate length, and an anastomosis |

| | |is performed between the graft limb and the femoral artery. Vascular clamps are removed, and the anastomosis is|

| | |checked for hemostasis. Additional sutures are placed as required. |

| | |The aortic graft limb to the femoral artery anastomosis on the opposite side is performed in the identical |

| | |fashion and blood flow is restored. Both the lower extremities are checked to confirm adequate perfusion. The |

| | |abdominal cavity is checked once again for hemostasis, and appropriate manuevers are performed as needed. The |

| | |abdomen is irrigated with saline, and the viscera are replaced. The retroperitoneum is reapproximated to |

| | |prevent contact between the new aortic graft and the bowels. The laparotomy is closed. The groin incisions are |

| | |then closed. Irrigation and inspection is performed for hemostasis. Next, the subcutaneous tissue is closed in |

| | |multiple layers, and the skin is stapled or sutured. |

|[pic] |

|35647 |  |Clinical Example (35647) |

| | |A 75-year-old patient with coronary artery disease and emphysema presents with ischemic rest pain in his right |

| | |leg and dry gangrene of one toe. He has undergone a left above-knee amputation in the past. Physical |

| | |examination reveals the absence of femoral pulses and a very ischemic right lower extremity. His left |

| | |above-knee amp is warm and nicely healed. An arteriogram identifies occlusion of the distal aorta and both |

| | |common iliac arteries. The situation is discussed in detail with patient and family. Placement of an |

| | |aortofemoral bypass graft is recommended because the arterial disease has advanced beyond the point where |

| | |angioplasty is an option. Current alternatives include primary leg amputation, an obviously undesirable choice.|

| | |Following completion of a thorough pre-operative evaluation, an aortofemoral bypass is performed. |

| | |Description of Procedure (35647) |

| | |A laparotomy is performed under general anesthesia. Following a routine abdominal exploration, the small bowel |

| | |is mobilized towards the patient's right side. The retroperitoneum is incised, and the aorta is exposed along |

| | |its entire length from just beyond the renal artery origins to the aortic bifurcation. Complete circumferential|

| | |dissection of the proximal aorta is performed in order to place a vascular cross clamp. The proximal right |

| | |common iliac artery is exposed in a similar manner, care being taken to avoid injury to the ureters. The |

| | |retroperitoneum is elevated over the right iliac artery to create a tunnel for the graft limb. |

| | |Attention is directed to the right groin where an incision is performed over the common femoral artery. The |

| | |soft tissue is dissected until the femoral artery is encountered. The distal common femoral, and the proximal |

| | |superficial and profunda femoral arteries are dissected at the femoral bifurcation. These are isolated in a |

| | |region long enough to achieve vascular control and perform the graft anastomosis. |

| | |A tunnel is completed between the femoral region and the abdominal cavity. This oftentimes requires ligation of|

| | |multiple crossing veins. Hemostasis is achieved. Intravenous heparin is administered for anticoagulation. A |

| | |tubular synthetic graft is passed onto the surgical field. Proximal and distal vascular control of the aorta is|

| | |obtained, and cross clamps are placed. An anastomosis is performed between the aorta and the proximal end of |

| | |the bifurcated graft. Clamps are removed, and extra sutures are placed as required to achieve anastomotic |

| | |hemostasis. |

| | |The graft limb is passed through the tunnel created between the abdomen and the groin incision. The graft is |

| | |checked to make sure there are no kinks or twists. Vascular clamps are placed at the femoral bifurcation, and |

| | |an arteriotomy is performed. The graft limb is cut to appropriate length, and an anastomosis is performed |

| | |between the graft and the femoral artery. Vascular clamps are removed, and hemostasis is achieved with |

| | |additional sutures as required. |

|[pic] |

|35685 |  |Clinical Example (35685) |

| | |A 75-year-old male with gangrenous toe requires a femoral-distal anterior tibial artery. The patient has no |

| | |autogenous vein. Synthetic conduit is used for the bypass graft. A vein patch or cuff is added to the distal |

| | |anastomosis. |

| | |Description of Procedure (35685) |

| | |The surgeon isolates 2 cm more tibial artery than would be required for a routine distal anastomosis. A skin |

| | |incision at a distant site is made to harvest vein patch/cuff to find and isolate 6-8 cm vein, ligate vein |

| | |branches, ligate inflow and outflow ends of donor vein, and resect donor vein. The surgeon opens the harvested |

| | |vein in longitudinal fashion and performs modified distal anastomosis of bypass graft using harvested vein as |

| | |patch or cuff. Sutures are placed with 7-0 Polypropylene using loupe magnification, the vein donor site is |

| | |irrigated, while achieving hemostasis at the vein donor site. Subcutaneous tissue and skin is closed at the |

| | |vein donor site. |

|[pic] |

|35686 |  |Clinical Example (35686) |

| | |A 75-year-old male with gangrenous toe requires a femoral-distal anterior tibial artery. The patient has no |

| | |autogenous vein. Synthetic conduit is used for the bypass graft. A distal arteriovenous fistula is created. |

| | |Description of Procedure (35686) |

| | |An extra 3-5 cm of the tibial artery is dissected as well as 3-5 cm of the tibial vein is dissected. The vein |

| | |branches are ligated, with ligation of the inflow/outflow end of the donor vein. Occlusion of venous |

| | |backbleeding is performed by a temporary micro clip. A longitudinal incision in the vein is performed with a |

| | |modified distal bypass anastomosis to include the vein. Sutures are placed with 7-0 Polypropylene using loupe |

| | |magnification. The microclip is removed, and the vein donor site is irrigated, while achieving hemostasis at |

| | |the vein donor site. |

|[pic] |

|35697 |  |Clinical Example (35697) |

| | |A 75-year-old male undergoes open aortic aneurysm surgery. When the aneurysm is entered there is only a weak |

| | |dribble of back-bleeding from the IMA origin. The surgeon completes insertion of the aortic prosthesis and |

| | |restores blood flow, but the descending colon appears very dusky. The surgeon waits several minutes, but the |

| | |colon does not "pink up." A sterile hand-held Doppler is brought onto the surgical field, and no Doppler |

| | |signals can be obtained at the surface of the colon. Back-bleeding from the origin of the IMA remains minimal. |

| | |Gangrene of the colon will ensue if the IMAis not reimplanted. IMA reimplantation is performed. |

| | |Description of Procedure (35697) |

| | |The patient is anticoagulated with IV heparin. Soft tissue is dissected from around the origin of the IMA where|

| | |it exits the aorta. A 2 cm button of aortic tissue is cut from around the origin of the IMA to use as "Carrel |

| | |patch." The button is examined to ensure that the IMA origin is smooth and patent. A side-biting clamp is |

| | |placed on the aortic prosthesis at the proposed site of reimplantation. A hole is cut in the aortic prosthesis |

| | |to match the size of the aorta/IMA button. Anastomosis of the IMA Carrel patch to the hole in the aortic |

| | |prosthesis is performed with fine vascular sutures. The system is flushed to remove air and debris. Clamps are |

| | |removed to test the anastomosis. Additional sutures are applied as needed to control hemorrhage. The |

| | |anticoagulation is reversed with protamine, platelets, plasma, as required to achieve hemostasis. |

|[pic] |

|35879 |  |A 75-year-old man has a critical stenosis in a 1-year old femoralperoneal arterial bypass graft. |

|[pic] |

|35881 |  |A 75-year-old man has a critical stenosis in a one-year old femoralperoneal arterial bypass graft. |

|[pic] |

|35883 |  |Clinical Example (35883) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking underwent an aortobifemoral bypass graft 2 years |

| | |ago. He returns now complaining of left lower extremity calf claudication. Diagnostic studies (eg, duplex, |

| | |computed tomography, angiography, mannetic resonance angiography) reveal a severe focal stenosis at the |

| | |anastomosis between his bypass graft limb and the femoral artery in the left groin. Surgical exposure reveals |

| | |severe intimal hyperplasia in a focal pattern suitable for patch angioplasty treatment. A nonautogenous patch |

| | |is chosen (eg, polyester fiber, expanded polytetrafluoroethylene, bovine pericardium). |

| | |Description of Procedure (35883) |

| | |Incise the skin in the groin overlying the distal end of the graft limb and the femoral arteries. Dissect |

| | |through the scarred soft tissue until the graft limb is located. Dissect through the scarred tissue around the |

| | |graft limb with care to avoid the nerves and the veins that may be adherent to the graft limb. |

| | |Circumferentially dissect the graft limb and pass a soft rubber loop around it for control. Circumferentially |

| | |dissect the common femoral or distal-most external iliac artery and pass a soft rubber loop around it for |

| | |control. Circumferentially dissect the profunda femoris artery and pass another soft rubber loop for control. |

| | |Administer the intravenous anticoagulant agent and wait for it to take effect. Apply the vascular clamps to the|

| | |graft limb, common femoral, profunda, and superficial femoral arteries. Incise the hood of the graft and carry |

| | |the opening across the toe of the anastomosis onto the native artery. Examine the pathology inside the artery |

| | |to ensure that the patch angioplasty will be adequate treatment. Bring the patch onto the surgical field and |

| | |crop the edges to the final shape. Using fine vascular sutures, sew the patch circumferentially onto the |

| | |arteriotomy opening. Prior to closing the suture line, flush all of the vessels to remove any remaining air and|

| | |debris. Complete the suture line. Remove the vascular clamps and check for any leaks, applying additional |

| | |sutures as needed to seal the leaks. Administer the anticoagulant reversal agent and wait for it to take |

| | |effect. Irrigate the wound copiously with sterile saline. Use electrocautery or suture ligation to achieve |

| | |final hemostasis. Close the wound in multiple layers with special attention due to this reoperative site. Close|

| | |the skin. |

|[pic] |

|35884 |  |Clinical Example (35884) |

| | |A 68-year-old male with a 60-pack-per-year history of smoking underwent an aortobifemoral bypass graft 2 years |

| | |ago. He returns now complaining of left lower extremity calf claudication. Diagnostic studies (eg, duplex, |

| | |computed tomography, angiography, magnetic resonance angiography) reveal a severe focal stenosis at the |

| | |anastomosis between his bypass graft limb and the femoral artery in the left groin. Surgical exposure reveals |

| | |severe intimal hyperplasia in a focal pattern suitable for patch angioplasty treatment. An autogenous vein |

| | |patch is chosen. |

| | |Description of Procedure (35884) |

| | |Incise the skin in the groin overlying the distal end of the graft limb and the femoral arteries. Dissect |

| | |through the scarred soft tissue until the graft limb is located. Dissect through the scarred tissue around the |

| | |graft limb taking care to avoid the nerves and the veins that may be adherent to the graft limb. |

| | |Circumferentially dissect the graft limb and pass a soft rubber loop around it for control. Circumferentially |

| | |dissect the common femoral or distal-most external iliac artery and pass another soft rubber loop for control. |

| | |Circumferentially dissect the profunda femoris artery and pass a final soft rubber loop for control. |

| | |Perform the vein harvest. Shift attention to the vein harvest site, which is usually predetermined and |

| | |previously prepped. Incise the skin over the vein. Dissect through the soft tissue to find the vein. Carefully |

| | |dissect out the vein, tying and dividing all of the side branches. Check the original operative site to ensure |

| | |that a sufficient length of vein is exposed. Clamp the vein and excise the segment to be used for the patch. |

| | |Ligate the transected ends of the vein that remain in the patient. Open and examine the removed segment of the |

| | |vein on the back table to ensure suitability. Crop the vein to the shape required to serve as the patch. |

| | |Preserve the vein patch in a heparinized saline solution until it is time for use. |

| | |Move back to primary operative site. Administer the intravenous anticoagulant agent and wait for it to take |

| | |effect. Apply the vascular clamps to the graft limb, common femoral, profunda, and superficial femoral |

| | |arteries. Incise the hood of the graft and carry the opening across the toe of the anastomosis onto the native |

| | |artery. Examine the pathology inside the artery to ensure that the patch angioplasty will be adequate |

| | |treatment. Bring the patch onto the surgical field and crop the edges to the final shape. Using fine vascular |

| | |sutures, sew the patch circumferentially onto the arteriotomy opening. Before closing the suture line, flush |

| | |all of the vessels to remove any remaining air and debris. Complete the suture line. Remove the vascular clamps|

| | |and check for leaks, applying additional sutures as needed to seal all of the leaks. Administer the |

| | |anticoagulant reversal agent and wait for it to take effect. Irrigate the wound copiously with sterile saline |

| | |solution. Use electrocautery or suture ligation to achieve final hemostasis. Close the wound in multiple layers|

| | |paying special attention to the reoperative site. Close the skin. At the vein harvest site, use electrocautery |

| | |or suture ligation to achieve final hemostasis. Irrigate the wound copiously with sterile saline solution. |

| | |Close the subcutaneous tissue.Close the skin. |

|[pic] |

|36002 |  |Clinical Example (36002) |

| | |A 68-year-old male, status post-cardiac catheterization, develops an expanding painful hematoma not controlled |

| | |by compression. Physical examination reveals groin tenderness and a femoral bruit. A duplex examination is |

| | |performed, which demonstrates a pseudoaneurysm arising from the common femoral artery. The patient is referred |

| | |for percutaneous therapy. |

| | |Description of Procedure(s)/Service(s) (36002): |

| | |The physician examines the patient and explains the thrombin injection procedure to the patient and family, |

| | |obtaining informed consent. The patient's baseline vital signs are obtained and a brief physical exam of the |

| | |pseudoaneurysm site and pulses of that extremity are done. The patient is placed in supine position. The groin |

| | |is prepped with Betadine. The physician locates the pseudoaneurysm with imaging guidance and a biopsy guide for|

| | |accurate needle placement. The pseudoaneurysm is identified, as well as the native artery and vein adjacent to |

| | |the pseudoaneurysm. Using sterile technique and local anesthesia, the physician advances an angiocath, needle, |

| | |micropuncture catheter or other introducer into the pseudoaneurysm, using imaging guidance for accurate |

| | |positioning. A syringe containing thrombin solution is attached to the needle or catheter. Small amounts of the|

| | |thrombin mixture are injected into the pseudoaneurysm under imaging guidance until total thrombosis of the |

| | |pseudoaneurysm is demonstrated. The needle or catheter is withdrawn and the native artery, vein and the |

| | |thrombosed pseudoaneurysm are examined and recorded. Patency of the native artery and vein are confirmed. |

| | |Post-pseudoaneurysm occlusion vital signs are monitored. Patient remains on bed rest for a period of |

| | |observation. Many of these patients may be treated as outpatients. |

|[pic] |

|36400 |  |Clinical Example (36400) |

| | |A physician is called to the critical care unit to perform a technically difficult phlebotomy on a 2-year-old |

| | |child who is recovering from an overdose of an unknown medication. Laboratory tests of the blood have been |

| | |ordered on a 4 hour basis. The child has already had numerous phlebotomies of the arms and legs. Because of the|

| | |exceptional need for the laboratory evaluation and the condition of the old phlebotomy sites in the arms and |

| | |legs, the physician elects to draw blood from the femoral or jugular vein. The area is prepped for sterile |

| | |entry, necessary lighting and additional staff aid are summoned. After the physician obtains informed consent |

| | |from the parent/legal guardian, he/she obtains the specimen and prepares it for delivery to the laboratory. |

| | |Special attention is given to the site of the phlebotomy to ensure hemostasis and preserve the site for future |

| | |use. |

| | |Description of Procedure (36400) |

| | |The condition of the old phlebotomy sites are evaluated. The draw area is prepped for sterile entry. The |

| | |necessary lighting is then prepared. Staff is called in for assistance. Informed consent is obtained from the |

| | |parent or legal guardian. A specimen is obtained for delivery to the laboratory. |

|[pic] |

|36475 |  |Clinical Example (36475) |

| | |The patient is a 50-year-old, gravida 2, para 2, female with painful, unilateral leg swelling that increases |

| | |during the course of the day while she is at her job that requires standing for a significant portion of the |

| | |day. She has been diagnosed with great saphenous vein insufficiency with resultant superficial varicosities by |

| | |way of history, physical examination, and non-invasive ultrasound testing, all of which were performed during a|

| | |previous outpatient office visit. At that time, various treatment options were discussed and the patient has |

| | |decided to undergo percutaneous endovenous radiofrequency ablation therapy of the insufficient saphenous vein. |

| | |If it is necessary for endovenous ablation therapy to be coupled with stab phlebectomy and/or sclerotherapy, |

| | |these services are separately reportable using existing codes. |

| | |Description of Procedure (36475) |

| | |The physician sets up the operating field and then attaches a pressurized, heparin, saline drip to the sterile |

| | |radiofrequency ablation catheter. He/she then tests actuation, temperature, and impedance to ensure that all |

| | |components are connected and operating properly. Next, ultrasound guidance is used to find the targeted greater|

| | |saphenous vein (GSV) access site. Again using ultrasound guidance, the physician maps and marks the entire |

| | |length of the targeted vein, noting the vein depth and diameter, and vein tributaries. Local anesthetic is |

| | |given at the access site. The skin over the GSV access site is incised and a venotomy is performed. The |

| | |physician uses the Seldinger technique to introduce the guidewire next and then advances the dilator over the |

| | |guidewire. The exchange of the dilator for the sheath of the appropriate size occurs. The sheath is secured in |

| | |place by suture, the guidewire is removed and the sheath flushed. Next the radiofrequency (RF) probe is placed |

| | |through the sheath and advanced to the saphenofemoral junction using ultrasound guidance. The tip of the probe |

| | |just below the superficial epigastric tributary vein is located. Then the RF probe's position is verified by |

| | |ultrasound. Continuing the use of ultrasound guidance, the physician infiltrates tumescent anesthesic into the |

| | |perivenous space to create a "halo" of fluid around the GSV from the entry site to the saphenofemoral junction.|

| | |With the patient in the Trendelenburg position, he/she verifies that the target parameters are within |

| | |acceptable range. Afterward, the RF position is reconfirmed with ultrasound imaging. Next, RF energy is |

| | |applied. The physician carefully withdraws the probe, maintaining the target vein wall temperature by varying |

| | |the pullback rate and/or applying compression over the limb. The physician continues to monitor impedance, |

| | |power, and vein wall temperature throughout the procedure. Finally, he/she records the total RF application |

| | |time and repeats the ultrasound of the saphenous vein to confirm successful ablation. |

|[pic] |

|36476 |  |Clinical Example (36476) |

| | |The patient is a 50-year-old, gravida 2, para 2, female with painful, unilateral leg swelling that increases |

| | |during the course of the day while at her job that requires that she is standing for a significant portion of |

| | |the day. She has been diagnosed with great and small saphenous vein insufficiency with resultant superficial |

| | |varicosities by way of history, physical examination, and non-invasive ultrasound testing, all of which were |

| | |performed during a previous outpatient office visit. At that time various treatment options were discussed and |

| | |the patient has decided to undergo percutaneous endovenous radiofrequency ablation therapy of the insufficient |

| | |great and small saphenous veins. If it is necessary for endovenous ablation therapy to be coupled with stab |

| | |phlebectomy and/or sclerotherapy, these services are separately reportable using existing codes. |

| | |Description of Procedure (36476) |

| | |The physician retests actuation, temperature, and impedance to ensure that all components are connected and |

| | |operating properly. Next, he/she uses ultrasound guidance to find the targeted secondary vein access site. |

| | |Again using ultrasound guidance, he/she maps and marks the entire length of the targeted vein, noting vein |

| | |depth and diameter and maps vein tributaries. Local anesthesic is given at the new access site. Then skin is |

| | |incised over the new access site. A venotomy is performed. The physician uses the Seldinger technique to |

| | |introduce the guidewire next. Then he/she advances the dilator over the guidewire. The exchange of the dilator |

| | |for the sheath of the appropriate size occurs. Then the sheath is secured in place by suture, the guidewire is |

| | |removed, and the sheath flushed. Next the RF probe is placed through the sheath and advanced to the targeted |

| | |endpoint using ultrasound guidance. The RF probe position is verified by ultrasound. Continuing the use of |

| | |ultrasound guidance, the physician infiltrates tumescent anesthetic into the perivenous space to create a |

| | |"halo" of fluid around the targeted vein from the entry site to the endpoint. With the patient in the |

| | |Trendelenburg position, he/she verifies that the target parameters are within acceptable range. Afterward, the |

| | |RF position is reconfirmed with ultrasound imaging. Next, RF energy is applied. The physician carefully |

| | |withdraws the probe, maintaining the target vein wall temperature by varying pullback rate and/or applying |

| | |compression over the limb. The physician continues to monitor impedance, power and vein wall temperature |

| | |throughout the procedure. Finally, he/she records the total RF application time and repeats the ultrasound of |

| | |the saphenous vein to confirm successful ablation. |

|[pic] |

|36478 |  |Clinical Example (36478) |

| | |The patient is a 50-year-old, gravida 2, para 2, female with painful, unilateral leg swelling that increases |

| | |during the course of the day while she is at her job that requires standing for a significant portion of the |

| | |day. She has been diagnosed with great saphenous vein insufficiency with resultant superficial varicosities by |

| | |way of history, physical examination, and non-invasive, ultrasound testing, all of which were performed during |

| | |a previous, outpatient, office visit. At that time, various treatment options were discussed and the patient |

| | |has decided to undergo percutaneous, endovenous, laser, ablation therapy of the insufficient saphenous vein. If|

| | |it is necessary for endovenous, ablation therapy to be coupled with stab phlebectomy and/or sclerotherapy, |

| | |these services are separately reportable using existing codes. |

| | |Description of Procedure (36478) |

| | |The physician sets up the operating field and then attaches a pressurized, heparin, saline drip to the sterile,|

| | |laser, ablation catheter. He/she then tests actuation, temperature, and impedance to ensure that all components|

| | |are connected and operating properly. Next, he/she uses ultrasound guidance to find the targeted greater |

| | |saphenous vein (GSV) access site. Again using ultrasound guidance, he/she maps and marks the entire length of |

| | |the targeted vein, noting vein depth and diameter and maps vein tributaries. Local anesthetic is given at the |

| | |access site. Then skin over the GSV access site is incised. A venotomy is performed. The physician uses the |

| | |Seldinger technique to introduce the guidewire next. Then he/she advances the dilator over the guidewire. The |

| | |exchange of the dilator for the sheath of the appropriate size occurs. Then the sheath is secured in place by |

| | |suture, the guidewire is removed and the sheath flushed. Next the laser fiber is advanced through the sheath |

| | |and advanced to the saphenofemoral junction using ultrasound guidance. The tip of the fiber just below the |

| | |superficial epigastric tributary vein is located. Then the fiber position is verified by ultrasound. Continuing|

| | |the use of ultrasound guidance, the physician infiltrates tumescent anesthetic into the perivenous space to |

| | |create a "halo" of fluid around the GSV from the entry site to the saphenofemoral junction. With the patient in|

| | |the Trendelenburg position, he/she verifies that the target parameters are within acceptable range. Afterward, |

| | |the laser fiber position is reconfirmed with ultrasound imaging. Next laser energy is applied. The physician |

| | |carefully withdraws the probe, maintaining the target vein wall temperature by varying the pullback rate and/or|

| | |applying compression over the limb. The physician continues to monitor impedance, power and vein wall |

| | |temperature throughout the procedure. Finally, he/she records the total laser application time and repeats the |

| | |ultrasound of the saphenous vein to confirm successful ablation. |

|[pic] |

|36479 |  |Clinical Example (36479) |

| | |The patient is a 50-year-old, gravida 2, para 2, female with painful, unilateral leg swelling that increases |

| | |during the course of the day while she is at her job that requires standing for a significant portion of the |

| | |day. She has been diagnosed with great and small saphenous vein insufficiency with resultant superficial |

| | |varicosities by way of history, physical examination, and non-invasive ultrasound testing, all of which were |

| | |performed during a previous, outpatient, office visit. At that time, various treatment options were discussed |

| | |and the patient has decided to undergo percutaneous, endovenous, laser, ablation therapy of the insufficient |

| | |great and small saphenous veins. If it is necessary for endovenous, ablation therapy to be coupled with stab |

| | |phlebectomy and/or sclerotherapy, these services are separately reportable using existing codes. |

| | |Description of Procedure (36479) |

| | |The physician uses ultrasound guidance to find the targeted secondary vein access site. Again using ultrasound |

| | |guidance, he/she maps and marks the entire length of the targeted vein, noting the vein depth and diameter, and|

| | |maps vein tributaries. Local anesthetic is given at the new access site. Then skin over the new access site is |

| | |incised. A venotomy is performed. The physician uses the Seldinger technique to introduce the guidewire next. |

| | |Then he/she advances the dilator over the guidewire. The exchange of the dilator for the sheath of the |

| | |appropriate size occurs. Then the sheath is secured in place by suture, the guidewire is removed and the sheath|

| | |flushed. Next the laser fiber is placed through the sheath and advanced to target endpoint using ultrasound |

| | |guidance. The laser fiber position is verified by ultrasound. Again using ultrasound guidance, the physician |

| | |infiltrates tumescent anesthetic into the perivenous space to create a "halo" of fluid around the target vein |

| | |from the entry site to the endpoint. With the patient in the Trendelenburg position, he/she verifies that the |

| | |target parameters are within acceptable range. Afterward, the laser fiber position is reconfirmed with |

| | |ultrasound imaging. Laser energy is applied. The physician carefully withdraws the laser fiber, maintaining |

| | |target vein wall temperature by varying the pullback rate and/or applying compression over the limb. The |

| | |physician continues to monitor impedance, power and vein wall temperature throughout the procedure. Finally, |

| | |he/she records the total laser application time and repeats the ultrasound of the saphenous vein to confirm |

| | |successful ablation. |

|[pic] |

|36511 |  |Clinical Example (36511) |

| | |The typical patient is a 40-year-old female with acute leukemia who is found to have a leukemic blast count of |

| | |=50,000/µL or a total white blood cell count =100,000/µL. At such very high white blood cell or leukemic blast |

| | |counts there is an unacceptably high risk of cerebral or pulmonary leukostasis, a potentially fatal condition |

| | |that results from obstruction of small arteries or arterioles by adherent white blood cells. Patients typically|

| | |suffer strokes or respiratory failure. Emergent lowering of the circulating white blood cell mass, by |

| | |leukapheresis, is the only viable short-term management option. Under these circumstances, the patient is |

| | |hospitalized for the apheresis procedure. The physician who is responsible for the procedure must assess the |

| | |appropriateness of the procedure for the patient, calculate the parameters of apheresis prior to the procedure,|

| | |and manage the patient during the procedure. The procedure is typically performed emergently. |

| | |Description of Procedure (36511) |

| | |The procedure is performed using FDA-approved blood processing (apheresis) machines. The machine's tubing |

| | |system is connected to the patient's venous system either directly using the antecubital veins or, more |

| | |typically, through a large-bore, dual-lumen dialysis-type central venous catheter. The apheresis physician |

| | |either operates the machine or attends at the bedside while an apheresis nurse operates the machine. The |

| | |patient often requires intensive monitoring including cardiac monitoring and continuous pulse oximetry. The |

| | |patient is assessed at the end of the apheresis procedure. |

|[pic] |

|36512 |  |Clinical Example (36512) |

| | |The typical patient is a 21-year-old man with sickle cell anemia who has suffered a cerebral infarction and is |

| | |at very high risk of recurrent stroke. The only effective method for preventing a recurrence is to have his |

| | |blood chronically replaced with non-sickling blood. Simple red blood cell transfusion therapy is not acceptable|

| | |or appropriate because it would result in transfusional iron overload, a condition that results in heart |

| | |failure, liver failure, and death. Red blood cell exchange by apheresis does not result in iron overload. The |

| | |apheresis physician assesses the patient prior to initiating the procedure and determines the treatment |

| | |parameters necessary to achieve the targeted substitution of hemoglobin A blood for sickle hemoglobin blood. |

| | |Automated red blood cell exchange is performed at whole blood flow rates far in excess of typical blood |

| | |transfusions. The inherent risk of the procedure necessitates frequent attention on the part of the physician |

| | |during the procedure. A final assessment is performed at the termination of the procedure. |

| | |Description of Procedure (36512) |

| | |There are four FDA-approved apheresis machines to do this procedure. The patient is connected to the blood |

| | |processor (apheresis machine) by either the antecubital veins or using a large bore, dual-lumen dialysis |

| | |catheter. The apheresis procedure exchanges the patient's red blood cells for donor red blood cells. The |

| | |apheresis physician either operates the machine or attends the patient at the bedside while an apheresis nurse |

| | |operates the machine. The risk to the patient is moderate. The patient is assessed at the end of the apheresis |

| | |procedure. |

|[pic] |

|36513 |  |Clinical Example (36513) |

| | |The typical patient is a 65-year-old male with a myeloproliferative disorder (essential thrombocythemia, |

| | |chronic myelogenous leukemia, or polycythemia vera) whose platelet count is unusually high (=1,000,000/µL). |

| | |Because of the degree of thrombocytosis, there is a high risk of coronary or cerebral infarction. Therapeutic |

| | |apheresis often is performed emergently because of altered mental status resulting from the thrombocytosis. The|

| | |apheresis physician assesses the patient and determines the appropriateness of therapeutic apheresis. The |

| | |physician also calculates the exchange parameters and writes orders for the procedure. This is a high-acuity |

| | |setting and the physician is in attendance during the procedure. |

| | |Description of Procedure (36513) |

| | |The patient is connected to an apheresis machine. The patient's platelets are removed by an apheresis machine. |

| | |The patient is assessed at the end of the apheresis procedure. |

|[pic] |

|36514 |  |Clinical Example (36514) |

| | |The typical patient is a 25-year-old male with thrombotic thrombocytopenic purpura. The universally accepted |

| | |first-line therapy for this life-threatening condition is therapeutic plasma exchange. The apheresis physician |

| | |assesses the patient prior to the procedure, paying particular attention to clinical parameters that determine |

| | |the patient's ability to tolerate exposure to unusually large volumes of allogeneic plasma. The apheresis |

| | |physician writes orders for the procedure, which often must be performed on a daily basis, determines the |

| | |appropriate biological replacement fluid, and manages blood product support. These patients are typically |

| | |treated using a dual-lumen, large-bore dialysis-type catheter. The apheresis physician manages the catheter and|

| | |monitors the patient for catheter-related complications. |

| | |Description of Procedure (36514) |

| | |The patient's blood is drawn into the apheresis machine for the purpose of separating blood from plasma. The |

| | |plasma is diverted to a collection bag and the cells are returned to the patient with a biological replacement |

| | |fluid such as allogeneic plasma or human serum albumin as determined by the apheresis physician. The apheresis |

| | |physician manages the central venous dialysis-type catheter on treatment days and on off days. The apheresis |

| | |physician also must manage allergic reactions to the biological replacement fluids and transfusion reactions |

| | |that may occur when plasma is the replacement fluid. The patient is assessed at the end of the apheresis |

| | |procedure. |

|[pic] |

|36515 |  |Clinical Example (36515) |

| | |The typical patient has hereditary hemophilia A (factor VIII deficiency) and a high-titer immunoglobulin |

| | |inhibitor to human factor VIII replacement products. He is acutely and spontaneously hemorrhaging and is unable|

| | |to respond favorably to infusions of human factor VIII. The apheresis procedure is indicated for removal of the|

| | |high-titer IgG anti-factor VIII antibodies from the patient's plasma without removing other plasma proteins |

| | |such as clotting factors and fibrinogen. The apheresis machine is used to separate the patient's plasma from |

| | |the cellular components of whole blood so that the plasma can be adsorbed on a special affinity column which |

| | |removes the IgG but allows the rest of the plasma constituents to pass through unadsorbed. The factor VIII |

| | |inhibitor titer is thus lowered sufficiently to permit the patient to respond to infused human factor VIII. |

|[pic] |

|36516 |  |Clinical Example (36516) |

| | |The typical patient is a homozygote or heterozygote with familial hypercholesterolemia whose serum lipids have |

| | |not been satisfactorily controlled with maximum medical therapy. Often these patients will have had a |

| | |myocardial infarction or other manifestations of coronary artery disease before age 40 years. Weekly or |

| | |semi-monthly lipid apheresis is the only effective method for controlling symptomatic hyperlipidemias in these |

| | |patients. The apheresis physician is responsible for assessing the appropriateness of this therapy for the |

| | |individual patient, for writing appropriate orders, and for managing the patient during treatments. If a venous|

| | |access device or catheter is required, the apheresis physician is responsible for managing the catheter or |

| | |venous device as well. |

| | |Description of Procedure (36516) |

| | |Plasma separation is performed and LDL cholesterol is selectively removed. Depending on the specific device |

| | |used, the patient's treated plasma may require post-adsorption treatment prior to being reinfused into the |

| | |patient. The patient is monitored for allergic reactions and for thrombocytopenia. The risk to the patient is |

| | |above moderate. The patient is assessed at the end of the apheresis procedure. |

|[pic] |

|36521 |  |A 52-year-old woman has a diagnosis of class III rheumatoid arthritis and a 7-year history of active disease |

| | |and positive rheumatoid factor. Treatment with conventional disease-modifying, antirheumatic drugs, including |

| | |methotrexate and hydroxychloroquine has failed. Physical examination shows bilateral joint pain involving 10 |

| | |swollen and 13 painful joints. The patient complains of at least 60 minutes of morning stiffness. ESR is > 28 |

| | |mm/hour. The patient is currently receiving stable doses of nonsteroidal anti-inflammatory agents and 10 mg of |

| | |prednisone, once daily. The patient is on oral iron supplement for mild anemia associated with chronic |

| | |inflammatory disease process. |

|[pic] |

|36536 |  |Clinical Example (36536) |

| | |A 68-year-old male with gastric cancer and a subcutaneous port presents with a poorly functioning port. |

| | |Infusion/injection can be made but blood cannot be aspirated. |

| | |Description of Procedure (36536) |

| | |After venous access (work of access is separately billable and not included in code 36536), a vascular snare is|

| | |placed in the cava through the catheter, and the tip of the central venous catheter is engaged with the snare. |

| | |The fibrin sheath and thrombus are stripped from the catheter. |

|[pic] |

|36537 |  |Clinical Example (36537) |

| | |A 68-year-old male with gastric cancer and a subcutaneous port presents with a poorly functioning port. |

| | |Infusion/injection can be made but blood cannot be aspirated. |

| | |Description of Procedure (36537) |

| | |A ureteral brush is inserted into the catheter lumen and pushed toward the distal tip of the catheter, through |

| | |the distal end hole, and then retracted into the catheter. The maneuver is repeated several times to "brush" |

| | |the multiple side holes and the distal end hole. The ureteral brush is removed. The catheter is flushed with |

| | |appropriate amounts of saline and heparin and the ports are clamped. A sterile dressing is reapplied on the |

| | |chest wall at the catheter entry site. |

|[pic] |

|36550 |  |A cancer patient requiring ongoing, intermittent, and/or maintenance therapy requires the access and flush of |

| | |the device with a thrombolytic agent for a partially clotted implanted vascular access device. |

|[pic] |

|36555 |  |Clinical Example (36555) |

| | |A 2-year-old male needs a central venous catheter. A percutaneous non-tunneled centrally inserted central |

| | |venous (CV) catheter is inserted. |

| | |Description of Procedure (36555) |

| | |Local lidocaine anesthesia is administered. The subclavian/jugular vein is punctured and a guidewire passed |

| | |centrally. The CV catheter is then placed. The catheter is sutured in position and dressed in standard fashion,|

| | |and attached to IV infusion fluids. |

|[pic] |

|36556 |  |Clinical Example (36556) |

| | |A 40-year-old female needs a central venous catheter. A centrally inserted, non-tunneled, central venous |

| | |catheter is inserted. |

| | |Description of Procedure (36556) |

| | |Local lidocaine anesthesia is administered. The subclavian/internal jugular vein is punctured and a guidewire |

| | |passed centrally. The venotomy site is dilated to the appropriate size and the CV catheter is then placed. The |

| | |catheter is sutured in position and dressed in standard fashion, and flushed or attached to IV infusion fluids.|

|[pic] |

|36557 |  |Clinical Example (36557) |

| | |A 12-month-old girl requires long-term central venous access. A centrally inserted tunneled central venous |

| | |catheter is inserted. |

| | |Description of Procedure (36557) |

| | |Local lidocaine anesthesia is administered. A percutaneous or cut down approach is used in the neck and venous |

| | |access achieved. A subcutaneous tunnel is then created from the anterior chest wall to the venotomy site and |

| | |the catheter passed though the tunnel. The CV catheter is then placed. The catheter is sutured in position and |

| | |the skin incisions are sutured as needed. The wounds are dressed in standard fashion, and the catheter ports |

| | |attached to IV infusion fluids. |

|[pic] |

|36558 |  |Clinical Example (36558) |

| | |A 55-year-old male needs long-term central venous access. A tunneled centrally inserted central venous dialysis|

| | |catheter is placed. |

| | |Description of Procedure (36558) |

| | |Local lidocaine anesthesia is administered. The subclavian/internal jugular vein is punctured and a guidewire |

| | |passed centrally. A subcutaneous tunnel is then created from the anterior chest wall to the venotomy site and |

| | |catheter passed though the tunnel. The venotomy site is dilated to the appropriate size and the CV catheter is |

| | |then placed. The catheter is sutured in position and the skin incisions are sutured as needed. The wounds are |

| | |dressed in standard fashion, and catheter ports flushed or attached to IV infusion fluids. |

|[pic] |

|36560 |  |Clinical Example (36560) |

| | |A 3-year-old male is admitted and requires long-term central venous catheter. A tunneled centrally inserted |

| | |central venous catheter with a subcutaneous port is inserted. |

| | |Description of Procedure (36560) |

| | |Local lidocaine anesthesia is administered. The subclavian/internal jugular vein is punctured and a guidewire |

| | |passed centrally. A subcutaneous pocket and tunnel are then created from the anterior chest wall to the |

| | |venotomy site and catheter passed though the tunnel. The CV catheter is then placed. The catheter is connected |

| | |to the port device and connection checked with injection. The port is secured in the chest wall pocket. The |

| | |skin incisions are sutured. The wounds are dressed in standard fashion. |

|[pic] |

|36561 |  |Clinical Example (36561) |

| | |A 45-year-old female requires long-term central venous access. A tunneled centrally inserted central venous |

| | |catheter with subcutaneous port is inserted. |

| | |Description of Procedure (36561) |

| | |Local lidocaine anesthesia is administered. The internal jugular/subclavian vein is punctured and a guidewire |

| | |passed centrally. A subcutaneous pocket and tunnel are then created from the anterior chest wall to the |

| | |venotomy site and catheter passed though the tunnel. The CV catheter is then placed. The catheter is connected |

| | |to the port device and connection checked with injection. The port is secured in the chest wall pocket. The |

| | |skin incisions are sutured. The wounds are dressed in standard fashion. |

|[pic] |

|36563 |  |Clinical Example (36563) |

| | |A 57-year-old male requires long-term central venous therapy. A central venous catheter with subcutaneous pump |

| | |is placed. |

| | |Description of Procedure (36563) |

| | |Local lidocaine anesthesia is administered. The subclavian/internal jugular vein is punctured and a guidewire |

| | |passed centrally. A subcutaneous pocket and tunnel are then created from the anterior chest wall to the |

| | |venotomy site and catheter passed though the tunnel. The CV catheter is then placed. The catheter is connected |

| | |to the pump device and connection checked with injection. The pump is secured in the chest wall pocket. The |

| | |skin incisions are sutured. The wounds are dressed in standard fashion. |

|[pic] |

|36565 |  |Clinical Example (36565) |

| | |A 55-year-old male with end-stage renal disease is referred for a tunneled CV access device. Decision is made |

| | |to place a two-catheter system via separate venous access sites. |

| | |Description of Procedure (36565) |

| | |Local lidocaine anesthesia is administered. For each catheter and access site, the internal jugular vein is |

| | |punctured and a guidewire passed centrally. Two subcutaneous tunnels are created from the anterior chest wall |

| | |to the venotomy sites and catheters passed through the tunnels. Both venotomy sites are dilated to appropriate |

| | |size. The CV catheters are then placed. The catheters are sutured in position. The skin incisions are sutured. |

| | |The wounds are dressed in standard fashion and catheters flushed. |

|[pic] |

|36566 |  |Clinical Example (36566) |

| | |A 61-year-old female with chronic renal failure requires long-term catheter access for dialysis. She is |

| | |referred for placement of a multicatheter multiport central venous dialysis system for anticipated long-term |

| | |use. |

| | |Description of Procedure (36566) |

| | |Local lidocaine anesthesia is administered. For each catheter and access site, the internal jugular vein is |

| | |punctured and a guidewire passed centrally. Two subcutaneous pockets and tunnels from the anterior chest wall |

| | |to the venotomy sites are created and catheters passed though the tunnels. Both venotomy sites are dilated to |

| | |appropriate size. The CV catheters are then placed. The catheters are attached to their respective port devices|

| | |and the connections checked by injection. The ports are secured in the chest wall pockets. The skin incisions |

| | |are sutured. The wounds are dressed in standard fashion. |

|[pic] |

|36568 |  |Clinical Example (36568) |

| | |A 3-year-old male requires long-term antimicrobial therapy. A peripherally inserted central venous catheter |

| | |(PICC) is placed. |

| | |Description of Procedure (36568) |

| | |Local lidocaine anesthesia is administered. The basilic vein is punctured. The peripherally inserted central |

| | |venous catheter is cut to length and then placed. The catheter is fastened in position and dressed in standard |

| | |fashion, and flushed or attached to IV infusion fluids. |

|[pic] |

|36569 |  |Clinical Example (36569) |

| | |A 62-year-old male requires long-term antimicrobial therapy. A peripherally inserted central venous catheter |

| | |(PICC) is inserted. |

| | |Description of Procedure (36569) |

| | |Local lidocaine anesthesia is administered. The basilic vein is punctured and a guidewire passed centrally. The|

| | |peripherally inserted central venous catheter is cut to appropriate length and then placed. The catheter is |

| | |sutured in position and dressed in standard fashion, and flushed or attached to IV infusion fluids. |

| | |Implantable Venous access port (36570-36571, 36576, 36578) |

|[pic] |

|36570 |  |Clinical Example (36570) |

| | |A 4-year-old girl needs long-term intravenous therapy. A peripherally inserted central venous access catheter |

| | |with subcutaneous port is placed. |

| | |Description of Procedure (36570) |

| | |Local lidocaine anesthesia is administered. The basilic vein is punctured. Peripherally inserted central |

| | |catheter is measured and cut to length and then placed. A subcutaneous pocket is created. The catheter is |

| | |attached to the port and connection tested by injection. The port is secured in the pocket. The pocket is |

| | |sutured and dressed in standard fashion. |

|[pic] |

|36571 |  |Clinical Example (36571) |

| | |A 30-year-old male requires long-term intravenous therapy. A peripherally inserted central venous access device|

| | |with a subcutaneous port is inserted. |

| | |Description of Procedure (36571) |

| | |Local lidocaine anesthesia is administered. The basilic vein is punctured and a guidewire passed centrally. A |

| | |subcutaneous pocket is then created. The catheter is measured to length and then placed. The catheter is |

| | |connected to the port device and connection checked with injection. The port is secured into the pocket. The |

| | |skin incisions are sutured. The wounds are dressed in standard fashion. |

|[pic] |

|36575 |  |Clinical Example (36575) |

| | |A patient has a previously placed, single lumen central venous catheter without port/pump. In the process of |

| | |cutting tape for a home dressing change, the patient accidentally cuts the catheter six inches from the skin. |

| | |He has clamped the cut catheter and presents for catheter repair. |

| | |Description of Procedure (36575) |

| | |Under usual sterile conditions, the remaining catheter is trimmed perpendicular to the catheter axis. A new |

| | |catheter hub segment is spliced onto the existing catheter and the splice tested with injection. The catheter |

| | |is then redressed and flushed in standard fashion. |

|[pic] |

|36576 |  |Clinical Example (36576) |

| | |A patient presents with a radiologically confirmed leak in a previously placed central venous catheter with |

| | |subcutaneous port or pump immediately adjacent to the catheter connection to the subcutaneous port/pump. |

| | |Description of Procedure (36576) |

| | |Local lidocaine anesthesia is administered at the site of the existing subcutaneous pocket. Under usual sterile|

| | |conditions, the port pocket opened. The catheter is disconnected, trimmed proximal to the damaged section, and |

| | |reconnected to the port/pump. The connection is tested by injection. The port/pump is resecured in the pocket |

| | |and the pocket is sutured closed. The wound is dressed in standard fashion. |

|[pic] |

|36578 |  |Clinical Example (36578) |

| | |A patient presents with a double lumen tunneled central venous catheter (one catheter with two lumens through |

| | |one venous entry site) with subcutaneous port. The port cannot be aspirated but recent CXR demonstrated the |

| | |catheter tip to be in good position. Only the catheter requires replacement. |

| | |Description of Procedure (36578) |

| | |Local lidocaine anesthesia is administered at the site of the existing subcutaneous pocket. The pocket is |

| | |incised and the port dissected free. The port is examined and found to be functioning. The catheter channels |

| | |are found to be occluded. A guidewire is able to be advanced through one of the channels and the old catheter |

| | |withdrawn. A new dual channel catheter is cut to length and advanced over the guidewire into central venous |

| | |position. The catheter is connected to the port device and connections checked with injection. The port is |

| | |secured in the chest wall pocket. The skin incision is sutured and the wound dressed in standard fashion. |

|[pic] |

|36580 |  |Clinical Example (36580) |

| | |A patient with a non-tunneled central venous catheter is referred due to poor flow rates despite prior attempts|

| | |at removal of pericatheter and intracatheter material. Decision is made to replace the existing catheter |

| | |through the same venous entry site. |

| | |Description of Procedure (36580) |

| | |Local lidocaine anesthesia is administered. A guidewire is passed centrally through the existing catheter. The |

| | |existing catheter is removed and a new CV catheter is then placed. The catheter is sutured in position and |

| | |dressed in standard fashion, and flushed or attached to IV infusion fluids. |

|[pic] |

|36581 |  |Clinical Example (36581) |

| | |A patient with a tunneled central venous catheter without port/pump is referred due to poor flow rates despite |

| | |prior attempts at removal of pericatheter and intracatheter material. Decision is made to replace the existing |

| | |catheter through the same venous entry site. |

| | |Description of Procedure (36581) |

| | |Local lidocaine anesthesia is administered. The cuff of the indwelling tunneled catheter is dissected free from|

| | |the subcutaneous tissue. A guidewire is passed centrally through the existing catheter. The existing catheter |

| | |is removed and a new CV catheter is then placed. The catheter is sutured in position and dressed in standard |

| | |fashion, and flushed or attached to IV infusion fluids. |

|[pic] |

|36582 |  |Clinical Example (36582) |

| | |A patient presents with a double lumen tunneled central venous catheter (one catheter with two lumens through |

| | |one venous entry site) with subcutaneous ports. The ports cannot be aspirated but a recent chest x-ray |

| | |demonstrated the catheter tip to be in good position. |

| | |Description of Procedure (36582) |

| | |Local lidocaine anesthesia is administered. The subcutaneous pocket is surgically incised and the port |

| | |dissected free. The catheter is disconnected from the port and the port removed. A guidewire is passed |

| | |centrally through the existing catheter. The existing catheter is removed and a new CV catheter is measured to |

| | |correct length and then placed. The catheter is connected to the new port device and connections checked with |

| | |injection. The port is secured into the chest wall pocket. The skin incision is sutured. The wound is dressed |

| | |in standard fashion. |

|[pic] |

|36583 |  |Clinical Example (36583) |

| | |A 50-year-old male with an existing central venous catheter with subcutaneous pump is referred due to pump |

| | |malfunction. Decision is made to replace the pump and central venous catheter through the same venous access |

| | |site. |

| | |Description of Procedure (36583) |

| | |Local lidocaine anesthesia is administered. The subcutaneous pocket is surgically incised and the pump |

| | |dissected free. The pump is tested and found to be non-functional. The catheter is disconnected from the pump |

| | |and the pump removed. A guidewire is passed centrally through the existing catheter. The existing catheter is |

| | |removed and a new CV catheter is measured to correct length and then placed. The catheter is connected to a new|

| | |pump device and connection checked with injection. The pump is secured in the chest wall pocket. The skin |

| | |incision is sutured. The wound is dressed in standard fashion. |

|[pic] |

|36584 |  |Clinical Example (36584) |

| | |A patient is referred due to occlusion of the previously placed peripherally inserted central catheter (PICC) |

| | |line. |

| | |Description of Procedure (36584) |

| | |Local lidocaine anesthesia is administered. The existing catheter is cut and partially withdrawn. A vascular |

| | |sheath is placed over the occluded catheter into the access vein and the old catheter removed. A guidewire is |

| | |advanced through the new sheath centrally. The new catheter is then cut to appropriate length and advanced over|

| | |the guidewire through the sheath. The sheath is removed. The catheter is fastened in position and dressed and |

| | |flushed in standard fashion. |

|[pic] |

|36585 |  |Clinical Example (36585) |

| | |A patient presents with a previously placed peripherally inserted central venous access device with a |

| | |subcutaneous port that is occluded and not functional. Decision is made to replace the port and catheter from |

| | |the same venous access site. |

| | |Description of Procedure (36585) |

| | |Local lidocaine anesthesia is administered. The skin is surgically incised and the existing port dissected |

| | |free. The port is disconnected from the catheter and found to be non-functional. A guidewire is advanced |

| | |centrally through the existing catheter. The new catheter is then cut to length and advanced over the |

| | |guidewire. The new catheter is connected to the new port device and connection checked with injection. The port|

| | |is placed into the pocket and secured. The skin incision is sutured. The wounds are dressed in standard |

| | |fashion. |

|[pic] |

|36589 |  |Clinical Example (36589) |

| | |A patient with a previously placed tunneled central venous dialysis catheter no longer needs central venous |

| | |access. Discussion with the patient and physician confirms the decision to remove the previously placed |

| | |catheter. |

| | |Description of Procedure (36589) |

| | |Local lidocaine anesthesia is injected. The tunneled central venous catheter is surgically removed by cut-down |

| | |and blunt dissection. Hemostasis is established with manual pressure. The wound is closed and dressed in |

| | |standard fashion. |

|[pic] |

|36590 |  |Clinical Example (36590) |

| | |A patient has completed treatment and no longer needs the previously placed central venous access device with |

| | |port/pump. Discussion with the patient and their primary physician confirms the decision to remove the |

| | |previously placed tunneled central venous catheter and port/pump device. |

| | |Description of Procedure (36590) |

| | |Local lidocaine anesthesia is administered. The skin is surgically incised and the existing port dissected |

| | |free. The port and catheter are removed. Hemostasis is established with manual pressure. The port pocket is |

| | |closed and dressed in standard fashion. |

|[pic] |

|36597 |  |Clinical Example (36597) |

| | |The patient is a 60-year-old male with congestive heart failure who had a single lumen left subclavian central |

| | |venous catheter placed for central pressure monitoring. Chest radiograph following insertion of the catheter |

| | |showed the misposition of the catheter tip in the right internal jugular vein. Repositioning of the central |

| | |venous catheter to the superior vena cava with fluoroscopic guidance was requested. |

| | |Description of Procedure (36597) |

| | |The physician evaluates the position of the catheter. Following the evaluation, the catheter is manipulated and|

| | |repositioned to the desired location, and sutured to the skin. A report is dictated. |

|[pic] |

|36598 |  |Clinical Example |

| | |A 45-year-old patient with Hodgkin’s lymphoma is undergoing several weeks of chemotherapy, and a Hickman |

| | |catheter was previously placed to allow for ongoing intravenous chemotherapy and frequent blood draws. After 2 |

| | |months, however, the oncology staff is no longer able to draw blood from the catheter. It is not clear whether |

| | |the catheter tip remains in the vein, and the oncology staff is unable to administer the chemotherapy without |

| | |knowing the location of the catheter tip. The patient is referred for imaging of the catheter to determine its |

| | |position, patency, and if anything can be done to restore the ability to draw blood from the catheter. |

| | |Description of Procedure |

| | |The physician performs a quick physical inspection of the catheter site. If the catheter is not dislodged or |

| | |kinked, the physician exposes and preps the external port of the catheter in sterile fashion. Fluoroscopic |

| | |evaluation of the catheter is performed by the physician, confirming that the tip of the catheter lies in the |

| | |central vein as intended and has not migrated into the heart or been pulled back into a peripheral vein or out |

| | |of the vein. Fluoroscopy also determines if the catheter has been fractured or kinked. The physician aspirates |

| | |the catheter and indwelling anticoagulant is discarded if possible. Contrast is injected by the physician with |

| | |imaging of the catheter tip and the vein where the catheter tip is positioned. If necessary, imaging is |

| | |performed along the course of the catheter to determine if there is a leak in the catheter. (Once imaging is |

| | |completed, any procedures that are done to try to restore function of the catheter, if necessary, are coded |

| | |separately.) The catheter is flushed with saline and may be locked with anticoagulant solution. |

|[pic] |

|36818 |  |Clinical Example (36818) |

| | |A 38-year-old, obese, diabetic female requires hemodialysis for chronic renal failure. On physical exam, she |

| | |has no visible superficial veins on either side at the wrist, forearm, antecubital fossa or upper arm. Duplex |

| | |ultrasound identifies a normal diameter cephalic vein 1 cm under the skin on the lateral aspect of her upper |

| | |arm. To create an autogenous, hemodialysis access, the vein must be rerouted through a superficial tunnel to |

| | |reach the brachial artery on the medial aspect of her arm, just above the elbow. A cephalic vein transposition |

| | |is recommended. |

| | |Description of Procedure (36818) |

| | |The physician makes a skin incision over the approximate location of the cephalic vein from the elbow towards |

| | |the shoulder for distance that is long enough to accomplish transposition. Then the subcutaneous tissue is |

| | |dissected until the vein is located. Next, he/she ligates and divides all vein branches. The vein is dissected |

| | |entirely from the surrounding tissue with careful attention to avoid venous injury. The physician makes |

| | |separate small incisions over the brachial artery just proximal to the antecubital crease. Then, he/she |

| | |dissects brachial veins and adjacent soft tissue from the artery. Small branches of the artery are encircled |

| | |with silk ties. The physician then creates a superficial, subcutaneous tunnel that is long enough for adequate |

| | |hemodialysis access and appropriate to allow the vein to reach across the arm to the brachial artery. |

| | |Intravenous anticoagulant is administered. The physician ligates and divides the cephalic vein near the |

| | |antecubital area. The physician then inserts the cannula into the transected end of the vein and gently |

| | |distends the vein. Next, he/she searches for any venous leaks and sutures them if found. The physician marks a |

| | |stripe on the vein longitudinally with a tissue marking pen to avoid twisting on its passage through the |

| | |tunnel. The end of the cephalic is clamped and pulled through the tunnel. The brachial artery is occluded with |

| | |vascular clamps. Next, the brachial artery is incised to create a 7 mm longitudinal arteriotomy. The end of the|

| | |cephalic vein is trimmed to match the arteriotomy. The physician performs a cobra-head-shaped anastomosis |

| | |end-of-vein to side-of-artery with suture. The proximal and distal artery are vented to flush air and debris |

| | |out of the anastomosis. Then the anastomotic suture is tied and the physician checks for thrill in the vein. |

| | |The vein is inspected in the tunnel to ensure no leaks or kinks exist. The wounds are irrigated and hemostasis |

| | |is achieved. The physician closes the subcutaneous tissue of both incisions. He/she then closes the skin of |

| | |both incisions. Finally, the wrist pulse and hand are checked to ensure adequate perfusion. |

|[pic] |

|36819 |  |A 38-year-old diabetic woman requires hemodialysis for chronic renal failure due to diabetic nephropathy. She |

| | |has no superficial veins of adequate size to perform an arteriovenous Cimino-type fistula at the wrist. She has|

| | |no visible antecubital veins. A normal-size basilic vein is identified by duplex ultrasound in her upper arm, |

| | |but this vein is in its typical deep subcutaneous location. Placement of a synthetic dialysis graft is not the |

| | |best clinical choice for this young woman. A basilic vein transposition is recommended to provide her with a |

| | |fully autogenous dialysis access. |

|[pic] |

|36820 |  |Clinical Example (36820) |

| | |A 38-year-old diabetic female requires hemodialysis for chronic renal failure due to diabetic nephropathy. She |

| | |has no superficial veins of adequate size to perform a traditional arteriovenous Cimino-type fistula at the |

| | |wrist. She has no visible antecubital veins. However, using Duplex ultrasound, a 3 mm vein is identified in the|

| | |medial aspect of the forearm. This vein is not adequately close to the radial artery to perform a direct |

| | |arteriovenous anastomosis without transposition (eg, 36821). Placement of a synthetic dialysis graft is not the|

| | |best clinical choice for this young woman. Transposition of the forearm vein is recommended to provide her with|

| | |a fully autogenous dialysis access. |

| | |Description of Procedure (36820) |

| | |Skin incision is made over the approximate location of the forearm vein starting at the wrist and proceeding |

| | |proximally to the elbow. The subcutaneous tissue is dissected until the vein is located. Care is taken to avoid|

| | |the sensory nerves that almost always cross the vein. All vein branches are ligated and divided. The vein is |

| | |dissected entirely from the surrounding tissue from the wrist to the elbow, paying close attention to avoid |

| | |venous injury. Dissection is continued proximally until the whole venous segment is free. |

| | |A separate small incision is made over the radial artery just above the wrist. The radial veins and adjacent |

| | |soft tissue are dissected from the artery. Small branches of the artery are encircled with silk ties. A |

| | |subcutaneous tunnel is created from the radial artery towards the elbow. Intravenous heparin is administered |

| | |for anticoagulation. The forearm vein is ligated and divided as close to the wrist as possible. The end of the |

| | |forearm vein is clamped and pulled through the tunnel. The radial artery is temporarily occluded. A |

| | |longitudinal arteriotomy is performed. The end of the forearm vein is fashioned in order to perform a |

| | |cobra-head-shaped anastomosis to the artery, and that is carried out with fine polypropylene suture. Upon |

| | |finishing the anastomosis and before tying the suture, proximal and distal bleeding is allowed to flush the |

| | |anastomosis. The suture is tied. A good thrill along the vein in the tunnel indicates adequate flow. The wound |

| | |is irrigated, hemostasis achieved, and the subcutaneous tissue and skin are closed. Distal wrist pulse is |

| | |evaluated and the hand checked for adequate perfusion. |

|[pic] |

|36821 |  |A 38-year-old diabetic woman requires hemodialysis for chronic renal failure due to diabetic nephropathy. She |

| | |has superficial veins of adequate size to perform a traditional arteriovenous Cimino-type fistula at the wrist.|

|[pic] |

|36823 |  |Clinical Example (36823) |

| | |A 55-year-old male two years status post-resection of an intermediate thickness malignant melanoma returns with|

| | |multiple in-transit metastases on his right, lower extremity. The patient is medically fit and there is no |

| | |evidence of other metastatic disease. He is subsequently taken to the operative suites where an isolated |

| | |hyperthermic limb perfusion is performed. The patient subsequently recovers from the operative procedure in the|

| | |intensive care unit initially, and subsequently on the floor. He is discharged home on the fifth post operative|

| | |day. |

| | |Description of Procedure (36823) |

| | |Upon arrival in the operative suite after the mandatory general anesthesia has been secured, a urinary drainage|

| | |catheter is routinely placed and the appropriate limb is widely prepped and draped in a standard fashion. |

| | |Incisions are made for the exposure of the perfusion vessels (such as external iliac, femoral or popliteal) |

| | |then the vessels are encircled with appropriate vascular instrumentation. |

| | |Cannulas are placed in position and manipulated beyond the proposed tourniquet site. The cannulas are then |

| | |connected to the perfusion circuit and management of intraoperative anticoagulation is initiated. The |

| | |appropriate site for tourniquet application is made and the tourniquet applied and the perfusion begun. |

| | |Cannulas frequently require manipulation to insure optimal flow rates. Once this stable perfusion circuit is |

| | |established, the limb may be warmed to facilitate the chemotherapeutic effect, which must be coordinated using |

| | |sterile tissue warmers, and invasive extremity temperature probes are routinely placed. The appropriate |

| | |chemotherapeutic drugs are then administered. |

| | |Evaluation of leakage rates from the perfusion circuit must be assessed. Following completion of the prescribed|

| | |perfusion dose and time, the tourniquet is removed as are the cannulas. The arteriotomy and venotomy are then |

| | |repaired using standard vascular surgical techniques. This procedure may be combined with nodal dissections |

| | |when needed (which should be coded for separately). The anticoagulation is then managed with or without |

| | |reversal, and after placement of appropriate drainage catheters, the wounds are closed in multiple layers. |

| | |Appropriate dressings are applied and the patient is transferred to a recovery area after appropriate operative|

| | |notes, dictations, and orders are completed. |

|[pic] |

|36838 |  |Clinical Example (36838) |

| | |A 65-year-old diabetic with renal failure underwent creation of a brachio-cephalic hemodialysis fistula (CPT |

| | |36821) 1 month ago. She returns with complaint of increasingly severe hand and finger pain. Noninvasive |

| | |vascular studies confirm hand ischemia with finger pressures 30 mm Hg, LESP > 5 mm Hg, complete LES |

| | |relaxation in response to swallow, a DeMeester score >14.7, Hetzel grade 1 esophagitis, and no hiatal hernia > |

| | |2 cm. Under conscious sedation, an upper GI endoscopy, with delivery of radiofrequency thermal energy to the |

| | |muscle of the lower esophageal sphincter and/or gastric cardia, is performed. |

| | |Description of Procedure (43257) |

| | |After intravenous access is obtained and conscious sedation administered, an esophagogastroduodenoscopy (EGD) |

| | |is performed to confirm the absence of pathology that would represent a contraindication to the performance of |

| | |the proposed procedure. The upper endoscope is then positioned in the gastric antrum, and a guidewire is passed|

| | |through the endoscope into the duodenum or gastric antrum. The endoscope is withdrawn while noting the distance|

| | |from the incisors to the gastroesophageal junction. The thermal catheter is passed over the guidewire and |

| | |positioned 1 cm proximal to the squamocolumnar junction. The thermal catheter balloon is inflated to 2.5 psi, |

| | |needle electrodes (4) deployed, and radiofrequency (RF) energy delivery commenced. This treatment is repeated |

| | |after rotating the catheter 45 degrees and then again by advancing it 5 mm (4 treatments thus far). The |

| | |catheter is then advanced into the stomach. An endoscope is re-introduced per-oral and passed alongside the |

| | |catheter to confirm accurate positioning of the first 2 rings. The endoscope is then withdrawn. Third and |

| | |fourth rings, comprised of eight lesions per ring, are then placed in 5 mm increments distal to the second |

| | |ring, adjusting the measurements according to the endoscopic findings. The catheter is then advanced into the |

| | |stomach, fully inflated to 25 cc of air, and withdrawn into the gastric cardia. Three such deployments and |

| | |lesion sets are created, totaling 12 lesions in the distal cardia. This is repeated with a balloon inflated to |

| | |22 cc, creating 12 lesions in the proximal cardia. A third EGD is performed to confirm lesion placement. The |

| | |catheter is then withdrawn. |

|[pic] |

|43259 |  |Clinical Example (43259) |

| | |A 67-year-old woman who develops painless jaundice is identified to have dilation of her bile duct and |

| | |pancreatic duct on CT scan. A discrete mass lesion is not identified. The patient is referred for an endoscopic|

| | |ultrasound to identify if a mass lesion is present, and, if so, then stage the tumor and determine operability.|

|[pic] |

|43280 |  |A 35-year-old male has been treated for 6 months with omeprazole for severe symptoms of reflux esophagitis. He |

| | |is evaluated by upper endoscopy, barium swallow radiographs, and manometric and pH studies of the esophagus. |

|[pic] |

|43313 |  |Clinical Example (43313) |

| | |A 2.0 kg infant has respiratory difficulty, inability to tolerate feedings, and inability to pass a |

| | |naso-gastric tube. The diagnosis of tracheoesophageal fistula with proximal esophageal atresia is made. After |

| | |initial stabilization, a thoracotomy with primary repair is performed. Postoperative management includes |

| | |initial ventilator management for three days, management of drain for 5 days, nutrition management including |

| | |postoperative oral or tube feedings and hyperalimentation as needed, airway management including |

| | |tracheomalacia, discharge management, and post operative office management. |

| | |Description of Procedure (43313) |

| | |The arterial line is placed percutaneously or by cutdown. The patient is positioned for bronchoscopy with |

| | |preparation to block fistula if needed. A bronchoscopy is performed with attention to size and configuration of|

| | |airway, position of fistula, anomalies including multiple fistulae. The patient is repositioned for right |

| | |thoracotomy with attention to padding and skin protection. The skin incision is made with extension through |

| | |thoracic musculofascial layers. The scapula is retracted and confirmation of the level of thoracotomy is made. |

| | |A thoracotomy is performed, sparing the pleura. A retropleural dissection is performed until right lung can be |

| | |retracted and thoracic structures are identified, including azygous vein, proximal and distal esophagus, |

| | |trachea, and fistula. The azygous vein is ligated. The proximal pouch is mobilized from mediastinal tissue and |

| | |trachea, looking for proximal fistulae. The gap length is tested, using the orogastric tube to place the |

| | |proximal segment on tension. Circular esophageal myotomies are performed if necessary to lengthen the proximal |

| | |segment. Both the proximal and distal esophageal segments are trimmed to healthy tissue and stay sutures placed|

| | |to maintain alignment and length. |

| | |Posterior wall sutures are placed with care to include all layers of the wall. The posterior wall sutures are |

| | |tied. The orogastric tube is guided through open anastomosis into distal esophagus and stomach; anesthesia is |

| | |requested to secure the tube at the appropriate position. Placing and tying anterior sutures completes the |

| | |anastomosis. |

| | |The mediastinal tissue is mobilized and brought between the tracheal and esophageal closures. The retropleural |

| | |drainage tube is placed, with care to keep the tip clear of the anastomosis. The re-inflation and expansion of |

| | |lung is monitored, repairing any rents in pleura and evacuating intrapleural air. The pleural cavity is |

| | |irrigated and checked meticulously for bleeding. The ribs are approximated and the thoracic musculofascial |

| | |layers are closed in layers. The skin is closed. |

|[pic] |

|43314 |  |Clinical Example (43314) |

| | |A 2.0 kg infant has respiratory difficulty, inability to tolerate feedings, and inability to pass a |

| | |naso-gastric tube. The diagnosis of tracheoesophageal fistula with proximal esophageal atresia is made. After |

| | |initial stabilization, a thoracotomy with primary repair is performed. Postoperative management includes |

| | |initial ventilator management for three days, management of drain for 5 days, nutrition management including |

| | |postoperative oral or tube feedings and hyperalimentation as needed, airway management including |

| | |tracheomalacia, discharge management, and post operative office management. |

| | |Description of Procedure (43314) |

| | |The arterial line is placed percutaneously or by cutdown. The patient is positioned for bronchoscopy with |

| | |preparation to block fistula if needed. A bronchoscopy is performed with attention to size and configuration of|

| | |airway, position of fistula, and anomalies including multiple fistulae. The patient is repositioned for right |

| | |thoracotomy with attention to padding and skin protection. Skin incision is made with extension through |

| | |thoracic musculofascial layers. The scapula is retracted and confirmation of the level or thoracotomy is made. |

| | |A thoracotomy is performed, sparing the pleura. A retropleural dissection is performed until right lung can be |

| | |retracted and thoracic structures are identified, including azygous vein, proximal and distal esophagus, |

| | |trachea, and fistula. The azygous vein is ligated. The fistula is isolated, with careful sparing of recurrent |

| | |nerve. The fistula is transected at the trachea, repairing posterior wall of trachea with interrupted sutures. |

| | |The security of the tracheal closure is tested. The proximal pouch is mobilized from mediastinal tissue and |

| | |trachea, looking for proximal fistulae. The gap length is tested, using the orogastric tube to place the |

| | |proximal segment on tension. Circular esophageal myotomies are performed if necessary to lengthen the proximal |

| | |segment. Both the proximal and distal esophageal segments are trimmed to healthy tissue and stay sutures placed|

| | |to maintain alignment and length. |

| | |Posterior wall sutures are placed with care to include all layers of the wall. The posterior wall sutures are |

| | |tied. The orogastric tube is guided through open anastomosis into distal esophagus and stomach; anesthesia is |

| | |requested to secure the tube at the appropriate position. Placing and tying anterior sutures completes the |

| | |anastomosis. |

| | |The mediastinal tissue is mobilized and brought between the tracheal and esophageal closures. The retropleural |

| | |drainage tube is placed, with care to keep the tip clear of the anastomosis. Re-inflation and expansion of lung|

| | |is monitored, repairing any rents in pleura and evacuating intrapleural air. The pleural cavity is irrigated |

| | |and checked meticulously for bleeding. The ribs are approximated and the thoracic musculofascial layers are |

| | |closed in layers. The skin is closed. |

|[pic] |

|43644 |  |Clinical Example (43644) |

| | |A 44-year-old male, who stands 5 feet 11 inches tall, weighs 390 pounds for a body mass index (BMI) of 55 |

| | |kg/m2, presents with a history of Type II diabetes controlled with three oral hypoglycemic medications, and |

| | |hypertension controlled with two medications. A recent sleep study showed severe, obstructive sleep apnea for |

| | |which he was placed on continuous positive airway pressure (CPAP) with subjective improvement, but complaints |

| | |of poor tolerance of the mask. His gastroesophageal reflux is controlled with an H2-blocker, but his mobility |

| | |is compromised due to severe arthritis of his lower back and right knee. Family and diet history confirm morbid|

| | |obesity began at age nine. The patient underwent multiple weight-loss programs, losing up to 75 pounds three |

| | |times. However, the weight loss was never maintained for more than six months and each weight regain was more |

| | |than what was originally lost. Weight loss programs utilized included very low calorie diets, a popular |

| | |commercial program, exercise, appetite suppressants, and meal replacements. At operation, he undergoes a |

| | |laparoscopic gastric restrictive procedure with gastric bypass and Roux-en Y gastroenterostomy. |

| | |Description of Procedure (43644) |

| | |Under general anesthesia, the abdomen is entered under direct vision or using a Veress needle technique to |

| | |obtain access for pneumoperitoneum. Carbon dioxide is pumped into the abdominal cavity, through tubing |

| | |connected to an insufflator, to expand the abdominal cavity. A laparoscopic camera is introduced into the |

| | |abdomen to allow visualization of the internal organs. Four to six trocar ports are placed in the anterior |

| | |abdominal wall above the umbilicus. The liver is retracted to expose the upper stomach. (Because the liver is |

| | |typically fatty, it must be handled with extra care to avoid tearing, puncture or cracking.) The |

| | |gastroesophageal junction is identified and a small incision is made in the gastrohepatic ligament along the |

| | |edge of the lesser curve between the first and second vessel caudad to the gastroesophageal junction. Using |

| | |blunt and ultrasonic dissection, a retrogastric tunnel is made cephalad, toward the angle of His. A small |

| | |(15-20 cc) gastric pouch is made after the stomach is transected with repeated firings of an endoscopic linear |

| | |stapler. An orogastric tube may be used to calibrate the size of the pouch. Minor bleeding from the staple |

| | |lines is controlled using hemoclips. The ligament of Treitz is identified, and the small intestine measured |

| | |distally for a short distance and transected with a linear stapler. The distal limb is brought up to the |

| | |proximal gastric pouch; either anterior to the transverse colon (ante-colic) or posterior to the transverse |

| | |colon (retro-colic). The omentum may be divided longitudinally with an ultrasonic scalpel or endoscopic |

| | |stapler, to allow for decreased tension for passage of the Roux limb in an ante-colic position. The transverse |

| | |mesocolon is incised to create a tunnel for a retro-colic Roux limb position, as indicated. Care must be taken |

| | |to avoid twisting of the Roux limb to avoid obstruction or ischemia of the intestine. The mesenteric defect is |

| | |closed to prevent internal herniation. A gastrojejunal anastomosis is performed between the Roux limb and the |

| | |gastric pouch, by using either hand-sewn technique, stapled technique or a combination of both. The Roux limb |

| | |is then measured up to 150 cm distal from the gastrojejunal anastomosis and marked. A jejunojejunostomy is |

| | |performed between the bypassed biliopancreatic limb and the marked segment of the Roux limb. This anastomosis |

| | |is performed by using either hand-sewn technique, stapled technique, or combination of both. Intra-operative |

| | |testing for anastomotic leak may be performed as clinically indicated, utilizing air, intra-operative endoscopy|

| | |or methylene blue. Drains(s) are placed and/or distal gastrostomy performed as indicated. Finally, the fascia |

| | |and skin are closed. |

|[pic] |

|43645 |  |Clinical Example (43645) |

| | |A 44-year-old male, who stands 5 feet 11 inches tall, weighs 420 pounds for a body mass index (BMI) of 60 |

| | |kg/m2, presents with a history of Type II diabetes controlled with three oral hypoglycemic medications and |

| | |hypertension controlled with two medications. A recent sleep study showed severe obstructive sleep apnea for |

| | |which he was placed on continuous positive airway pressure (CPAP) with subjective improvement, but complaints |

| | |of poor tolerance of the mask. His gastroesophageal reflux is controlled with an H2-blocker, but his mobility |

| | |is compromised due to severe arthritis of his lower back and right knee. Family and diet history confirm morbid|

| | |obesity began at age nine. The patient underwent multiple weight-loss programs, losing up to 75 pounds three |

| | |times. However, the weight loss was never maintained for more than six months and each weight regain was more |

| | |than what was originally lost. Weight loss programs utilized included very low calorie diets, a popular |

| | |commercial program, exercise, appetite suppressants, and meal replacements. At operation, he undergoes a |

| | |laparoscopic, gastric, restrictive procedure with gastric bypass and small intestine reconstruction to limit |

| | |absorption. |

| | |Description of Procedure (43645) |

| | |Under general anesthesia, the abdomen is entered under direct vision or using a Veress needle technique to |

| | |obtain access for pneumoperitoneum. Carbon dioxide is pumped into the abdominal cavity through tubing connected|

| | |to an insufflator to expand the abdominal cavity. A laparoscopic camera is introduced into the abdomen to allow|

| | |visualization of the internal organs. Four to six trocar ports are placed in the anterior abdominal wall above |

| | |the umbilicus. The liver is retracted to expose the upper stomach. (Because the liver is typically fatty, it |

| | |must be handled with extra care to avoid tearing, puncture or cracking.) The gastroesophageal junction is |

| | |identified and a 2 cm incision is made in the gastrohepatic ligament along the edge of the lesser curve between|

| | |the first and second vessel caudad to the gastroesophageal junction. Using blunt and ultrasonic dissection, a |

| | |retrogastric tunnel is made cephalad, toward the angle of His. A small (15-20 cc) gastric pouch is made after |

| | |the stomach is transected with repeated firings of an endoscopic linear stapler. An orogastric tube may be used|

| | |to calibrate the size of the pouch. Minor bleeding from the staple lines is controlled using hemoclips. The |

| | |small bowel is transected using a specialized endoscopic linear stapler at a measured distance from the |

| | |ligament of Treitz or the ileocecal valve. The distal limb is brought up to the proximal gastric pouch, either |

| | |anterior to the transverse colon (ante-colic) or posterior to the transverse colon (retro-colic). The omentum |

| | |may be divided longitudinally using an ultrasonic scalpel or endoscopic stapler, to allow for decreased tension|

| | |for passage of the Roux limb in an ante-colic position. The transverse mesocolon is incised to create a tunnel |

| | |for a retro-colic Roux limb position, if indicated. Care must be taken to avoid twisting of the Roux limb to |

| | |avoid obstruction or ischemia of the intestine. The mesenteric defect is closed to prevent internal herniation.|

| | |A gastrojejunal anastomosis is performed between the Roux limb and the gastric pouch by using either hand-sewn |

| | |technique, stapled technique, or a combination of both. The Roux limb is then measured greater than 150 cm |

| | |distal from the gastrojejunal anastomosis and marked. An enteroenterostomy is performed between the bypassed |

| | |biliopancreatic limb and the marked segment of the Roux limb. This anastomosis is performed by using either |

| | |hand-sewn technique, stapled technique, or a combination of both. The length of the biliopancreatic limb and |

| | |the Roux limb may vary in order to produce malabsorption of variable nutrients. The variations may include: (1)|

| | |a short biliopancreatic limb measuring 20 to 90 cm with a very long Roux limb measuring 150 to 250 cm from the |

| | |gastrojejunostomy; or (2) transection of the small intestine at a point 250 to 360 cm proximal to the ileocecal|

| | |valve, to create a 151 to 250 cm Roux limb, with a distal enteroenterostomy anastomosis at a point 50 to 150 cm|

| | |proximal to the ileocecal valve. Both techniques result in fat malabsorption. Intra-operative testing for |

| | |anastomotic leak may be performed as clinically indicated, utilizing air, intra-operative endoscopy or |

| | |methylene blue. Drains(s) are placed and/or distal gastrostomy performed as indicated. Finally, the fascia and |

| | |skin are closed. |

|[pic] |

|43653 |  |A 65-year-old man presents with an obstructing carcinoma of the esophagus and inability to eat. Attempts to |

| | |relieve the obstruction by flexible endoscopy, dilatation, and laser therapy are unsuccessful. The patient is |

| | |malnourished and needs enteral nutritional support prior to future definitive cancer therapy, which may include|

| | |chemotherapy, radiation therapy, and/or an operation. |

|[pic] |

|43752 |  |Clinical Example (43752) |

| | |A 74-year-old patient with a known hiatal hernia recently suffered a stroke and requires placement of a |

| | |nasogastric tube for feeding. Attempts at nasogastric tube placement were made by the nursing staff, and each |

| | |time the tube was mispositioned in the distal esophagus. The patient's physician ordered nasogastric tube |

| | |placement using fluoroscopic guidance to assure proper placement of the tube in the stomach. |

| | |Description of Procedure (43752) |

| | |A preliminary fluoroscopic evaluation of the thorax is performed. The patient's swallowing function is checked |

| | |with water. The nasogastric tube is placed into the proximal esophagus in the usual manner. Fluoroscopy is used|

| | |to aid manipulation of the tube through the hiatal hernia and across the gastroesophageal junction. Fluoroscopy|

| | |and spot radiographs are used to confirm placement of the tube in the stomach. The tube is secured at the nose |

| | |in the usual manner. The procedure is documented in the patient's chart. |

|[pic] |

|43770 |  |Clinical Example |

| | |A 44-year-old woman presents with a body mass index of 48, hypertension, and poorly controlled diabetes. She |

| | |has failed nonoperative obesity interventions and has elected gastric banding instead of gastric bypass |

| | |surgery. She undergoes laparoscopic placement of an adjustable gastric band and subcutaneous port. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. Pneumoperitoneum is established to distend the |

| | |abdomen, and the laparoscope is introduced. Gas flow and intra-abdominal pressure are carefully monitored so as|

| | |not to impair ventilation or venous return. Four to six trocar ports are sited through the anterior abdominal |

| | |wall above the umbilicus. The viscera are inspected. An orogastric tube may be placed to decompress the |

| | |stomach. The liver is retracted to expose the gastroesophageal junction. A path is made behind the upper |

| | |stomach 2 cm below the gastroesophageal junction. The dissection plane may be guided by use of a per-oral |

| | |gastric balloon catheter, which defines the location of the gastroesophageal junction, or by anatomical |

| | |landmarks from the right crus of the diaphragm to the Angle of His. Excess visceral fat covering the upper |

| | |stomach may need to be excised to prevent incorporation within the band, which would cause external compression|

| | |and subsequent obstruction. The adjustable gastric band is introduced into the abdomen and pulled through the |

| | |prepared retro-gastric path and around the upper stomach, just below the gastroesophageal junction. The band is|

| | |locked. The band position is secured with strategically placed gastro-gastric sutures to prevent band slippage |

| | |or gastric prolapse. The tubing attached to the band is tunneled through the abdominal wall. It is connected to|

| | |an access port that is secured in or on the abdominal rectus muscle or other secure subcutaneous location. |

| | |Hemostasis is obtained. The trocars are removed and all fascial and skin openings are closed as appropriate. |

|[pic] |

|43771 |  |Clinical Example |

| | |A 45-year-old woman presents 15 months after surgical placement of adjustable gastric banding for a body mass |

| | |index of 45. She has lost 85 lbs since surgery but has developed recent new onset symptoms of night-time |

| | |gastroesophageal reflux that wake her from sleep. She also complains of decreased restriction and a capacity to|

| | |eat more food. A contrast esophagram has confirmed band slippage or gastric prolapse. She undergoes |

| | |laparoscopic revision of the adjustable gastric band. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A supraumbilical incision is made, and the |

| | |peritoneum is grasped with sutures on the fascia. Insertion of the first trocar is handled cautiously in view |

| | |of the prior surgery. Gas flow is initiated to distend the abdomen, and the laparoscope is introduced. Gas flow|

| | |and intra-abdominal pressure are carefully monitored so as not to impair ventilation or venous return. Four to |

| | |six trocar ports are sited through the anterior abdominal wall above the umbilicus. The viscera are inspected. |

| | |Pneumoperitoneum is maintained at 15 mm Hg throughout the procedure. An orogastric tube may be placed to |

| | |decompress the stomach. The liver is retracted anteriorly to expose the upper stomach. Adhesions (which can be |

| | |extensive) of the stomach to the undersurface of the liver are lysed with an ultrasonic scalpel. The band and |

| | |its tubing are identified. The band is freed from the fibrin seal created by adhesions. The gastro-gastric |

| | |sutures are cut and the securing gastric plication is released. The enlarged pouch is reduced by gentle |

| | |retraction of the stomach tissue below the band in a caudad direction. This slides the stomach that has |

| | |prolapsed upwards through the band back down through the band to its appropriate original position below. The |

| | |band is re-positioned 1 to 2 cm below the gastroesophageal junction to create an appropriately small pouch. The|

| | |gastric wall integrity is inspected. A leak test using methylene blue or air is performed to test for |

| | |inadvertent gastrotomy. Any gastric wall injury is repaired with intra-corporeal sutures. A new gastro-gastric |

| | |imbrication of the band is completed. Additional posterior-lateral sutures are added as necessary to secure the|

| | |stomach-band position. Hemostasis is obtained. The trocars are removed, and all fascial and skin openings are |

| | |closed as appropriate. |

|[pic] |

|43772 |  |Clinical Example |

| | |A 45-year-old woman presents 15 months after surgical placement of adjustable gastric banding for a body mass |

| | |index of 45. She has lost 85 lbs since surgery but has developed recent new onset symptoms of severe abdominal |

| | |(epigastric) pain with dysphagia and vomiting. A contrast esophagram has confirmed a large band slippage or |

| | |gastric prolapse. She undergoes laparoscopic removal of the adjustable gastric band. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. Insertion of the first trocar is handled |

| | |cautiously in view of prior surgery. Gas flow is initiated to distend the abdomen, and the laparoscope is |

| | |introduced. Gas flow and intra-abdominal pressure are carefully monitored so as not to impair ventilation or |

| | |venous return. Four to six trocar ports are placed in the anterior abdominal wall above the umbilicus. The |

| | |viscera are inspected. Pneumoperitoneum is maintained at 15 mm Hg throughout the procedure. An orogastric tube |

| | |may be placed to decompress the stomach. The liver is retracted anteriorly to expose the upper stomach. |

| | |Adhesions (which can be extensive) of the stomach to the undersurface of the liver are lysed with an ultrasonic|

| | |scalpel. The band and its tubing are identified. The band is freed from the fibrin seal created by adhesions. |

| | |Some of the gastro-gastric suturing may be divided, taking care not to create a gastrotomy. The band is removed|

| | |by cutting the buckle or the band next to the buckle. Gastric wall defects are identified and repaired in |

| | |layers with sutures. Testing for leaks is performed with methylene blue, air insufflated though a nasogastric |

| | |tube, or by intraoperative endoscopy. The tube connecting the band to the port is cut and the band with part of|

| | |the tubing is removed from the abdomen. Hemostasis is obtained. The trocars are removed, and all fascial and |

| | |skin openings closed as appropriate. |

|[pic] |

|43773 |  |Clinical Example |

| | |A 45-year-old woman presents 15 months after surgical placement of adjustable gastric banding for a body mass |

| | |index of 45. She has lost 85 lbs since surgery. She has had a known chronic slippage diagnosed by contrast |

| | |esophagram and has now developed worsening symptoms of dysphagia and/or vomiting. She undergoes laparoscopic |

| | |removal of the old adjustable gastric band and placement of a new adjustable gastric band. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. Initial trocar insertion is handled in a cautious |

| | |manner in view of prior surgery. Gas flow is initiated to distend the abdomen, and the laparoscope is |

| | |introduced. Gas flow and intra-abdominal pressure are carefully monitored so as not to impair ventilation or |

| | |venous return. Four to six trocar ports are placed in the anterior abdominal wall above the umbilicus. The |

| | |viscera are inspected. Pneumoperitoneum is maintained at 15 mm Hg throughout the procedure. An orogastric tube |

| | |may be placed to decompress the stomach. The liver is retracted anteriorly to expose the upper stomach. |

| | |Adhesions (which can be extensive) of the stomach to the undersurface of the liver are lysed with an ultrasonic|

| | |scalpel. The band and its tubing are identified. The band is freed from the fibrin seal created by adhesions. |

| | |The gastro-gastric sutures are cut and the securing gastric plication is released. The enlarged pouch is |

| | |identified and attempts are made to reduce it by gentle retraction of the stomach tissue below the band in a |

| | |caudad direction. The adhesions of the prolapsed stomach prevent adequate reduction of stomach into the correct|

| | |position. Removal of the band to release the gastric prolapse is necessary. The band is cut along the side of |

| | |the buckle to release the locking mechanism, or the band may be cut through the ring or shell section next to |

| | |the buckle. The band portion is completely removed and a new band is placed in the correct position. This |

| | |requires a new retrogastric dissection typically in a location above the original band placement and is time |

| | |consuming due to scarring from the previous band. The gastric wall integrity is inspected. A leak test using |

| | |methylene blue or air may be performed to test for inadvertent gastrotomy. Any gastric wall injury is repaired |

| | |with intra-corporeal sutures. A new gastro-gastric imbrication of the band is completed. Additional |

| | |posterior-lateral sutures may be added as necessary to secure the stomach-band position. The old band is |

| | |removed from the abdomen; the tubing leading to the access port is cut and reconnected to the tubing of the |

| | |newly placed band. Hemostasis is obtained. The trocars are removed, and all fascial and skin openings are |

| | |closed as appropriate. |

|[pic] |

|43774 |  |Clinical Example |

| | |A 40-year-old woman presents 18 months after surgical placement of adjustable gastric banding for a body mass |

| | |index of 45. She has had inadequate weight loss. The band system is determined to be functioning appropriately.|

| | |She undergoes laparoscopic removal of the adjustable gastric band and the subcutaneous port. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. Insertion of the first trocar in handled in a |

| | |cautious manner in view of prior surgery. Gas flow is initiated to distend the abdomen, and the laparoscope is |

| | |introduced. Gas flow and intra-abdominal pressure are carefully monitored so as not to impair ventilation or |

| | |venous return. Four to six trocar ports are sited through the anterior abdominal wall above the umbilicus. The |

| | |viscera are inspected. Pneumoperitoneum is maintained at 15 mm Hg throughout the procedure. An orogastric tube |

| | |may be placed to decompress the stomach. The liver is retracted anteriorly to expose the upper stomach. |

| | |Adhesions (which can be extensive) of the stomach to the undersurface of the liver are lysed. The band and its |

| | |tubing are identified. The band is freed from the fibrin seal created by adhesions. Some of the gastro-gastric |

| | |suturing may be divided, taking care not to open into the stomach lumen. The band is removed by cutting the |

| | |buckle or the band next to it. Gastric wall defects are identified and repaired. A methylene blue test or air |

| | |leak test through a nasogastric tube or intraoperative endoscopy is performed. The tube connecting the band to |

| | |the port is cut and the band is removed from the abdomen. An incision is made over the access port. The port |

| | |sutures are released and the access port is removed. Hemostasis is obtained. The trocars are removed, and all |

| | |fascial and skin openings are closed as appropriate. |

|[pic] |

|43845 |  |Clinical Example (43845) |

| | |The patient is a 44-year-old male who stands 5 feet 11 inches tall, weighs 390 pounds (210 pounds overweight) |

| | |for a body mass index (BMI) of 55 kg/m2. He has a history of Type II diabetes mellitus, which was diagnosed 4 |

| | |years ago and is presently controlled with 3 oral hypoglycemics, as well as hypertension for which he takes 2 |

| | |medications. In addition, a recent sleep study showed severe obstructive sleep apnea, for which he was placed |

| | |on continuous positive airway pressure (CPAP) with subjective improvement, but complains of poor tolerance of |

| | |the mask. His gastroesophageal reflux is controlled with H2-blocker, but his mobility is severely compromised |

| | |due to severe arthritis of his lower back and right knee. Family history and diet history confirm morbid |

| | |obesity, with obesity beginning since age 9. The patient underwent multiple weight loss programs resulting in |

| | |weight losses of up to 75 pounds three times. However, the weight loss was never maintained for more than 6 |

| | |months, and each weight regain was more than what was originally lost. Weight loss programs utilized included |

| | |very low calorie diets, support groups, exercise, appetite suppressants, and meal replacements. |

| | |Description of Procedure (43845) |

| | |The patient is positioned, prepped, and draped with special attention to positioning to prevent neuropraxias |

| | |and pressure necrosis of skin. Under general anesthesia, generally a midline incision is employed with lysis of|

| | |adhesions as needed. Starting from the lateral mid antrum, the stomach is divided longitudinally with a staple |

| | |division technique to the top of the gastric fundus lateral to the gastroesophageal junction at the angle of |

| | |His. The gastric pouch may be sized with a bougie placed in the stomach, to make a longitudinal 150-200 cc |

| | |pouch. The lateral gastric specimen is discarded. The first portion of the duodenum is mobilized and transected|

| | |with a stapler approximately 3 to 5 cm distal to the pylorus. The small bowel is transected with a stapler |

| | |approximately 250 cm from the ileocecal valve. The distal end (alimentary limb) is anastomosed to the |

| | |proximally divided duodenal limb. The proximal transected small bowel (biliopancreactic limb) is anastomosed 50|

| | |to 100 cm proximal to the ileocecal valve on the distal previously divided small bowel. Close fascia and skin. |

| | |Drain, as indicated by clinical situation. |

|[pic] |

|43846 |  |Clinical Example (43846) |

| | |The patient is a 40-year-old male who weighs 390 pounds (210 pounds overweight), is hypertensive on two |

| | |medications without good control, has severe gastroesophageal reflux, and near disabling arthritis of his lower|

| | |back and right knee. In addition, a recent sleep study showed severe obstructive sleep apnea and he has been |

| | |placed on continous positive airway pressure (CPAP) with some limited improvement, but continued dependent |

| | |edema suggestive of right heart failure. Family history and diet history confirm morbid obesity with obesity |

| | |since childhood and multiple weight losses of up to 75 pounds in the past with no significant weight |

| | |maintenance and rapid recent weight gain since sleep apnea symptoms have been present. Preoperatively, the |

| | |surgeon re-evaluates history, laboratory, and physical findings and finalizes extensive informed consent. At |

| | |laparotomy, a gastric bypass procedure with a measured 30 cc pouch and 45 cm Roux-en-Y gastrojejunostomy is |

| | |fashioned and the small gastic pouch is divided from the remainder of the stomach. A gastrostomy tube is placed|

| | |and the wound is drained. Postoperatively, the patient is stabilized in the intensive care unit (ICU) with |

| | |careful monitoring of ventilation, hemodynamics, fluid balance, and also with nightly recorded oximetry with |

| | |alteration of CPAP pressure and oxygen volumes as needed. Vigorous pulmonary re-inflation measures are pressed |

| | |due to the marked intra-abdominal obesity. Special bed with trapezes is used. Mini-dose heparin, drains and |

| | |tube losses are monitored with wound checks and dressing changes. Drains and tubes are removed appropriately |

| | |and oral fluids are begun on the 4th postoperative day and advanced. The patient is discharged on the 7th to |

| | |9th postoperative day with extensive instructions concerning the dramatically altered gastric physiology, |

| | |including inability to take food and liquids simultaneously with avoidance of true solids for several weeks. |

| | |Techniques of taking vitamins and medications orally are stressed. Arrangements are made for continued CPAP and|

| | |oxygen postoperatively. |

| | |Description of Procedure (43846) |

| | |Special positioning of the patient with a footboard, taping of the ankles and strapping of the knees in |

| | |preparation for a 50% tilt of the table. The patient was prepped, draped and set up with mechanical, |

| | |table-mounted retractors. The gastric bypass procedure is performed with total division of the |

| | |pressure/volume-measured 30 mL pouch from the remainder of the stomach with a 45 cm Roux limb and a 10 mm |

| | |gastrojejunostomy. A gastrostomy is performed in the distal stomach, the wound drained and closed in layers. A |

| | |medication block is placed to aid postoperative pulmonary mechanics. The wound and tubes are dressed. |

|[pic] |

|43848 |  |Clinical Example |

| | |Four years ago, a 65-year-old female underwent vertical banded gastroplasty for morbid obesity. She was very |

| | |compliant, and her weight decreased from 385 to 205 lbs. Within the last 3 months, she has suddenly gained 35 |

| | |lbs and has developed severe gastroesophageal reflux symptoms. Barium swallow and upper GI endoscopy confirm |

| | |break down of the staple line with restoration of gastric continuity. At re-operation, after difficult and |

| | |extensive lysis of adhesions in the left upper quadrant, a 30-ml gastric pouch with a Roux-en-Y |

| | |gastrojejunostomy is fashioned. The pouch is completely divided from the remainder of the stomach. She develops|

| | |a wound hematoma, which becomes infected and requires bedside incision and drainage. The patient is discharged |

| | |on the 14th postoperative day. |

| | |Description of Procedure |

| | |The patient is specially positioned with a footboard and taping of the ankles; strapping of the knees; |

| | |preparing for a 50° tilt of the operating table; prepping and draping of the patient; and setting up the |

| | |mechanical, table-mounted retractors. Lysis of adhesions is accomplished in the mid-abdomen and a 45-cm Roux |

| | |limb is created. The severe adhesions between the left lobe of the liver and stomach and the distal esophagus, |

| | |colon, and spleen are painstakingly taken down in a time-consuming manner. A pressure or volume-measured 30-ml |

| | |pouch is created and divided from the remainder of the stomach. A 10-mm gastroenterostomy is created and a |

| | |gastrostomy placed in the distal stomach. The wound is drained and closed in layers, and an intercostal block |

| | |is placed to aid postoperative pulmonary mechanics. The wound and tubes are dressed. |

|[pic] |

|43886 |  |Clinical Example |

| | |A 45-year-old woman presents 3.5 months after surgical placement of adjustable gastric banding for a body mass |

| | |index of 45. Attempts to access the subcutaneous port component are unsuccessful. An abdominal radiograph |

| | |reveals that the subcutaneous port component has flipped. She undergoes revision of the subcutaneous port. |

| | |Description of Procedure |

| | |Under general anesthesia, an incision is made over the access port. The subcutaneous fat and capsule around the|

| | |port are divided. The port is found to be flipped over with the access portion facing the fascia. The securing |

| | |suture is found to have been disrupted. The port is replaced into its original position with the silicone |

| | |access portion facing up. The access port is secured to the anterior abdominal wall fascia with nonabsorbable |

| | |sutures. Saline may be injected into the band for tightening via the access port during surgery. Hemostasis is |

| | |obtained and the wound is closed. |

|[pic] |

|43887 |  |Clinical Example |

| | |A 45-year-old woman presents 3 weeks after surgical placement of an adjustable gastric banding for a body mass |

| | |index of 45. She has developed a wound infection at the subcutaneous port component site, which has failed to |

| | |respond to antibiotic treatment. She undergoes removal of the subcutaneous port. |

| | |Description of Procedure |

| | |Under general anesthesia, an incision is made over the access port. The subcutaneous fat and capsule around the|

| | |port are divided. The port sutures are released, the tubing connecting the access port to the band is divided, |

| | |and the port is removed. The band is left intact, with the remaining tubing tied off and placed inside the |

| | |peritoneal cavity. The wound is irrigated copiously and packed with gauze dressings. The dressings will need to|

| | |be changed daily until the infection has cleared and the wound can be closed secondarily or heal by secondary |

| | |intention. |

|[pic] |

|43888 |  |Clinical Example |

| | |A 45-year-old woman presents 9 months after surgical placement of an adjustable gastric banding for a body mass|

| | |index of 45. Band adjustments are ineffective at maintaining band diameter. A determination is made that there |

| | |is a leak from the subcutaneous port component or tubing. She undergoes removal of the old subcutaneous port |

| | |and placement of a new subcutaneous port. |

| | |Description of Procedure |

| | |Under general anesthesia, an incision is made over the access port. The subcutaneous fat and capsule around the|

| | |port are divided. The port sutures are released, the tubing connecting the access port to the band is divided, |

| | |and the port is removed. The band is left intact with the remaining tubing. A new access port is connected to |

| | |the existing tubing, leading to the gastric band, using a tubing connector. The tubing is replaced into the |

| | |peritoneal cavity. The access port is secured to the anterior abdominal wall fascia with nonabsorbable sutures.|

| | |Saline may be injected into the band for tightening via the access port during the time of surgery. Hemostasis |

| | |is obtained and the wound is closed. |

|[pic] |

|44126 |  |Clinical Example (44126) |

| | |The patient is a 1500 gram 32-week gestation male infant born to a 16-year-old unmarried mother. The pregnancy |

| | |was complicated by minimal prenatal visits. At delivery, the obstetrician noted polyhydramnios. The patient was|

| | |admitted to the Neonatal Intensive Care Unit for observation and IV fluids. The infant vomited green material |

| | |after six hours of life. Abdominal x-rays showed a large distended upper small intestinal bowel loop with no |

| | |distal gas. A colon contrast study refluxed contrast into the terminal ileum; there was a microcolon. The |

| | |pediatric surgeon who was consulted made a probable diagnosis of high small bowel and recommended an operation.|

| | |Description of Procedure (44126) |

| | |The patient is positioned for laparotomy and the surgeon then scrubs, while the patient is prepped and draped. |

| | |The surgeon makes an abdominal incision and explores the abdomen. There is a jejunal atresia approximately 15 |

| | |cm from the ligament of Treitz. In order to insure that there are no other atresias, the bowel is examined and |

| | |injected with sterile saline until the contrast from the distal colon study is encountered. There are no other |

| | |atresias. The ligament of Treitz is taken down and the most bulbous distal portion of the proximal jejunum is |

| | |resected and remaining proximal jejunum is tapered with a 12-cm suture line. An end-to-back intestinal |

| | |anastomosis is then performed using fine interrupted sutures with magnification. The abdominal wall and skin |

| | |are closed in layers. A sterile dressing is applied to the wound. |

|[pic] |

|44127 |  |Clinical Example (44127) |

| | |A 1500 gram 32-week gestation male infant is born to a 16-year-old unmarried mother with polyhydramnios. The |

| | |infant vomitted green material, and the abdominal X-rays show a large distended upper small intestinal bowel |

| | |loop with no distal gas. A colon contrast study refluxed contrast into the terminal ileum; there was a |

| | |microcolon. |

| | |Description of Procedure (44127) |

| | |At laparotomy, there is a jejunal atresia approximately 15 cm from the ligament of Treitz. In order to insure |

| | |that there are no other atresias, the bowel is examined and injected with sterile saline until the contrast |

| | |from the distal colon study is encountered. There are no other atresias. The ligament of Treitz is taken down |

| | |and after, the most bulbous distal portion of the proximal jejunum is resected. Examination of the intestine is|

| | |performed to assess level of atresia. The abdomen is explored to check for other distal atresias or anomalies |

| | |and to determine continuity of the distal segment. A site for tapering or plicating the proximal dilated |

| | |atretic segment is chosen. The dilated atretic segment is tapered using stapler or suture being careful to |

| | |avoid narrowing the lumen of the intestine excessively. The appropriate mesenteric vessels are divided and |

| | |ligated. The bowel lumen is controlled with noncrushing bowel clamps. An end-to-back anastomosis is performed |

| | |with interrupted suture. The mesenteric defect is closed carefully to avoid damaging the blood supply. The |

| | |fascia and skin are closed. |

|[pic] |

|44128 |  |Clinical Example (44128) |

| | |A 1500 gram 32-week gestation male infant is born to a 16-year-old unmarried mother with polyhydramnios. The |

| | |infant vomitted green material, and the abdominal X-rays show a large distended upper small intestinal bowel |

| | |loop with no distal gas. A colon contrast study refluxed contrast into the terminal ileum; there was a |

| | |microcolon. |

| | |Description of Procedure (44128) |

| | |At laparotomy, there is a jejunal atresia approximately 15 cm from the ligament of Treitz. There is one other |

| | |atresia in the ileum. An additional site is chosen for resection of atretic segment if there is adequate length|

| | |of gut. The appropriate mesenteric vessels are divided and ligated. The bowel lumen is controlled with |

| | |noncrushing bowel clamps. An end-to-back anastomosis is performed with interrupted suture. The mesenteric |

| | |defect is closed with care to avoid damaging the blood supply. |

|[pic] |

|44132, |  |Clinical Example (44132-44136) |

|44133, | |This is a 41-year-old woman with short gut syndrome secondary to mesenteric artery thrombosis and extensive |

|44135, | |intestinal resection eight years ago. The patient was placed on total parenteral nutrition at the time of |

|44136 | |resection to maintain her nutritional requirements. The periodic biochemical liver injury tests declared |

| | |significant elevation in the liver enzymes with mild increase in the total serum bilirubin at the time of |

| | |referral. The percutaneous Tru-cut liver biopsy showed histopathologic changes consistent with significant |

| | |cholestasis, which is most probably related to total parenteral nutrition therapy. The venous angiogram of the |

| | |central venous system was performed and showed occlusion of the right subclavian and innominate vessels with a |

| | |stenosis of the left subclavian vein. The patient was evaluated by the hematology team to rule out a |

| | |hypercoagulable state. An upper endoscopy and lower colonoscopy were performed to rule out the presence of |

| | |esophageal varices, and colonic pathology respectively. The patient had a history of multiple episodes of |

| | |dehydration, central line infection, sepsis and frequent hospitalizations for line replacement. The patient was|

| | |then cleared by the anesthesia team. The patient was reviewed by the transplant committee and deemed an |

| | |appropriate candidate for isolated intestinal transplantation. |

| | |Description of Procedure (44132-44136) |

| | |After the patient was put to sleep and intubated, the abdomen was prepped and draped in a standard fashion. The|

| | |end jejunostomy was also closed using a 3-0 Prolene suture in a running fashion. The abdominal cavity was |

| | |entered through an extended midline incision. There were extensive adhesions between the parietal abdominal |

| | |wall and the remaining native intestine. Sharp and blunt dissection was carried out along the entire procedure.|

| | |The liver was then identified, and the falciform ligament was taken down. The liver was slightly enlarged with |

| | |no evidence of cirrhosis. There was some evidence of portal hypertension with engorgement of the splenic |

| | |circulation. The midline incision was then extended to the right side through a right subcostal incision. |

| | |Further dissection was carried out, and the jejunostomy was taken down. There were extensive adhesions between |

| | |the transverse mesocolon and the gallbladder that were taken down. Then, the gallbladder was removed in a |

| | |standard fashion. There were extensive collaterals between the gallbladder, the abdomen and the liver bed that |

| | |required electrocautery and careful dissection. The cystic duct and the cystic artery were identified, ligated |

| | |and interrupted. Attention was then turned to the right colon. The appendix was identified and the previous |

| | |resection margin was flush with the cecum with no ileocecal valve or terminal ileum. The remaining part of the |

| | |small bowel as well as proximal jejunum were measured at 40 cm distal to the ligament of Treitz. |

| | |Further dissection was carried out, and the cecum was mobilized from the retroperitoneal structures. The root |

| | |of the mesentery was also dissected carefully from the retroperitoneal structures. The inferior vena cava was |

| | |then identified and was dissected all the way out to the level of the renal vein. Attempts were made to dissect|

| | |the superior mesenteric vein as well as the portal vein. This was carried out very carefully and successfully. |

| | |The infrarenal aorta was then approached and dissected. The inferior mesenteric artery was preserved. During |

| | |dissection of the cecum, there was a small fistula between the sigmoid colon and the cecum that was resected |

| | |and repaired. A liver biopsy was not done because the patient had a liver biopsy done two months ago that |

| | |showed focal bridging fibrosis. The total bilirubin at the time of evaluation was about 5 mg/dl with good |

| | |hepatic synthetic functions. However, the patient was on blood thinners at the time of transplant, and the |

| | |prothrombin time was above 20 with an INR of 3.2. |

| | |The donor was a local donor, 20 years old. The CMV of the donor was positive as well as the EBV. The donor was |

| | |a multi-organ donor including the intestines, pancreas, liver, kidneys, heart and lungs. Dissection of the |

| | |donor organs was carried out in situ, and the intestine was separated from the pancreas by transecting the |

| | |superior mesenteric artery and superior mesenteric vein. Venous and arterial grafts were brought from the donor|

| | |carotid vessels and innominate vessels. |

| | |The recipient operation continued with placement of an arterial graft on the infrarenal aorta as well as a |

| | |venous graft on the inferior vena cava. Because of the short arterial graft, an interposition graft was placed |

| | |on the arterial conduit, which was done by using the donor carotid vessels. After successful placement of the |

| | |venous and arterial grafts, the intestinal graft was brought to the operative field, and the arterial |

| | |anastomosis was performed between the donor intestinal arterial graft and the recipient infrarenal aorta using |

| | |6-0 Prolene. After completion of both vessels, the arterial and then the venous clamps were released and the |

| | |intestine perfused well. The cold ischemia time was 6 hours and 10 minutes, and the warm ischemia time was 32 |

| | |minutes. The estimated blood loss was about 800cc. This blood loss was mainly due to the extensive dissection |

| | |with lysis of adhesions and the relative prolongation of the prothrombin time. After proper hemostasis, |

| | |attention was then paid to the native jejunum and about 5 cm was resected using the GIA stapler to refresh the |

| | |jejunal anastomotic site. The proximal anastomosis was carried out between the proximal transplanted jejunum |

| | |and the remaining native intestine. The distal anastamosis was carried out between the distal ileal segment of |

| | |the graft and the recipient cecum in a side-to-side fashion and in two layers. There were serosal tears in the |

| | |cecum that were repaired with interrupted 4-0 silk sutures. Appendectomy was carried out in a standard fashion |

| | |and imbricated with pursestring sutures. After proper hemostasis, a gastrostomy tube was placed using two |

| | |pursestring sutures, and the stomach was anchored to the parietal abdominal wall. A #24 French Foley catheter |

| | |was used. A jejunostomy tube was also inserted using the Witzel technique, and the tube used was a Malecot size|

| | |15. Also, the jejunostomy tube was anchored to the anterior abdominal wall. The end of the graft ileum was then|

| | |brought to the right lower quadrant of the abdominal wall and was exteriorized as a chimney ileostomy. Also, it|

| | |is important to mention that about 10 cm of the proximal jejunum and 15 cm of the graft terminal ileum were |

| | |resected and sent for histopathological examination. |

| | |At the end of the operation, a second run of hemostasis was carried out and four Jackson-Pratt drains were |

| | |inserted in the different compartments of the abdominal cavity. The right subcostal abdominal incision was |

| | |closed in a standard fashion using nonabsorbable sutures in two layers. The midline incision was also closed |

| | |using nonabsorbable material in a single layer. The skin was then closed with a stapler on the right side and |

| | |with an interrupted 2-0 nylon suture throughout the midline incision. The jejunostomy and gastrostomy tubes |

| | |were secured with 2-0 silk sutures. The stoma was then matured using 4-0 semi-absorbable sutures. The patient |

| | |was hemodynamically stable during the entire procedure with controlled hemostasis and a good urine output. |

| | |It is of interest to know that the patient required a large volume of intravenous crystalloids and colloids |

| | |which is a common observation during isolated intestinal transplantation. This leaking syndrome is probably due|

| | |to the extensive abdominal dissection and the underlying subclinical liver dysfunction due to prolonged total |

| | |parenteral therapy. At the end of the operation the patient was transferred to the Intensive Care Unit in |

| | |stable condition. |

|[pic] |

|44137 |  |Clinical Example (44137) |

| | |A 22-year-old male with a history of multiple abdominal surgeries and recurrent episodes of line infection, |

| | |thrombosis of the major central veins, significant elevation of liver enzymes, and histopathologic evidence of |

| | |portal fibrosis required small bowel transplantation. Following the transplantation, he experienced acute and |

| | |chronic rejection that resulted in chronic graft dysfunction and repeated episodes of bacterial translocation. |

| | |He now requires surgical removal of the entire intestinal allograft with reinstitution of total parenteral |

| | |nutrition (TPN) therapy. |

| | |Description of Procedure (44137) |

| | |Pre-operative orders for peri-operative medications are written. Next, a review of pre-operative work-up is |

| | |performed with particular attention to pathology reports and films. The physician changes into scrub clothes, |

| | |and checks with lab making certain that blood and/or x-match is available. A review of the surgical procedure |

| | |and expected outcome(s) is detailed for the patient and family, including a review of expectations for |

| | |post-operative recovery both in and out of the hospital. The physician answers questions for both the patient |

| | |and the family and obtains informed consent. A review of the length and type of anesthesia by the |

| | |anesthesiologist is provided. The physician reviews the planned procedure and positioning and draping of |

| | |patient, verifying that all necessary surgical instruments and supplies are readily available in the operative |

| | |suite. The physician will also monitor the patient's positioning and draping and assist with positioning as |

| | |needed. |

| | |An extended midline skin incision is made and anterior abdominal wall is carefully divided. The peritoneal |

| | |cavity is entered and the bowel protected. A self-retaining retractor is inserted to facilitate exposure. |

| | |Adhesions are lysed, freeing the small intestine. After full mobilization of the bowel, the intestinal loops on|

| | |the left side are retracted medially and the aorta is exposed. The infrarenal aortic graft that was constructed|

| | |at the time of transplantation is dissected from the intestinal loops and encircled with a vessel loop. This |

| | |same technique is applied to the venous graft that connects the superior mesenteric vein of the intestine to |

| | |the recipient native portal vein. After clamping and transecting both the aortic and venous grafts, both the |

| | |proximal and distal bowel anastomoses are identified and a stapler is applied to each limb and fired, dividing |

| | |the transplanted bowel from the native remaining intestine both proximally and distally. The allograft |

| | |intestine is removed en-bloc and the remnant stumps of both the aortic and vein graft are oversewn with prolene|

| | |sutures. The enterectomy specimen is sent for full histopathologic examination. The distal stump of the native |

| | |residual large bowel, if present, is oversewn with non-absorbable sutures. The proximal end of the remaining |

| | |native small intestine is exteriorized as an end stoma. A gastrostomy tube is placed and anchored to the |

| | |abdominal wall. Hemostasis is carried out through the entire operation using the Argon beam and suture |

| | |ligature. The abdominal cavity is checked meticulously for bleeding and irrigated. Multiple drains are applied |

| | |and the abdominal wall is closed in a single layer using semi-absorbable material. The abdominal wall is closed|

| | |using interrupted sutures. The skin is closed using non-absorbable monofilament interrupted sutures. |

|[pic] |

|44157 |  |Clinical Example (44157) |

| | |An 18-year-old female with a family history of familial polyposis presents with diffuse polyposis. During the |

| | |procedure, a total proctocolectomy, ileoanal anastomosis, loop ileostomy, and mucosectomy are performed. |

| | |Description of Procedure (44157) |

| | |A skin incision is made using sharp dissection. Hemostasis is achieved using electrocautery as necessary. The |

| | |linea alba is identified and carefully divided. The peritoneum is grasped, elevated, and carefully incised to |

| | |avoid injury to the bowel. The peritoneal cavity is entered under direct vision. Adhesions, if present, are |

| | |cleared by sharp dissection to expose all of the abdominal viscera. |

| | |A visual and manual complete exploration of the abdominal cavity and its contents is carried out. A nasogastric|

| | |tube is placed and its position is confirmed. The stomach is inspected and palpated for pathology. The duodenum|

| | |is visualized and palpated. The gallbladder is inspected and palpated for the presence of gall stones. The |

| | |liver is palpated bimanually to detect potential hepatic metastases, as is the porta hepatis. The pancreas is |

| | |inspected through the hepatico gastric ligament and palpated for possible masses. The tail of the pancreas is |

| | |palpated for possible lymphadenopathy. The small bowel is inspected and palpated from the ligament of Treitz to|

| | |the ileocecal valve. The small-bowel mesentery is inspected and palpated for the presence of lymphadenopathy. |

| | |The uterus is inspected and the ovaries are carefully packed to minimize adhesions and risk of infertility. The|

| | |cecum and appendix, and the ascending, transverse, and descending colon are inspected and palpated. The |

| | |cul-de-sac and pelvic contents are inspected and palpated. Any suspicious finding(s) are noted. Appropriate |

| | |biopsies are taken and sent to pathology for frozen section. |

| | |A self-retaining retractor is carefully inserted into the abdominal incision, avoiding injury or entrapment of |

| | |abdominal contents. An incision is made along the right lateral peritoneal reflection, allowing for complete |

| | |mobilization and devascularization of the cecum and ascending colon. The terminal ileum and its mesentery are |

| | |divided 46 cm from the ileocecal valve between bowel clamps. The omentum is dissected off the anterior surface |

| | |of the transverse colon from the hepatic flexure to the splenic flexure to allow access to the lesser sac. The |

| | |mesentery of the transverse colon is then divided and ligated and the hepatic and splenic flexures are fully |

| | |released. The descending and sigmoid colon are mobilized from the lateral peritoneal attachments and the |

| | |mesentery is sequentially divided and ligated. During the mobilization of the right and left colonic segments, |

| | |the ureters are identified and protected prior to vascular division. The rectal dissection is begun posterior |

| | |to the rectum, directly on the rectal mesentery, taking care not to disturb the hypogastric plexus of nerves. |

| | |The lateral attachments of the rectum are sharply dissected to the level of the levators. The anterior |

| | |dissection of the rectum is done directly on the rectum, taking care not to enter the vagina. The rectovaginal |

| | |septum is completely separated down to the pelvic floor. The surgeons then move to the perineal field. |

| | |A retractor is placed around the anus near the dentate line. The dentate line is isolated and an epinephrine |

| | |solution injected into the submucosa of the rectal lining. A mucosectomy is performed, with complete detachment|

| | |of the rectum from the anus. The entire colon and rectum are handed off the field and sent to pathology. The |

| | |distal ileum is brought through the anus and hand-sewn to the anal canal with interrupted absorbable sutures. |

| | |The surgeon rescrubs and gowns and returns to the abdominal wound. After irrigating the abdomen and pelvis, a |

| | |drain is placed posterior to the anastomosis and brought out through a small stab wound incision on the left |

| | |side of the abdomen. The ovaries are repositioned and carefully placed to minimize adhesions to the tubes and |

| | |ovaries. On the right side of the abdomen, through a previously marked site, a small ellipse of skin is |

| | |removed, the anterior rectus sheath is divided, and the rectus muscle is bluntly separated to allow for |

| | |dividing the posterior. A portion of the distal ileum proximal to the ileoanal anastomosis is brought out |

| | |through this incision and placed over an ileostomy rod that is anchored to the skin with silk sutures. The |

| | |fascia is reapproximated with a continuous running suture. The subcutaneous tissue is irrigated with a sterile |

| | |solution and the skin is reapproximated with staples. The ileum is opened on its antimesenteric border and the |

| | |mucocutaneous anastomosis is constructed with eversion of the functional limb of the loop ileostomy, while the |

| | |distal limb is sutured to the subcuticular layer of skin. A second instrument, needle, sponge, and lap-pad |

| | |count is conducted. |

|[pic] |

|44158 |  |Clinical Example (44158) |

| | |An 18-year-old female with a family history of familial polyposis presents with diffuse polyposis. During the |

| | |procedure, a total proctocolectomy, ileoanal anastomosis, creation of ileal reservoir, loop ileostomy, and |

| | |mucosectomy are performed. |

| | |Description of Procedure (44158) |

| | |A skin incision is made using sharp dissection. Hemostasis is achieved using electrocautery as necessary. The |

| | |linea alba is identified and carefully divided. The peritoneum is grasped, elevated, and carefully incised to |

| | |avoid injury to the bowel. The peritoneal cavity is entered under direct vision. Adhesions, if present, are |

| | |cleared by sharp dissection to expose all of the abdominal viscera. |

| | |A visual and manual complete exploration of the abdominal cavity and its contents is carried out. A nasogastric|

| | |tube is placed and its position is confirmed. The stomach is inspected and palpated for pathology. The duodenum|

| | |is visualized and palpated. The gallbladder is inspected and palpated for the presence of gall stones. The |

| | |liver is palpated bimanually to detect potential hepatic metastases, as is the porta hepatis. The pancreas is |

| | |inspected through the hepatico gastric ligament and palpated for possible masses. The tail of the pancreas is |

| | |palpated for possible lymphadenopathy. The small bowel is inspected and palpated from the ligament of Treitz to|

| | |the ileocecal valve. The small-bowel mesentery is inspected and palpated for the presence of lymphadenopathy. |

| | |The uterus is inspected and the ovaries are carefully packed to minimize adhesions and risk of infertility. The|

| | |cecum and appendix, and the ascending, transverse, and descending colon are inspected and palpated. The |

| | |cul-de-sac and pelvic contents are inspected and palpated. Any suspicious finding(s) are noted and appropriate |

| | |biopsies taken and sent to pathology for frozen section. |

| | |A self-retaining retractor is carefully inserted into the abdominal incision, avoiding injury or entrapment of |

| | |abdominal contents. An incision is made along the right lateral peritoneal reflection to allow for complete |

| | |mobilization and devascularization of the cecum and ascending colon. The terminal ileum and its mesentery are |

| | |divided 4-6 cm from the ileocecal valve between bowel clamps. The omentum is dissected off the anterior surface|

| | |of the transverse colon from the hepatic flexure to the splenic flexure to allow access to the lesser sac. The |

| | |mesentery of the transverse colon is then divided and ligated and the hepatic and splenic flexures are fully |

| | |released. The descending and sigmoid colon are mobilized from the lateral peritoneal attachments and the |

| | |mesentery is sequentially divided and ligated. During the mobilization of the right and left colonic segments, |

| | |the ureters are identified and protected prior to vascular division. The rectal dissection is begun posterior |

| | |to the rectum, directly on the rectal mesentery, taking care not to disturb the hypogastric plexus of nerves. |

| | |The lateral attachments of the rectum are sharply dissected to the level of the levators. The anterior |

| | |dissection of the rectum is done directly on the rectum, taking care not to enter the vagina. The rectovaginal |

| | |septum is completely separated down to the pelvic floor. The surgeons then move to the perineal field. |

| | |A retractor is placed around the anus near the dentate line. The dentate line is isolated and an epinephrine |

| | |solution is injected into the submucosa of the rectal lining. A mucosectomy is performed with complete |

| | |detachment of the rectum from the anus. The entire colon and rectum are handed off the field and sent to |

| | |pathology. The distal ileum is then brought through the anus and hand-sewn to the anal canal with interrupted |

| | |absorbable sutures. |

| | |The surgeon rescrubs and gowns and returns to the abdominal wound. After irrigation of the abdomen and pelvis |

| | |is performed, a drain is placed posterior to the anastomosis and brought out through a small stab wound |

| | |incision on the left side of the abdomen. The ovaries are repositioned and carefully placed to minimize |

| | |adhesions to the tubes and ovaries. On the right side of the abdomen, through a previously marked site, a small|

| | |ellipse of skin is removed, the anterior rectus sheath is divided, and the rectus muscle is bluntly separated |

| | |to allow for dividing the posterior. A portion of the distal ileum proximal to the ileoanal anastomosis is |

| | |brought out through this incision and placed over an ileostomy rod that is anchored to the skin with silk |

| | |sutures. The fascia is reapproximated with a continuous running suture. The subcutaneous tissue is irrigated |

| | |with a sterile solution and the skin is reapproximated with staples. The ileum is opened on its antimesenteric |

| | |border and the mucocutaneous anastomosis is constructed with eversion of the functional limb of the loop |

| | |ileostomy, while the distal limb is sutured to the subcuticular layer of skin. A second instrument, needle, |

| | |sponge, and lap-pad count is conducted. |

|[pic] |

|44187 |  |Clinical Example |

| | |A 58-year-old man, who recently underwent a supra-pubic prostatectomy, presents with rectal discharge of urine.|

| | |His urinalysis is positive for fecal flora and sediment. He has a computed tomography-confirmed abscess in the |

| | |prostate bed and communication between the rectum and the neck of the bladder at the urethral anastomosis and a|

| | |contrast-confirmed recto-urethral fistula. At laparoscopy, to achieve fecal diversion, the terminal ileum is |

| | |identified and brought out as an ileostomy through the skin in a preoperatively selected site. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A supraumbilical incision is made and a 12-mm port|

| | |is placed. Gas flow is initiated to distend the abdomen, and the laparoscope is introduced. Gas flow and |

| | |intra-abdominal pressure are carefully monitored so as not to impair ventilation or venous return. Two |

| | |additional 5-mm ports are placed: one in the right paraumbilical region in the preoperative marked stoma site |

| | |and one in the left iliac fossa, lateral to the rectus muscle. The abdomen is explored with the patient in |

| | |steep Trendelenburg and left-side-down position. Through the right-sided port site, the bowel at the terminal |

| | |ileum is gently grasped to ensure adequate mobilization of the terminal ileum to reach the anterior abdominal |

| | |wall. The proximal and distal end is marked with one and two clips, respectively. The stoma site is created |

| | |with the use of the Bovie and splitting the rectus muscle, working around the trocar in the stoma site. The |

| | |bowel is delivered through the abdominal wall after releasing the pneumoperitoneum, which is then reestablished|

| | |to inspect the abdomen to ensure hemostasis, bowel viability, and a tension-free ileostomy without unwanted |

| | |twists. The trocars are removed, the fascial openings are closed as appropriate, and the individual wounds of |

| | |the port sites are closed. |

|[pic] |

|44188 |  |Clinical Example |

| | |A gravida 4 para 4 (G4P4) 78-year-old woman, who is undergoing preoperative chemotherapy and radiation therapy |

| | |for a distal stage 3 rectal cancer located at 2 cm from the dentate line, presents with complaints of severe |

| | |tenesmus, fecal incontinence, worsened by the diarrhea associated with the chemotherapy. Her perineum is |

| | |severely excoriated and associated with severe ulcerative dermatitis. At laparoscopy, the left colon is |

| | |mobilized and brought out as a colostomy through the skin in a preoperatively selected site to allow for relief|

| | |from fecal incontinence and perineal irritation and completion of the neo-adjuvant treatment, prior to |

| | |definitive resection. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A supraumbilical incision is made and carried down|

| | |to the linea alba, which is grasped with clamps. Divided sutures are placed in the linea alba. The peritoneum |

| | |is identified and divided. The port is placed. Gas flow is initiated to distend the abdomen, and the |

| | |laparoscope is introduced. Gas flow and intra-abdominal pressure are carefully monitored so as not to impair |

| | |ventilation or venous return. Three additional ports are placed, one in the left paraumbilical region, one in |

| | |the right paraumbilical region, and one in the right iliac fossa, each lateral to the rectus muscle, each |

| | |placed under direct vision. The abdomen is explored with the patient in steep Trendelenburg and right-side-down|

| | |position. Adhesions of the sigmoid to the anterior abdominal wall are divided. The line of Toldt is divided to |

| | |achieve mobilization and the left ureter is identified and reflected posteriorly out of harm’s way. A trocar is|

| | |placed in the previously marked stoma site. The proximal and distal ends of the loop are marked with one and |

| | |two clips, respectively, and grasped. The stoma site is created around the trocar and enlarged to accept two |

| | |fingers. After decompressing the pneumoperitoneum, the bowel is exteriorized and divided with a linear stapler |

| | |cutter. The distal end is returned in the abdomen and the proximal end secured to the skin. The |

| | |pneumoperitoneum is then reestablished to inspect the abdomen to ensure hemostasis, bowel viability, and a |

| | |tension-free colostomy, without unwanted twists. The trocars are removed and the fascial openings are closed as|

| | |appropriate, and the individual wounds of the port sites are closed. |

|[pic] |

|44200 |  |A 55-year-old woman, who has had a previous hysterectomy and bilateral salpingo-oophorectomy, presents with |

| | |nausea and vomiting. Abdominal radiographs reveal multiple air-fluid levels consistent with small-bowel |

| | |obstruction. Conservative management with nasogastric tube decompression is begun. Signs and symptoms of |

| | |small-bowel obstruction continue and are confirmed by repeat abdominal radiographs. |

|[pic] |

|44201 |  |A 70-year-old man who has had a previous CVA presents with esophagogastric dysmotility and repeated episodes of|

| | |pulmonary aspiration. The patient requires enteral feedings for long-term nutritional support. |

|[pic] |

|44202 |  |Clinical Example |

| | |A 23-year-old female with Crohn’s disease has a severe sigmoid stenosis. Failing medical treatment, the |

| | |operation includes laparoscopic assessment of the intestinal tract for active Crohn’s disease. The sigmoid |

| | |colon is mobilized through four laparoscopic ports. The mesenteric and intestinal resection is accomplished |

| | |intra- and extracorporeally. The resected specimen is delivered through a suprapubic incision. Intestinal |

| | |continuity is restored with an end-to-end anastomosis using a transanal stapling device. The incision and port |

| | |sites are closed. Postoperative care manages the associated ileus, immunosuppressive medications, and wound |

| | |care. Outpatient follow-up includes assessment for anastomotic complications. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A supraumbilical incision is made, and the |

| | |peritoneum is grasped with sutures on the fascia. The peritoneum is opened under direct vision. A blunt trocar |

| | |is inserted. Gas flow is initiated to distend the abdomen, and the laparoscope is introduced. Gas flow and |

| | |intra-abdominal pressure are carefully monitored so as not to impair ventilation or venous return. The viscera |

| | |are inspected. Three additional trocars are placed to expose the mobilized area and resect the pathologic |

| | |segment of intestine (in this case, the sigmoid). The mesenteric vessels are identified, double clamped and |

| | |ligated through the laparoscope. The specimen is delivered to the abdominal wall in the lower abdomen. A |

| | |separate incision is placed in the abdomen to deliver the specimen from the wound. An extracorporeal |

| | |anastomosis is performed through the incision. Intracorporeal anastomoses are performed through the |

| | |laparoscope. A trans-anal circular stapling device is used to perform the anastomosis. Meticulous hemostasis is|

| | |obtained and the trocar are removed. The trocar sites are individually closed as is the lower abdominal |

| | |incision. |

|[pic] |

|44203 |  |Clinical Example (44203) |

| | |The patient is a 68-year-old white male with well-controlled essential hypertension and non-insulin dependent |

| | |diabetes mellitus (managed by oral hypoglycemic) and 2 prior attacks of sigmoid diverticulitis requiring |

| | |hospitalization and a course of intravenous antibiotics. The patient has responded to his medical treatment of |

| | |2 weeks of intra-venous/oral antibiotics and a low residue diet. He is currently afebrile and has no abdominal |

| | |pain or abnormalities of bowel function. A CT scan at the last admission demonstrated a pericolic phlegmon |

| | |without abscess. The patient has undergone prior colonoscopy recently to rule out colonic neoplasia. An |

| | |elective laparoscopic colectomy is recommended to avoid the risks associated with recurrent diverticulitis and |

| | |associated complications. |

| | |Description of Procedure (44203) |

| | |The patient is administered general anesthesia. The initial 10 mm trocar is inserted using open technique and |

| | |pneumoperitoneum is established at 12 mm Hg. Right lower quadrant, left lower quadrant, and right upper |

| | |quadrant trocars are inserted under direct vision. The small bowel is mobilized out of the pelvis after placing|

| | |the patient in Trendelenburg position. The sigmoid colon is assessed for laparoscopic resectability based on |

| | |size of phlegmon and related adhesions. A visual inspection of abdominal and pelvic organs is performed. The |

| | |superior hemorrhoidal vessels are dissected from the right side and elevated to expose the left ureter, which |

| | |is completely visualized. The vessels are then divided between metal clips just distal to the left colic |

| | |artery. Dissection is then continued into the pre-sacral space to expose the proximal rectum that will be the |

| | |site of division of the bowel distally. The inflammatory adhesions between the sigmoid colon and lateral |

| | |abdominal and pelvic walls are lysed and the ureter is once again visualized. After the sigmoid colon is |

| | |completely freed of lateral attachments to the level of the upper rectum, the mesorectum is divided using a |

| | |combination of monopolar cautery, bipolar cautery, and metal clips. The rectosigmoid junction is divided using |

| | |an endoscopic linear stapler/cutter. The sigmoid colon is mobilized and exteriorized through a left lower |

| | |quadrant 3 cm incision. The descending colon is divided extracorporeally and the circular anvil is held in |

| | |place using a polypropylene pursestring suture. The bowel is returned to the abdomen and the incision is closed|

| | |in layers. The descending colon is mobilized to allow a tension-free anastomosis. The circular stapler is |

| | |inserted transanally and the trocar brought through the distal staple line. The anvil is fitted to the |

| | |instrument, which is then closed and fired forming the anastomosis. An air leak test is performed. The 10 mm |

| | |trocar fascial sites are closed with suture and the skin incisions are closed with running subcuticular |

| | |sutures. Dressings are applied. The procedure lasts 170 minutes. The patient is transferred to the post |

| | |anestheia care unit (PACU) and then a surgical floor. He is evaluated daily for cardiorespiratory function, |

| | |analgesic status, and bowel function. His diet is advanced and he is discharged on the fourth post-operative |

| | |day. All appropriate medical records are completed including operative dictation, daily progress notes, |

| | |discharge summary, and discharge instructions. He is seen in the office at 2 weeks and 6 weeks for wound |

| | |assessment, post-operative recovery, and dietary instruction. Evaluation and management components are recorded|

| | |and information forwarded to the primary care physician. |

|[pic] |

|44205 |  |Clinical Example (44205) |

| | |A 27-year-old male patient has had Crohn's disease of the terminal ileum for six years. He has been treated |

| | |with multiple medications but continues to have exacerbations of his disease that are severe enough to require |

| | |time off work on a regular basis. The decision is made to proceed with surgery to remove the involved segment |

| | |of terminal ileum. |

| | |Description of Procedure (44205) |

| | |The patient is seen on the day of surgery and the labs and procedure are all reviewed with the patient. The |

| | |patient is brought to the operating room and given general anesthesia. The patient continues in the supine |

| | |position and all extremities are checked for proper positioning and padding to minimize the risk of neuropathy.|

| | |The abdomen is prepped and draped in a sterile fashion. Trocars are placed through the abdominal wall at the |

| | |umbilicus, right lower quadrant and lower midline. Special care is taken to avoid the epigastric vessels and |

| | |all intra-abdominal and retroperitoneal structures with the trocars. An additional port may be necessary |

| | |depending on patient anatomy. After insufflation with CO2 the laparoscope is inserted and a visual inspection |

| | |of the abdominal contents is carried out. The terminal ileum and ascending colon are then mobilized by incising|

| | |the lateral peritoneal attachments. The hepaticocolic ligament must also be divided to allow mobilization of |

| | |the hepatic flexure. The duodenum and right ureter must be visualized and protected during this mobilization. |

| | |Once the mobilization is complete, the trocar in the right lower quadrant is removed and the incision enlarged |

| | |to allow for delivery of the involved terminal ileum and cecum out of the abdominal cavity. The terminal ileum |

| | |is then divided 5 cm proximal to the Crohn's disease with a stapling device. The ascending colon is divided in |

| | |a similar fashion. The ileocolic vessels and any other mesentery to the involved bowel are then ligated and |

| | |divided. The resected specimen is then handed off the surgical field. The anastomosis between the ileum and the|

| | |remaining ascending colon is accomplished by stapling to join the two limbs of bowel. Another stapler is used |

| | |to close the remaining enterotomy and colotomy. The defect in the mesentery is closed using an absorbable |

| | |running stitch and then the bowel placed back within the abdominal cavity. The fascial defect is then closed in|

| | |two layers and the abdomen insufflated again to irrigate and inspect. All remaining trocars are then removed |

| | |under direct vision. The skin is closed using a running subcuticular absorbable stitch. |

|[pic] |

|44206 |  |Clinical Example (44206) |

| | |A 56-year-old female presents to the emergency room with a 24-hour history of severe abdominal pain. Evaluation|

| | |reveals rebound tenderness throughout the entire abdomen, fever to 39°C, and WBC elevation to 24,000. A CT scan|

| | |of the abdomen is suggestive of perforated diverticulitis. The patient undergoes a laparoscopic evaluation of |

| | |the abdomen with plans to proceed with a laparoscopic-aided sigmoid colectomy and colostomy if necessary. |

| | |Description of Procedure (44206) |

| | |The patient is brought to the OR and placed on an electric OR bed and given general anesthesia. She is placed |

| | |supine with her legs in hydraulic stirrups. All extremities are checked for proper positioning and padding to |

| | |avoid neuropathy. The abdomen is prepped and draped in a sterile manner. The initial 10-mm trocar is inserted |

| | |using open technique and pneumoperitoneum is established at 12-mm Hg. Additional trocars are placed under |

| | |direct vision in the right lower quadrant, right upper quadrant, and then in the left lower quadrant at the |

| | |same site chosen for the colostomy. Laparoscopic evaluation of the abdomen indicates perforated diverticulitis |

| | |with considerable free purulence. A single loop of small bowel is adhered to the inflammatory phlegmon and has |

| | |to be mobilized out of the pelvis. The considerable adhesions between the sigmoid colon and the pelvic sidewall|

| | |are meticulously taken down and the sigmoid colon mobilized by incising the lateral peritoneal attachments. The|

| | |distal resection margin is chosen at the rectosigmoid junction and the bowel divided here using an endoscopic |

| | |linear stapler/cutter. The mesosigmoid is divided with a combination of clips and harmonic scalpel. The left |

| | |colon is further mobilized to allow enough length of bowel to exteriorize. Because of the peritonitis, a |

| | |colostomy is elected rather than an anastomosis. The abdominal cavity is thoroughly irrigated. A stoma site is |

| | |prepared at the left lower quadrant trocar site and the divided end of the sigmoid colon delivered up through |

| | |the stoma site. All trocars are removed and the fascia closed at these sites. The proximal resection site is |

| | |chosen, the bowel divided, and a colostomy matured. Sterile dressings and a colostomy appliance are placed. The|

| | |patient is then transferred to the post-anesthesia care unit (PACU). |

|[pic] |

|44207 |  |Clinical Example (44207) |

| | |The patient is a 62-year-old male who presents with a rectal cancer in the upper rectum. Colonoscopy reveals no|

| | |other abnormality and CT scan is normal. The patient undergoes a laparoscopic resection of the rectosigmoid |

| | |with a coloproctostomy. |

| | |Description of Procedure (44207) |

| | |The patient is brought to the OR and placed on an electric OR bed and given general anesthesia. He is placed |

| | |supine with his legs in hydraulic stirrups. All extremities are checked for proper positioning and padding to |

| | |avoid neuropathy. A catheter is placed. The abdomen is prepped and draped in a sterile manner. The initial |

| | |10-mm trocar is inserted using open technique and pneumoperitoneum is established at 12-mm Hg. Additional |

| | |trocars are placed under direct vision in the right lower quadrant, right upper quadrant, and then in the left |

| | |lower quadrant at the same site chosen for the colostomy. Laparoscopic evaluation of the abdomen indicates a |

| | |mass in the upper rectum. The liver appears normal. The sigmoid colon is mobilized by incising the lateral |

| | |peritoneal attachments. The superior rectal vessels are identified, dissected up off of the sacral promontory, |

| | |and then divided using a combination of clips and electrocautery. The rectum is then mobilized by incising |

| | |along the lateral edges of the mesorectum and entering the presacral space and dissecting distally to the |

| | |mid-to-distal rectum. Special care is taken to identify and preserve both ureters and the presacral sympathetic|

| | |chain. The distal resection margin is chosen at 5 cm distal to the mass. The bowel is divided here using a |

| | |reticulating endoscopic linear stapler/cutter. The mesorectum is divided with a combination of clips and |

| | |harmonic scalpel. The left colon is further mobilized to allow enough length of bowel to exteriorize. The |

| | |abdominal cavity is thoroughly irrigated. The left lower quadrant trocar site is enlarged and the divided end |

| | |of the rectosigmoid colon delivered up through the stoma site. The proximal resection site is chosen, the bowel|

| | |divided, and a purse-string suture placed around the end of the bowel. A 31-mm anvil is placed in the end of |

| | |the bowel and then the bowel placed back within the abdominal cavity. The left lower quadrant site is closed in|

| | |layers. An EEA stapler is passed transanally and the spike advanced out through the rectal stump. The anvil and|

| | |the stapler are mated and then fired to form an end-to-end anastomosis. The anastomosis is then air-tested |

| | |under water. All the remaining trocars are removed and all 10-mm and larger trocar sites are closed at the |

| | |fascial level. A closed suction drain is placed in the pelvis via a separate stab incision. The skin is closed |

| | |with a subcuticular stitch and sterile dressings are applied. The patient is then transferred to the PACU. |

|[pic] |

|44208 |  |Clinical Example (44208) |

| | |A 62-year-old male presents with a large, fixed rectal cancer in the upper rectum. Colonoscopy reveals no other|

| | |abnormality and CT scan is normal. Following adjuvant radiochemotherapy, the patient undergoes a laparoscopic |

| | |resection of the rectosigmoid with a coloproctostomy. |

| | |Description of Procedure (44208) |

| | |The patient is brought to the OR and placed on an electric OR bed and given general anesthesia. He is placed |

| | |supine with his legs in hydraulic stirrups. All extremities are checked for proper positioning and padding to |

| | |avoid neuropathy. A catheter is placed. The abdomen and perineum are prepped and draped in a sterile manner. |

| | |The initial 10-mm trocar is inserted using open technique and pneumoperitoneum is established at 12-mm Hg. |

| | |Additional trocars are placed under direct vision in the right lower quadrant, right upper quadrant, and then |

| | |in the left lower quadrant at the same site chosen for the colostomy. Laparoscopic evaluation of the abdomen |

| | |indicates a mass in the upper rectum. The liver appears normal. The sigmoid colon is mobilized by incising the |

| | |lateral peritoneal attachments. The superior rectal vessels are identified, dissected up off of the sacral |

| | |promontory, and then divided using a combination of clips and electrocautery. The rectum is then mobilized by |

| | |incising along the lateral edges of the mesorectum and entering the presacral space and dissecting distally to |

| | |the mid- to distal rectum. Special care is taken to identify and preserve both ureters and the presacral |

| | |sympathetic chain. The distal resection margin is chosen at 5 cm distal to the mass. The bowel is divided here |

| | |using a reticulating endoscopic linear stapler/cutter. The mesorectum is divided with a combination of clips |

| | |and harmonic scalpel. The left colon is further mobilized to allow enough length of bowel to exteriorize. The |

| | |abdominal cavity is thoroughly irrigated. The left lower quadrant trocar site is enlarged and the divided end |

| | |of the rectosigmoid colon delivered up through the stoma site. The proximal resection site is chosen, the bowel|

| | |divided, and a purse-string suture placed around the end of the bowel. A 31-mm anvil is placed in the end of |

| | |the bowel and then the bowel placed back within the abdominal cavity. The left lower quadrant site is closed in|

| | |layers. An EEA stapler is passed transanally and the spike advanced out through the rectal stump. The anvil and|

| | |the stapler are mated and then fired to form an end-to-end anastomosis. The anastomosis is then air-tested |

| | |under water. At the time of testing a small air leak is identified at the anterior border of the anastomosis. |

| | |This is repaired with interrupted sutures. Because of the air leak and the previous radiotherapy, a diverting |

| | |ileostomy is placed. The ileostomy site is developed in the right lower quadrant. The ileum is then brought up |

| | |out through the ileostomy site. A closed suction drain is placed into the pelvis and brought out via a separate|

| | |stab incision. All the remaining trocars are removed and all 10-mm and larger trocar sites are closed at the |

| | |fascial level. The skin is closed with a subcuticular stitch and sterile dressings are applied. The ileostomy |

| | |is matured and a stoma appliance placed. The patient is then transferred to the PACU. |

|[pic] |

|44210 |  |Clinical Example (44210) |

| | |The patient is a 22-year-old female with known familial polyposis with minimal number of polyps in the rectum. |

| | |After considering the alternatives, she elects to proceed with a laparoscopic total abdominal colectomy with |

| | |ileoproctostomy. |

| | |Description of Procedure (44210) |

| | |The patient is brought to the OR and given general anesthesia. Her legs are placed in hydraulic stirrups. All |

| | |extremities are checked for adequate padding. A Foley catheter is placed. The abdomen and perineum are prepped |

| | |and draped in a sterile manner. The initial port is placed in the umbilical port using the open technique and |

| | |then four additional trocars (two on each side) are placed under direct vision. The bowel is completely |

| | |mobilized by incising the lateral peritoneal attachments and by separating the omentum from the transverse |

| | |colon. Starting with the left colon and then proceeding proximally, the mesentery of the abdominal colon is |

| | |divided using a combination of clips and the harmonic scalpel. The rectosigmoid junction is divided using an |

| | |endoscopic linear stapler/cutter. The umbilical port site is then enlarged, allowing the colon to be extracted |

| | |out through this site. The terminal ileum is divided just proximal to the ileocecal valve and a 28-mm circular |

| | |stapler anvil is placed in the terminal ileum with a pursestring suture. The terminal ileum is then placed back|

| | |within the abdominal cavity, the incision closed, and pneumoperitoneum re-established. The circular stapler is |

| | |passed transanally and the spike brought out through the end of the rectal stump. The anvil in the terminal |

| | |ileum is fitted to the stapler and the stapler is then fired, forming an end-to-end anastomosis. An air test is|

| | |performed and then all the trocars are removed. The fascia is closed at the 10-mm trocar sites and all skin |

| | |incisions are closed with subcuticular stitches. Sterile dressings are applied and the patient is transferred |

| | |to PACU. |

|[pic] |

|44211 |  |Clinical Example (44211) |

| | |An 18-year-old female from a known familial polyposis kindred presents with diffuse polyposis. She undergoes a |

| | |laparoscopic total proctocolectomy, ileoanal anastomosis, creation of ileal reservoir, loop ileostomy, and |

| | |mucosectomy. |

| | |Description of Procedure (44211) |

| | |The patient is brought to the operating room and given general anesthesia. Her legs are placed in hydraulic |

| | |stirrups. All extremities are checked for adequate padding. A Foley catheter is placed. The initial port is |

| | |placed in the umbilical port using the open technique and then four additional trocars (two on each side) are |

| | |placed under direct vision. The bowel is completely mobilized by incising the lateral peritoneal attachments |

| | |and by separating the omentum from the transverse colon. Starting with the left colon and then proceeding |

| | |proximally, the mesentery of the abdominal colon is divided using a combination of clips and the harmonic |

| | |scalpel. Dissection is then carried out in the pelvis. The ureters are both identified and the peritoneum |

| | |incised circumferentially. The presacral space and the rectovaginal plane are entered and dissection is carried|

| | |out down to the pelvic floor. The rectal dissection is then carried out transanally with a mucosectomy being |

| | |carried out using a retractor. A low transverse incision is made to gain access to the abdominal cavity. The |

| | |rectum is divided just above the pelvic floor and the colon and rectum are delivered out through the low |

| | |transverse incision. The terminal ileum is divided at the ileocecal junction and then a J pouch is constructed |

| | |using linear stapler/cutters. The J pouch is then placed back inside the abdomen and delivered to the pelvis. A|

| | |hand-sewn ileoanal anastomosis is completed and then air-tested. A significant air leak is detected and the |

| | |anastomosis is found to have a small defect that is then repaired. Because of the repair and some moderate |

| | |tension on the anastomosis, a diverting ileostomy is elected. A proximal loop of ileum is chosen for the |

| | |diverting ileostomy and a Penrose drain placed around the bowel at this point. The right lower quadrant trocar |

| | |is removed and this site used for the ileostomy. The skin is excised in a circular fashion and the muscle and |

| | |fascia split. The ileum is brought out through the stoma site. A closed suction drain is placed into the pelvis|

| | |and brought out through a separate stab incision. The low transverse incision is closed after irrigating out |

| | |the abdominal cavity. After removing all the remaining trocars, the fascia is closed at the 10-mm trocar sites |

| | |and all skin incisions are closed with subcuticular stitches. The ileostomy is matured by incising on the |

| | |antimesenteric border and then forming a Brooke-type ileostomy. An ileostomy appliance and sterile dressings |

| | |are applied and the patient is transferred to PACU. |

|[pic] |

|44212 |  |Clinical Example (44212) |

| | |The patient is a 32-year-old female who is discovered to have familial polyposis with a large, fixed rectal |

| | |cancer. Following adjuvant chemoradiotherapy, she elects to proceed with a laparoscopic total proctocolectomy |

| | |with ileostomy. |

| | |Description of Procedure (44212) |

| | |The patient is brought to the OR and given general anesthesia. The patient's legs are placed in hydraulic |

| | |stirrups. A catheter is placed. All extremities are checked for adequate padding. The abdomen and perineum are |

| | |prepped and draped in a sterile manner. The initial port is placed in the umbilical port using the open |

| | |technique and then four additional trocars (two on each side) are placed under direct vision. The bowel is |

| | |completely mobilized by incising the lateral peritoneal attachments and by separating the omentum from the |

| | |transverse colon. Starting with the left colon and then proceeding proximally, the mesentery of the abdominal |

| | |colon is divided using a combination of clips and the harmonic scalpel. The terminal ileum is divided just |

| | |proximal to the ileocecal valve and the rectum is then dissected out. First, both ureters are identified and |

| | |the peritoneum is incised circumferentially. The presacral space and the rectovaginal plane are entered and |

| | |dissection is carried out down to the pelvic floor. The operating surgeon then goes to the pelvis and makes an |

| | |elliptical incision around the anus and incises through the ischiorectal fossa and then the levator muscle to |

| | |completely free the rectum. The colorectum is delivered out through the perineal wound. The perineal wound is |

| | |closed in layers and pneumoperitoneum re-established. The terminal ileum is grasped, an ileostomy site is |

| | |fashioned through all layers in the right lower quadrant, and the terminal ileum is brought out through this |

| | |opening. All the trocars are removed. The fascia is closed at the 10-mm trocar sites and all skin incisions are|

| | |closed with subcuticular stitches. The ileostomy is matured in a Brooke-type fashion, sterile dressings and an |

| | |ileostomy appliance are applied, and the patient is transferred to PACU. |

|[pic] |

|44213 |  |Clinical Example |

| | |After laparoscopic colon resection for middle to low rectal cancer, an end-to-end colorectal anastomosis |

| | |between the splenic flexure and the rectum is performed, requiring mobilization of the entire splenic flexure. |

| | |Description of Procedure |

| | |Laparoscopic mobilization of the splenic flexure involves placement of additional operative trocar ports (one |

| | |or possibly two) to attain proper traction tension for the tedious dissection. With medial traction to expose |

| | |the lateral line of Toldt, dissection of the colon is carried out cephalad, along the line of Toldt, lateral to|

| | |the descending colon. The transverse colon is retracted toward the pelvis, while the omentum is retracted |

| | |cephalad, then the omentum is dissected from the transverse colon, in order to enter the lesser sac for access |

| | |to the colon mesentery. This dissection is carried to the spleen and then the ligaments are taken down from the|

| | |lower pole of the spleen and the splenic hilum. Next, the colonic mesentery is divided in one of two ways: (1) |

| | |the transverse mesentery is divided through the lesser sac up to the splenic flexure and the proximal |

| | |descending colon; or (2) the transverse colon is retracted in the cephalad direction and the descending colon |

| | |is retracted laterally in order to isolate the ligament of Treitz as a landmark for the retroperitoneal |

| | |dissection of splenic flexure mesentery. During the procedure, the operative table will be repositioned |

| | |multiple times to allow gravity to assist in the retraction of the hollow organs. For example, the |

| | |Trendelenburg position is used while the omentum is dissected off of the transverse colon and the reverse |

| | |Trendelenburg position is used while the mesentery of the transverse colon is divided through the lesser sac. |

|[pic] |

|44227 |  |Clinical Example |

| | |A 73-year-old man, 3 months status post Hartmann procedure for perforated diverticulitis presents for reversal |

| | |of his colostomy. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A supraumbilical incision is made, and the |

| | |peritoneum is grasped with sutures on the fascia. The peritoneum is opened under direct vision. A Hassan blunt |

| | |trocar is inserted. Gas flow is initiated to distend the abdomen, and the laparoscope is introduced. Gas flow |

| | |and intra-abdominal pressure are carefully monitored so as not to impair ventilation or venous return. Two 5-mm|

| | |trocars are placed in the right lower quadrant and another 5-mm trocar is placed in the mid-epigastrium. The |

| | |viscera are inspected. The previous operation typically involves pelvic sepsis and creates dense adhesions that|

| | |maximally complicate the re-exploration; therefore, laparoscopic lysis of adhesions is oftentimes the first |

| | |step performed. The rectal stump is identified after mobilizing any adherent small bowel off the top of the |

| | |Hartmann pouch. The stoma is dissected free from the anterior abdominal wall fascia. The colon is mobilized |

| | |from the transverse colon distally including the splenic flexure. The descending colon will serve as the |

| | |segment for the anastomosis. The ureters are identified bilaterally with care to prevent injury. Once the colon|

| | |is fully mobilized from inside the abdomen, the colostomy is freed up from the skin of the anterior abdominal |

| | |wall using an elliptical incision, and carried down into the peritoneal cavity. With the transient loss of |

| | |pneumoperitoneum, the colostomy is resected and the anvil of a circular stapler is placed in the proximal |

| | |colon. After securing it with a purse-string suture, the proximal bowel is reduced into the abdominal cavity |

| | |and the colostomy site is closed in two layers. Once pneumoperitoneum has been reinstituted, an anastomosis is |

| | |performed using the circular stapling device. While the pelvis is filled with irrigation solution, a rigid |

| | |proctoscopy is performed with insufflation of the rectum to assure that the anastomosis does not create an air |

| | |leak and remains intact. Hemostasis is obtained. The trocars are removed, the fascial openings are closed as |

| | |appropriate, and the individual wounds of the port sites are closed. |

|[pic] |

|44320 |  |Clinical Example |

| | |A 67-year-old male presents with a history of rectal bleeding and a biopsy-proven sigmoid carcinoma at 35 cm |

| | |from the anal verge. The lesion is completely obstructing the patient and, because of multiple medical |

| | |problems, the decision is made to perform a diverting colostomy to decompress the colon and to allow time for |

| | |proper medical stabilization of the patient prior to definitive resection. After the decision to operate has |

| | |been made, the surgeon reviews laboratory and radiologic studies, and assesses the need for further diagnostic |

| | |procedures prior to surgery. The surgeon discusses the procedure with the patient, and obtains informed |

| | |consent. At operation, a dissection of the left colon is performed. The left colon is mobilized and brought out|

| | |as a colostomy and drains placed as indicated. Postoperative care of the patient includes monitoring of |

| | |ventilator settings, hemodynamics, intravenous nutrition, antibiotics, and fluid balance. Wound checks and |

| | |dressing changes are made to assure an absence of infection, hematoma, and drainage. Communication occurs with |

| | |the patient and family, as well as coordination of care with other physicians and health care providers. Drains|

| | |are removed as indicated. Oral feeding is resumed after a return of bowel function. The patient’s diet is |

| | |advanced, intravenous feeding is discontinued, and the nutritional status of the patient is also monitored to |

| | |ensure that adequate nutritional intake occurs. The medical status of the patient is reviewed with other |

| | |consultants, discussed with the patient and family, and appropriate decisions are then made for further care of|

| | |the patient. A decision is made to discharge the patient to allow further stabilization of his medical status, |

| | |prior to definitive resection. The patient is followed in the office as needed to monitor for wound |

| | |complications or infection until cleared for surgery by the medical consultants. |

| | |Description of Procedure |

| | |A skin incision is made, and the anterior abdominal wall is carefully divided. The peritoneum is entered and a |

| | |thorough exploration of the abdomen is undertaken, including palpating and visualizing (where possible) the |

| | |spleen, liver, stomach, duodenum, pancreas, small bowel, large bowel, kidneys, and pelvis, including bladder |

| | |and rectum. Adhesions are lysed by sharp and blunt dissection. A self-retaining retractor is secured to the |

| | |operating table, and rings and blades are selected and inserted to obtain adequate visualization of the |

| | |operative site. The small bowel is mobilized and isolated with laparotomy packs. An incision of the |

| | |muco-cutaneous junction of the previously constructed ileostomy is incised and the ileostomy is carefully |

| | |separated from the subcutaneous fat and fascia or muscle of the abdominal wall, taking care to preserve the |

| | |blood supply of the ileum. The distal bowel is measured for the appropriate length to create a pouch. A point |

| | |chosen proximal to the distal end is isolated from its mesenteric blood supply for future use as an |

| | |intussuscepted nipple valve. The pouch components are folded into the appropriate pouch configuration and held |

| | |in place with sutures. The common wall anastomosis is performed. The valve component is intussuscepted and |

| | |secured in place with suture or staples. The prior ileostomy site is assessed for suitability for placement of |

| | |the pouch nipple and, if adequate, is prepared for a pouch nipple-mucocutaneous anastomosis. The pouch is |

| | |delivered through the abdominal wall into the ileostomy site and carefully secured in place with sutures. The |

| | |position of the nasogastric tube is adjusted and ascertained to be in the correct place for drainage. The |

| | |abdominal cavity is irrigated with saline, and another inspection of the abdomen is made for other |

| | |abnormalities. A closed-system suction drain may be inserted for drainage of a localized area. |

| | |The self-retaining retractor is removed and disassembled; sponge, needle, and instrument counts are obtained |

| | |and confirmed, prior to closure of the abdomen. The anterior abdominal wall is closed with a standard |

| | |technique, and subcutaneous tissue is irrigated and drained with a closed-suction drain when indicated. The |

| | |skin is closed in a standard fashion. After the skin is closed and dressed, a special pouch intubation catheter|

| | |is selected and placed into the nipple valve and the pouch. |

|[pic] |

|44397 |  |Clinical Example (44397) |

| | |A 70-year-old man underwent diverting colostomy for an obstructing sigmoid carcinoma. At the time of initial |

| | |presentation the patient was extremely ill with complete colonic obstruction. The primary tumor was found to be|

| | |a colorectal neoplasm with extensive nodal metastases. The colostomy was never taken down and the patient now |

| | |presents with CT findings of a progressive mass in the mid-transverse colon. There is some suggestion by the CT|

| | |scan that there is near-complete obstruction of the lumen to the mid-transverse colon. The patient now has |

| | |malignant ascites and is considered a non-resectable candidate. Endoscopy is now done to palliate his impending|

| | |colonic obstruction. |

| | |Description of Procedure (44397) |

| | |The patient is sedated with intravenous Demerol, versed, or Valium. An adult colonoscope introduced through the|

| | |patient's colostomy site and passed to the mid-transverse colon where there is an obstructing neoplasm. The |

| | |endoscope can not be advanced through the lesion. The procedure is performed using fluoroscopic guidance. Using|

| | |a standard 5 Fr biliary catheter and a 0.035" guidewire, the catheter is advanced beyond the stricture. The |

| | |guidewire is removed and water soluble contrast is injected through the catheter to the delineate the length of|

| | |the stricture. The guidewire is reinserted and the catheter is withdrawn. Over the guidewire and through the |

| | |endoscope, a 20 mm internal diameter by 90 mm long expandable metal stent is deployed across the stricture |

| | |using both endoscopic and fluoroscopic guidance. The endoscope is then withdrawn. With sedation and |

| | |manipulation, the treatment session takes approximately 40 minutes. |

|[pic] |

|44701 |  |Clinical Example (44701) |

| | |The patient is a 65-year-old male who is undergoing emergency surgery for an obstructing sigmoid colon cancer. |

| | |Intra-operatively it is decided to perform a single-stage procedure. |

| | |Description of Procedure |

| | |After resection of the cancer a decision to perform on-table colonic lavage is made. Mobilization of both the |

| | |hepatic and splenic flexures is performed. The cecum is cannulated with a catheter through the base of the |

| | |newly removed appendix. The distal end of the previously resected colon is opened and cannulated with a piece |

| | |of sterile corrugated anesthesia tubing. The tubing is secured in place with an umbilical tape. The tube is |

| | |then passed off the operating table and connected to a plastic container. The colon is then irrigated through |

| | |the catheter in the appendix with warm normal saline until the effluent is clear. The catcher is removed, and |

| | |the appendiceal stump is closed. The anesthesia tubing is removed and the distal end of the bowel swabbed with |

| | |povidone-iodine solution. A one-stage operation is then completed. |

|[pic] |

|44715 |  |Clinical Example (44715) |

| | |An intestine allograft that has been procured with cold preservation and maintained cold is received at the |

| | |transplant recipient site of service and requires preparation prior to transplantation. Standard backbench |

| | |preparation, including mobilization and fashioning of the superior mesenteric artery and vein, is performed. |

| | |Description of Procedure (44715) |

| | |The intestine allograft is received in a sterile container and is maintained in cold preservation solution. The|

| | |surgeon requests and confirms that a sterile backbench is set up in the operating room (OR), with appropriate |

| | |instruments for the backbench dissection. An appropriate recipient has been identified. The correct |

| | |identification process is carried out to make sure that the intestine allograft is being allocated to the right|

| | |recipient. The surgeon must make the appropriate arrangements with the operating room and staff to allow for |

| | |sterile dissection of the allograft in coordination with the recipient procedure. The surgeon scrubs and gowns.|

| | |The allograft is removed from the sterile container and placed on a sterile table, on ice, while bathing in |

| | |cold preservation solution. The intestine allograft is inspected to be certain that it is grossly intact and |

| | |that its appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, dissection and removal of surrounding soft tissues are |

| | |carried out. The superior mesenteric artery and vein are identified and evaluated to ensure that their |

| | |integrity is not violated and that they have been mobilized to an adequate length and are otherwise fashioned |

| | |appropriately to perform anastomoses with the intended recipient vessels. |

| | |The intestine allograft is kept cold in anticipation of transplantation. If necessary, the intestine allograft |

| | |is repackaged in a sterile fashion prior to transplantation. |

|[pic] |

|44720 |  |Clinical Example (44720) |

| | |A vein of an intestine allograft is too short or is damaged in such a way that it is not suitable for |

| | |anastomosis with the intended transplant recipient artery. Using a vein graft procured from the donor (or |

| | |properly preserved vein graft procured from another ABO compatible donor allograft), a backbench venous |

| | |anastomosis is performed on the allograft to create an extension graft. |

| | |Description of Procedure (44720) |

| | |On ice, with continuous bathing in cold preservation solution, a vein graft is procured from the donor (or |

| | |properly preserved vein graft procured from another ABO compatible donor). The ends of the extension graft and |

| | |the superior mesenteric vein are brought in close apposition. Using 5-0 or 6-0 prolene suture, the two vessels |

| | |are sewn together end-to-end to create an extension graft. (Alternatively, if no vein graft is available, a |

| | |comparably sized arterial graft obtained from the donor, the recipient, or another ABO compatible donor may be |

| | |used.) |

|[pic] |

|44721 |  |Clinical Example (44721) |

| | |An artery of an intestine allograft is too short or is damaged in such a way that it is not suitable for |

| | |anastomosis with the intended transplant recipient artery. Using an arterial graft procured from the donor (or |

| | |properly preserved arterial graft procured from another ABO-compatible donor allograft), a backbench, arterial |

| | |anastomosis is performed on the allograft to create an extension graft. |

| | |Description of Procedure (44721) |

| | |On ice, with continuous bathing in cold preservation solution, an arterial graft is procured from the donor (or|

| | |properly preserved arterial graft procured from another ABO-compatible donor). The ends of the extension graft |

| | |and the superior mesenteric artery are brought in close apposition. Using 6-0 or 7-0 prolene suture, the two |

| | |vessels are sewn together end-to-end to create an extension graft. (Alternatively, if no arterial graft is |

| | |available, a comparably sized vein graft obtained from the donor, the recipient, or another ABO-compatible |

| | |donor may be used.) |

|[pic] |

|45119 |  |Clinical Example |

| | |A 53-year-old female requires radical extirpation of a 4-cm rectal cancer with a resection margin at the level |

| | |of the levators. A total mesorectal resection with proctectomy is performed. The remaining colon is mobilized |

| | |proximal to the splenic flexure. A colonic J-pouch is fashioned in the descending colon. The J-pouch |

| | |anastomosis to the rectum is either through a transanal or abdominal approach. A diverting loop ilesotomy in |

| | |the right lower quadrant protects the anastomosis. The abdominal incision is closed. Postoperative care manages|

| | |the associated ileus and wound care. Outpatient follow-up includes assessment for anastomotic complications. |

| | |Description of Procedure |

| | |Through a midline incision, the abdomen is explored. The physician establishes the intraoperative staging of |

| | |the rectal cancer assessing for extra pelvic extension of the tumor. The colon is mobilized from the |

| | |midtransverse colon distally including the splenic flexure. The descending colon will serve as the segment for |

| | |creation of the J-pouch. The sigmoid colon is resected enbloc with the rectum. A total mesorectal excision |

| | |(TME) is included to provide adequate margins for a malignancy. The ureters are identified bilaterally with |

| | |care to prevent injury. The rectosigmoid segment is resected and removed from the operative field. The specimen|

| | |is forwarded to the pathologist where it is properly opened; thus, allowing the surgeon to establish the |

| | |adequacy of the distal margin. The J-pouch is created using a linear gastrointestinal stapler. The anorectal |

| | |junction is prepared by placing circumferential sutures transanally. The J-pouch is introduced into the pelvis |

| | |and advanced to the anorectal junction. A hand-sewn, transanal anastomosis is performed. The previously marked |

| | |ileostomy site is identified in the right lower quadrant. The ileostomy is prepared by incising the skin and |

| | |opening the rectus fascia. The rectus muscles are split and the posterior fascia is incised. The terminal ileum|

| | |is brought out through the ileostomy site. A stoma bar is placed beneath the ileostomy to prevent stoma |

| | |retraction. Two active drains are placed within the pelvis and the abdominal incision is closed. The ileostomy |

| | |is secured to the stoma. |

|[pic] |

|45136 |  |Clinical Vignette (45136) |

| | |A 54-year-old male had previously undergone a total proctocolectomy with ileoanal pouch reconstruction for |

| | |ulcerative colitis. Following re-establishment of gastrointestinal continuity, he develops multiple pelvic |

| | |abscesses and fistulas. Multiple medical and surgical interventions fail to clear his pelvic sepsis and he |

| | |elects to have removal of his ileoanal pouch. |

| | |Description of Procedure (45136) |

| | |The patient undergoes a mechanical bowel preparation, IV antibiotic prophylaxis, and steroid preparation. |

| | |The patient is given general anesthesia and placed in the supine position with the legs in stirrups to allow |

| | |access to the perineum. Special attention is given to padding the legs to avoid neuropathy. A midline incision |

| | |is made and the extensive intra-abdominal and small bowel/pouch adhesions are lysed. The ileoanal pouch is |

| | |dissected free from the surrounding pelvic structures, which is complicated by the obliteration of normal |

| | |planes because of the previous surgery. Special care is taken to try to keep the dissection close to the pouch |

| | |to minimize the chance of injury to the autonomic nervous system in the pelvis, which controls sexual as well |

| | |as urinary function. Both aortas are completely exposed and protected during the dissection. Perineal |

| | |dissection is used to disconnect the pouch from the anus. After excising the pouch, an ileostomy permanent is |

| | |placed in the right lower quadrant. A soft closed suction drain is placed in the pelvis and the abdominal |

| | |incision is closed. The ileostomy is matured and a sterile dressing placed over the wound. |

|[pic] |

|45327 |  |Clinical Example (45327) |

| | |A 70-year-old man with a history of extensive gastric carcinoma underwent palliative subtotal gastrectomy. Six |

| | |months later the patient develops obstipation. A CT scan of the abdomen reveals extensive metastasis into the |

| | |pelvis with encasement of the rectum. A barium enema revealed near-complete obstruction at the level of the |

| | |mid-rectum from an extrinsic mass. The patient undergoes proctosigmoidoscopy with stent placement to palliate |

| | |obstruction. |

|[pic] |

|45335 |  |Clinical Example (45335) |

| | |A 68-year-old gentleman was previously identified to have a large sessile polyp in his rectum that had been |

| | |removed endoscopically. The pathology evaluation showed high-grade dysplasia. He now returns for a follow-up |

| | |surveillance sigmoidoscopy to assess for evidence of recurrence or neoplasm. The patient is prepped for |

| | |flexible sigmoidoscopy, using enemas. |

| | |Description of Procedure (45335) |

| | |The physician explains the procedure to the patient and obtains informed consent. The patient is brought to the|

| | |endoscopy suite and is prepared for endoscopy. A digital exam is performed, which is unremarkable. The flexible|

| | |sigmoidoscope is inserted through the anus and advanced into the rectum where a stellate scar is identified in |

| | |the mid-rectum. The instrument is advanced into the descending colon and careful inspection of the mucosa is |

| | |made on withdrawal. No other abnormalities are identified. Due to the location of the polypectomy site behind |

| | |one of the Valves of Houston, and to facilitate future identification of this site, india ink injection is |

| | |undertaken. A sclerotherapy needle is prepared with sterile india ink and passed by the physician through the |

| | |flexible sigmoidoscope to the site of the stellate scar. At the site of scarring from the previous polypectomy |

| | |site, sterile india ink is injected to facilitate future identification of the previously removed lesion. The |

| | |sclerotherapy needle is withdrawn, and the physician observes the site for signs of bleeding. The sigmoidoscope|

| | |instrument is then withdrawn. The physician records a post-procedure note, assesses the patient's |

| | |post-procedure vital signs and status, prepares post-procedure orders, dictates a note to the referring |

| | |physician, and discusses the findings with the family. |

|[pic] |

|45340 |  |Clinical Example (45340) |

| | |A 72-year-old gentleman who previously underwent a low anterior resection for a sigmoid colon cancer has |

| | |developed symptoms of constipation and difficulty defecating at 8 weeks postoperatively. The patient's surgeon |

| | |had performed a barium enema that demonstrated a stricture at the anastomotic site. Before the patient's |

| | |surgery a colonoscopy had been performed, and the only lesion that was identified was that which was surgically|

| | |removed. The surgeon has requested that balloon dilation of the surgical anastomosis be performed in an attempt|

| | |to improve the patient's symptoms. |

| | |Description of Procedure (45340) |

| | |The physician explains the procedure to the patient and obtains informed consent. The patient undergoes a full |

| | |colon preparation with a lavage solution to facilitate completion of the examination. The patient is brought to|

| | |the endoscopy suite and is prepared for endoscopy. A digital rectal examination is performed and is |

| | |unremarkable. The flexible sigmoidoscope is advanced through the anus into the rectum and at 10-cm from the |

| | |anal verge, the surgical anastomosis is identified with significant luminal narrowing. The sigmoidoscope is |

| | |able to traverse the narrowing with some degree of resistance. No mass lesions are identified, and the |

| | |stricture is typical to that of a postoperative nature. A 15-mm through-the-scope balloon is prepared. The |

| | |balloon is passed by the physician through the flexible sigmoidoscope channel into the rectum and placed across|

| | |the strictured segment. An assistant carefully inflates the balloon using a special gauge and pressure set to a|

| | |previously designated value, while the balloon is held in place by the physician under direct visualization. |

| | |The balloon is deflated and is removed from the endoscope. Another attempt is made by the physician to traverse|

| | |the stricture. No evidence of perforation is identified. The physician records a post-procedure note, assesses |

| | |the patient's vital signs and status post-procedure, prepares post-procedure orders, dictates a note to the |

| | |referring physician, and discusses the findings and expected treatment with the family. The patient is again |

| | |re-examined after awakening to assess for the development of complications such as perforation. |

|[pic] |

|45341 |  |Clinical Example (45341) |

| | |A 59-year-old man with hematochezia is identified to have an adenocarcinoma of the rectum. Rectal ultrasound is|

| | |requested to assess the depth of tumor invasion and regional lymph nodes. |

| | |Description of Procedure (45341) |

| | |The patient is provided with a preparation including laxatives and enemas to allow cleaning of the lower colon.|

| | |A rigid or flexible endoscopic ultrasound probe is advanced into the rectum above the level of the patient's |

| | |tumor. Continuous imaging with ultrasound is performed on withdrawal of the probe. Analysis of the depth of |

| | |tumor invasion (mucosa, submucosal, muscularis propia, transmural or adjacent organ involvement) is made as |

| | |well as evidence for regional lymph node involvement. |

|[pic] |

|45342 |  |Clinical Example (45342) |

| | |A 59-year-old man with hematochezia is identified to have an adenocarcinoma of the rectum. Rectal ultrasound is|

| | |requested to assess the depth of tumor invasion and regional lymph nodes. |

| | |Description of Procedure (45342) |

| | |Conscious sedation is provided to the patient while continuously monitoring pulse oximetry and sequential |

| | |non-invasive blood pressure measurements. Sedation is needed due to the length of the exam, the need to have |

| | |the patient in a quite restful state for precise imaging and the discomfort associated with expansion of the |

| | |rectum and sigmoid colon caused by insufflation of water to allow for acoustic coupling. Digital rectal exam is|

| | |performed to characterize the location and degree of infiltration of the tumor. A standard flexible |

| | |sigmoidoscope is advanced into the rectum and then sigmoid colon to allow an endoscopic assessment of the |

| | |lesion. This is necessary since the oblique forward viewing optics available with the echoendoscopes are not |

| | |adequate to allow complete circumferential visualization of the rectal lumen. The proximal and distal distance |

| | |of the rectal mass from the anus is noted. A retroflex view is performed in the rectum to evaluate the |

| | |relationship of the mass to the anal verge. The instrument is then withdrawn. |

| | |A dedicated echoendoscope is then prepared with a balloon placed over the transducer housing. Since the |

| | |dedicated instrument cannot be attached to the endoscope processor until the initial endoscopy is completed, |

| | |the air is purged from the balloon chamber by repetitively inflating and deflating the channel. The |

| | |echoendoscope is then introduced into the anus and advanced into the sigmoid colon under direct endoscopic |

| | |visualization. The acoustic coupling balloon is inflated with water. Continuous imaging with ultrasound is |

| | |performed on withdrawal of the echoendoscope. Visualization of the iliac vessels and regional lymphadenopathy |

| | |is procured. The primary tumor is assessed with an analysis of depth of invasion (mucosa, submucosa, muscularis|

| | |propria, perirectal space, adjacent organs such as prostate, bladder, vagina) and circumferential extent are |

| | |made. Involvement of the internal and/or external anal sphincter are searched for. Frequently, imaging will be |

| | |done at a low and high frequency to allow assessment of near and distant structures. Regional lymph node |

| | |involvement in the peritumoral, proximal, and distal rectal regions are identified. Frequently, the |

| | |echoendoscope is advanced under direct endoscopic visualization to permit reassessment of abnormalities. |

| | |Documentation of the exam findings, including measurements of the lesion(s), labeling of the identified |

| | |structures, and magnified images of the abnormality are obtained and sent to a hard copy device. A |

| | |determination is made on the risk/benefit of biopsying a regional or distant lymph node. If a lymph node(s) |

| | |that can be safely biopsied is identified and the biopsy results may impact on the patient's therapy, then the |

| | |biopsy is undertaken. Intravenous antibiotics are administered to the patient. |

| | |A linear scanning echoendoscope is prepared for the exam. Since this instrument cannot be attached to the |

| | |endoscope processor until the radial scanning echoendoscopy is completed, the air is purged from the balloon |

| | |chamber by repetitively inflating and deflating the channel. The level of sedation of the patient is reassessed|

| | |and additional medication is administered as needed. The echoendoscope is then introduced into the rectum and |

| | |advanced into the sigmoid colon under direct endoscopic visualization. Sagittal imaging requires spatial |

| | |reorientation of structures previously examined in a transverse plane. Integrating these imaging aspects, the |

| | |lymph node(s) is identified. A decision with respect to the most advanced lymph node site is made (eg, |

| | |peri-iliac versus perirectal). A needle biopsy catheter device is prepared. The needle biopsy device is |

| | |advanced through the biopsy channel of the ultrasound endoscope. Doppler imaging is performed to insure that |

| | |any vascular structures or areas within the lymph node are recognized prior to biopsy. Under direct ultrasound |

| | |visualization, the needle is advanced through the gastrointestinal wall into the lymph node. The central stylet|

| | |is removed from the needle by the nurse, negative pressure is applied to the hub of the device and to and fro |

| | |movements are made with the needle in the lymph node. After one to two minutes, the needle is removed from the |

| | |echoendoscope and the material is sprayed onto glass slides for cytologic examination. An attendant |

| | |cytotechnologist will provide an adequacy assessment on the collected material which requires 15 - 30 minutes. |

| | |Typically, five needle passes will be made for each biopsy site. For each biopsy, the needle and stylet |

| | |assembly will be rinsed to remove any blood and then reassembled for use. If an adequate specimen is not |

| | |obtained after five passes, then a new biopsy site will be selected when available. Otherwise the procedure |

| | |will be terminated. Throughout the biopsy component of the exam, documentation of the exam findings including |

| | |measurements of the lesion, labeling of the identified structures, recording of the needle position within the |

| | |lesion, and magnified images of the abnormality are obtained and sent to a hard copy device. Doppler findings |

| | |are annotated and labeling is performed by the physician. |

|[pic] |

|45345 |  |Clinical Example (45345) |

| | |A 65-year-old woman with a history of endometrial carcinoma presents for evaluation of a recurrent obstruction.|

| | |The patient had previously undergone total hysterectomy and received radiation therapy. Five months prior she |

| | |developed complete sigmoid obstruction. Biopsies of an obstructing mass confirmed uterine carcinoma. At that |

| | |time, a stent was placed at the sigmoid with relief of obstruction. She returns for follow-up complaining of |

| | |some rectal bleeding and intermittent constipation. A limited barium enema of the left colon reveals tumor |

| | |ingrowth with significant reduction in the luminal diameter of the previously placed stents. The patient is to |

| | |undergo recurrent stent placement. |

| | |Description of Procedure (45345) |

| | |The patient is sedated intravenously. An adult flexible sigmoidoscope is passed to the sigmoid where the |

| | |previous stent is encountered. The scope can be passed completely through the stent with some resistance. A |

| | |savory guide- wire is passed endoscopically to the point of the splenic flexure. The endoscope is removed |

| | |leaving the guidewire in place. The endoscope is reinserted along side the guidewire to the distal portion of |

| | |the previously placed stent. A new 18 mm internal diameter by 10 mm covered esophageal stent is back-loaded |

| | |over the guidewire and advanced through the previous stent under endoscopic visualization. The stent is then |

| | |deployed under endoscopic visualization without the use of fluoroscopy at any time during the procedure. The |

| | |guidewire is then removed. With sedation and pauses to deploy the stent, the treatment session takes |

| | |approximately 30 minutes. |

|[pic] |

|45381 |  |Clinical Example (45381) |

| | |A 55-year-old male with occult blood-positive stool has been previously identified to have an adenomatous |

| | |sessile polyp in the transverse colon. Colonoscopy has been requested in an attempt to remove the lesion. |

| | |Description of Procedure (45381) |

| | |The physician explains the procedure to the patient and obtains informed consent. The patient is prepared for |

| | |colonoscopy using a full colon prep. The patient is brought to the endoscopy suite, and an intravenous line is |

| | |started. The physician administers intravenous, conscious sedation, and the patient is carefully monitored. The|

| | |colonoscope is inserted through the anus into the rectum and advanced to the mid-transverse colon where a |

| | |nodular, flat polyp approximately 2 x 3-cm is encountered. The polyp is too flat to be excised with routine |

| | |snare technique. A decision is made that the lesion will be carefully marked for future surgical removal, using|

| | |submucosal injection of india ink. A biopsy forceps is passed through the colonoscope, and biopsies are taken |

| | |by the physician. The biopsy forceps is withdrawn, and a sclerotherapy-type sheathed needle is then advanced |

| | |through the colonoscope. The endoscopist carefully maneuvers the needle to the edge of the polyp and positions |

| | |the needle into the submucosa. Upon the endoscopist's command, an assistant, who has previously loaded the |

| | |sclerotherapy needle, injects sterile india ink into the four quadrants of the submucosal tissue surrounding |

| | |the polyp to adequately mark the lesion. The sclerotherapy needle is then withdrawn. The colonoscope is then |

| | |advanced into the proximal colon and cecum and then withdrawn; the procedure is completed without other |

| | |findings and the colonoscope is removed. The physician records a post-procedure note, assesses the patient's |

| | |vital signs and status post-procedure, prepares post-procedure orders, dictates a note to the referring |

| | |physician, and discusses the findings with the family. |

|[pic] |

|45386 |  |Clinical Example (45386) |

| | |A 65-year-old female is found to have occult blood-positive stool and crampy abdominal pain. The primary |

| | |physician orders a barium enema, which reveals a transverse colon stricture at a prior colonic anastomosis. She|

| | |also has a history of multiple medical problems including coronary artery disease, hypertension, and diabetes |

| | |mellitus. After examining the patient, it is decided that colonoscopy would provide the best evaluation for the|

| | |patient's signs and symptoms. |

| | |Description of Procedure (45386) |

| | |The physician explains the procedure to the patient and obtains informed consent. The patient is prepared for |

| | |colonoscopy using a full colon prep. The patient is brought to the endoscopy suite, where an intravenous line |

| | |is started. The physician administers intravenous, conscious sedation, while the patient is carefully |

| | |monitored. The video colonoscope is inserted through the anus into the rectum and advanced to the distal |

| | |transverse colon, where a narrowing of the colon is found that does not permit further passage of the |

| | |adult-diameter colonoscope. The colonoscope is withdrawn and a smaller-diameter scope is then inserted through |

| | |the anus into the rectum and advanced to the area of stricture. This colonoscope easily traverses the narrowed |

| | |area, revealing only a benign stricture. A 15-mm dilating balloon is passed through the colonoscope and |

| | |positioned across the area of narrowing in the distal transverse colon. An assistant carefully inflates the |

| | |balloon using a special gauge and pressure set to a previously designated value, while the balloon is held in |

| | |place by the physician with direct visualization. The stricture is dilated, the balloon is deflated, and the |

| | |smaller-caliber colonoscope is removed. The adult colonoscope is introduced through the anus into the rectum, |

| | |and another attempt to traverse the stricture with the adult colonoscope is made, which is successful. |

| | |Subsequently, the physician is able to reach the cecum using the adult colonoscope. The colonoscope is then |

| | |withdrawn, examining all areas. No other lesions are identified and the colonoscope is withdrawn. The physician|

| | |then records a post-procedure note, assesses the patient's vital signs and status post-procedure, prepares |

| | |post-procedure orders, dictates a note to the referring physician, and discusses the findings and expected |

| | |treatment with the family. The patient is again re-examined after awakening to assess for the development of |

| | |complications such as perforation. |

|[pic] |

|45387 |  |Clinical Example (45387) |

| | |A 59-year-old man with hematochezia is identified to have an adenocarcinoma of the rectum. Rectal ultrasound is|

| | |requested to assess the depth of tumor invasion and regional lymph nodes. Patient also has a 5 cm mass on CT |

| | |scan and multiple liver metastases, minimal ascites, and enlarged nodes in the pelvis. After admission, the |

| | |procedure was discussed with the patient. As liver biopsy confirms metastic adenocarcinoma consistent with a |

| | |colonic origin, and the general condition is poor, resection is deemed inappropriate. Palliative choices are a |

| | |permanent defunctioning colostomy, requiring laparotomy, or endoscopic replacement of a self-expanding metallic|

| | |stent through the obstructing tumor. |

| | |Clinical Example (45387) |

| | |A 70-year-old woman presents to the ER with a three-day history of lower abdominal pain and increasing |

| | |abdominal size, nausea, a decreased appetite, obstipation, and cessation of flatus per rectum. There was a |

| | |preceding history of a change in bowel habit with an increase in constipation accompanied by dark red blood per|

| | |rectum mixed with stool over three months, for which the patient had not sought medical attention. |

| | |Description of Procedure (45387) |

| | |Examination reveals a distressed ill-appearing patient with moderate abdominal distension, increased abdominal |

| | |percussion, and high-pitched frequent bowel sounds with no stool in the rectum on digital examination. Plain |

| | |abdominal radiograph confirms the clinical suspicion of large bowel obstruction with colonic fluid levels and |

| | |dilation of the ascending, transverse, and descending colon with absence of air in the rectum. CT scan shows |

| | |similar evidence of large bowel obstruction together with a 3 cm obstructing mass in the sigmoid colon and no |

| | |evidence of extracolonic disease. After admission to a surgical service and correction of dehydration and mild |

| | |anemia by IV fluids and blood transfusion, options for management are discussed. A sigmoidoscopy after enema |

| | |preparation is advised to confirm the suspicion of a sigmoid cancer, which can then be followed by emergency |

| | |laparotomy and a defunctioning colostomy with closure of the distal disconnected colon. A later second |

| | |laparotomy allows tumor resection or laparoscopic-assisted resection to be accompanied by or followed at a |

| | |later date by colostomy closure to restore bowel continuity. Alternatively, the sigmoidoscopy can also |

| | |facilitate the placement of a self-expanding metallic stent through the tumor to relieve the obstruction and |

| | |allow colonic decompression without surgery with the intention of allowing a subsequent single laparotomy or |

| | |laparoscopically-assisted cancer resection with primary anastomosis without colostomy. |

|[pic] |

|45391 |  |Clinical Example (45391) |

| | |Physical examination in a 52-year-old female reveals guaiac positive stools and a rectal mass identified on |

| | |digital rectal examination. A computed tomography (CT) scan reveals rectal wall thickening but no metastatic |

| | |disease. Colonoscopy with endoscopic ultrasound is requested to evaluate and further stage the suspected tumor,|

| | |and to assess the remainder of the colon for additional lesions. |

| | |Description of Procedure (45391) |

| | |A standard colonoscope is inserted into the rectum and advanced through the colon to the cecum. The colonic |

| | |mucosa appears normal except for an ulcerated 2 cm lesion which is seen in the lower rectum. A dedicated |

| | |echoendoscope is prepared with a balloon placed over the transducer housing. The echoendoscope is inserted into|

| | |the rectum and advanced under direct visualization. In the area of the mucosal lesion, the balloon is filled |

| | |with water to achieve acoustic coupling. Continuous imaging with ultrasound is performed and visualization of |

| | |the lesion, the colonic wall layers, and the peri-colonic structures is procured. No regional lymph node |

| | |enlargement is identified. The echoendoscope is withdrawn. |

|[pic] |

|45392 |  |Clinical Example (45392) |

| | |A 72-year-old male presents with left flank pain. He underwent gastrectomy for gastric cancer two years |

| | |earlier. An abdominal CT scan demonstrates a 2 cm mass adjacent to the sigmoid colon. Colonoscopy with |

| | |endoscopic ultrasound and a possible transendoscopic, ultrasound-guided biopsy are requested. |

| | |Description of Procedure (45392) |

| | |A standard colonoscope is inserted into the rectum and advanced through the colon to the cecum. The colonoscope|

| | |is withdrawn and the mucosa carefully examined. In the sigmoid colon, there is a smooth, extrinsic appearing |

| | |compression of the colonic lumen without obvious mucosal abnormalities. The remainder of the procedure is |

| | |unremarkable. A dedicated echoendoscope is prepared with a balloon placed over the transducer housing. The |

| | |echoendoscope is inserted into the rectum and advanced through the colon under direct visualization. In the |

| | |area of the suspected lesion, the acoustic coupling balloon is filled with water. Continuous imaging with |

| | |ultrasound is performed and visualization of the lesion, the colonic wall layers and the peri-colonic |

| | |structures is procured. An extracolonic mass is seen adjacent to the sigmoid colon. As the identified |

| | |abnormality may represent recurrent disease, fine needle aspiration biopsy is undertaken. Intravenous |

| | |antibiotics are administered to the patient. The first echoendoscope is withdrawn. A linear scanning |

| | |echoendoscope is prepared for the exam. The linear scanning echoendoscope is introduced into the rectum and |

| | |advanced to the sigmoid colon under direct visualization. A needle biopsy catheter is advanced through the |

| | |linear scanning echoendoscope and directed under ultrasound guidance into the lesion of interest. Multiple |

| | |biopsies are taken until an adequate sample is procured. The echoendoscope is withdrawn. |

|[pic] |

|45395 |  |Clinical Example |

| | |A 65-year-old man presents with a low rectal lesion that is 1 cm proximal to the dentate line and a |

| | |biopsy-proven moderately differentiated adenocarcinoma. The lesion is T2 on endorectal ultrasound and negative |

| | |for metastatic disease based on a previous computed tomographic position emission tomography (CT PET) scan. He |

| | |had received preoperative chemoradiation and is 1 month post-radiotherapy. At laparoscopic operation, he |

| | |undergoes a complete proctectomy with colostomy. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A right lower quadrant and suprapubic trocar and |

| | |right upper quadrant and left lower quadrant trocars are placed. After an exploratory laparoscopy, the sigmoid |

| | |colon is retracted medially and dissection along the line of Toldt is performed to the level of the splenic |

| | |flexure. Next, the sigmoid colon is retracted laterally in order to isolate and transect the inferior |

| | |mesenteric artery (IMA). The left ureter is isolated in the retroperitoneal space of the sigmoid and mobilized.|

| | |The mesentery of the sigmoid is opened at the level of the pelvic brim and sharp dissection is performed to |

| | |isolate and divide the IMA (through the right lower quadrant port with an endovascular stapler). The dissection|

| | |is continued along the medial mesentery to the level of the inferior mesenteric vein (IMV), which is divided |

| | |with an endovascular stapler. Sharp dissection of the lateral ligaments to the pelvic floor is carried out. The|

| | |rectum is mobilized posterior to Waldeyer’s fascia to the level of the pelvic floor. At the level of the |

| | |descending sigmoid junction, the colon is divided intracorporeally with an endogastrointestinal stapler. |

| | |Perineal dissection is carried out with transperineal removal of the specimen, and the perineal skin is closed.|

| | |The descending colon is brought out through a previously marked ostomy site. Hemostasis is obtained. The |

| | |trocars are removed and the fascial openings closed as appropriate, and the individual wounds of the port sites|

| | |closed. |

|[pic] |

|45397 |  |Clinical Example |

| | |A 72-year-old woman presents with a low rectal lesion 6 cm proximal to the dentate line that is a biopsy-proven|

| | |moderately differentiated adenocarcinoma. The lesion is T3 without adenopathy on endorectal ultrasound and |

| | |negative for metastatic disease based on CT PET scan. She had received preoperative chemoradiation and is 1 |

| | |month post-radiotherapy. At laparoscopic operation, a total mesorectal resection with proctectomy is performed.|

| | |The remaining colon is mobilized proximal to the splenic flexure. A colonic J-pouch is fashioned in the |

| | |descending colon and anastomosed to the rectal stump or anus. A diverting loop ileostomy is created in the |

| | |right lower quadrant to protect the anastomosis. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed. A right lower quadrant and suprapubic trocar and |

| | |right upper quadrant and left lower quadrant trocars are placed. After an exploratory laparoscopy, the sigmoid |

| | |colon is retracted medially and dissection along the line of Toldt is performed to the level of the splenic |

| | |flexure. The medial mobilization and dissection of the sigmoid mesentery with intracorporeal ligation of the |

| | |IMA and IMV is performed using an endovascular stapler. The rectum is mobilized to below the mesorectum for |

| | |eventual intracorporeal transection of the rectum with an endovascular stapler for total mesorectal excision |

| | |(TMC) resection. After transection of the rectum, the suprapubic or the left lower quadrant trocar site is |

| | |extended in order to remove the specimen. Construction of the colonic J-pouch is accomplished by transecting |

| | |the proximal colon at or near the descending sigmoid junction and folding the distal end of the remaining colon|

| | |onto itself, creating a pouch. A circular stapler is placed in the rectal stump and while the anvil of the |

| | |staple is placed in the J portion of the pouch, a double-stapled anastomosis is performed. If the lesion is |

| | |closer to the anus, a transanal mucosectomy is performed and a hand-sewn coloanal pouch anastomosis is |

| | |performed. A proximal diverting loop ileostomy is created. Hemostasis is obtained. The trocars are removed and |

| | |the fascial openings closed as appropriate and the individual wounds of the port sites closed. |

|[pic] |

|45400 |  |Clinical Example |

| | |A 75-year-old woman presents with full-thickness rectal prolapse. She has no history of constipation but has |

| | |moderate symptoms of fecal incontinence. Laparoscopically, the rectum is mobilized, the prolapse is reduced, |

| | |and the mobilized rectum is fixated to the sacrum. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed and a number of ports are inserted to permit |

| | |adequate instrumentation. After an exploratory laparoscopy, the sigmoid colon and rectum are mobilized off the |

| | |presacral fascia, with great care to protect the presacral autonomic nerves and ureters. The presacral space is|

| | |entered and the rectum mobilized adequately to reduce any prolapse. An appropriate section of the rectum is |

| | |chosen for attachment to the sacrum to maintain reduction of the prolapse. The mesorectum of this section of |

| | |rectum is affixed to the sacrum or sacral promontory. Hemostasis is obtained. The trocars are removed; the |

| | |fascial openings are closed as appropriate; and, the individual wounds of the port sites are closed. |

|[pic] |

|45402 |  |Clinical Example |

| | |A 75-year-old woman presents with full-thickness rectal prolapse. She has a history of severe constipation and |

| | |has no significant symptoms of fecal incontinence. Laparoscopically, the rectum is mobilized and the sigmoid |

| | |colon is resected. The specimen is removed through a small incision. Laparoscopically, an anastomosis is |

| | |fashioned using an end-to-end stapling device and the distal rectum is fixed to the sacrum. |

| | |Description of Procedure |

| | |Under general anesthesia, surgical laparoscopy is performed and a number of ports are inserted to permit |

| | |adequate instrumentation. After an exploratory laparoscopy, the sigmoid colon and rectum are mobilized off the |

| | |presacral fascia with great care to protect the presacral autonomic nerves and ureters. The presacral space is |

| | |entered and the rectum mobilized adequately to reduce any prolapse. The sigmoid colon is resected, with or |

| | |without an accompanying portion of the upper rectum. The vascular supply to this piece of bowel is ligated, |

| | |either by dividing the inferior mesenteric artery at the proximal and distal ends or by dividing individual |

| | |branches of the sigmoid arteries and preserving the inferior mesenteric artery. The bowel is divided at the |

| | |distal point of transection, below the confluence of the taeniae coli, using a laparoscopic stapling device. |

| | |The proximal bowel is extracted through a small muscle-splitting incision, and the anvil of a stapler inserted |

| | |before returning the proximal end of the bowel to the abdomen and closing the fascia. The anastomosis is |

| | |fashioned with a transanal circular stapling device. An appropriate section of the rectum is chosen for |

| | |attachment to the sacrum to maintain reduction of the prolapse. The mesorectum of this section of the rectum is|

| | |affixed to the sacrum or sacral promontory. Hemostasis is obtained. The trocars are removed and the fascial |

| | |openings closed as appropriate and the individual wounds of the port sites closed. |

|[pic] |

|45550 |  |Clinical Example |

| | |A 75-year-old female presents with a long history of chronic constipation and recent onset of full-thickness |

| | |rectal prolapse. After the decision to operate has been made, the surgeon reviews all laboratory and radiologic|

| | |studies, and determines that no further evaluation is required. The surgeon reviews the intended procedure with|

| | |the patient and her spouse and informed consent is obtained. A preoperative mechanical and antibiotic bowel |

| | |preparation is performed. At operation, a complete rectosigmoid mobilization is performed down to the pelvic |

| | |floor posteriorly. The redundant sigmoid colon is resected and a primary anastomosis is performed. The |

| | |mobilized rectum is sutured fixated to the sacral promontory with four permanent sutures. The wound is closed |

| | |in layers. Postoperative care includes all necessary hospital and office visits during the 90-day global period|

| | |to assure normal recovery and the absence of any complications. |

| | |Description of Procedure |

| | |The patient is prepped and draped under anesthesia, placed in the supine position, and readied for the |

| | |abdominal incision. The surgeon makes an abdominal incision of his or her choice. The incision is carried |

| | |through the subcutaneous tissues and other layers of tissue, individually entering the peritoneal cavity. The |

| | |peritoneal cavity is thoroughly explored for other abnormalities and is appropriately packed. The |

| | |self-retaining retractor is secured to the operating table and the appropriate appendages are attached to |

| | |provide visualization. The packs are repositioned as needed to mobilize the distal descending colon and the |

| | |sigmoid colon. Once that is done, rectal mobilization must be accomplished to the level of the lateral stocks |

| | |of the rectum. Rectopexy sutures are placed appropriately to the rectum at the upper level of the lateral |

| | |stocks and the presacral fascia. The sutures are tagged and not tied at this time. An appropriate length of |

| | |bowel for resection is determined. The mesentery is divided to that part of the bowel to devascularize it. The |

| | |resection is carried out controlling the distal rectal stump and proximal colon site of resection to avoid |

| | |leakage. Anastomosis is made in the fashion of choice by the operating surgeon. Rectopexy sutures are tied |

| | |down, securing the rectum to the presacral fascia. The abdominal cavity is irrigated with a saline solution to |

| | |ensure hemostasis and cleansing. Exploration for foreign bodies, such as sponges, instruments, and needles, is |

| | |carried out. All are removed and counts are verified. The retractor is removed and disassembled. The anterior |

| | |abdominal wall is closed in a standard technique, irrigating the subcutaneous tissue. The skin is closed in the|

| | |surgeon’s fashion of choice. |

|[pic] |

|45990 |  |Clinical Example |

| | |A 35-year-old man with severe rectal pain is referred for evaluation. Initial office evaluation revealed no |

| | |external evidence or signs of anorectal pathology. Due to severe pain, further evaluation including DRE, |

| | |anoscopy, and proctoscopy cannot be performed in the office and the patient is referred to a facility. Under |

| | |anesthesia (general, spinal, or epidural), a complete examination of the perianal skin, anal verge, anal canal,|

| | |and rectum is performed. This includes visual inspection of the perineal skin, digital rectal exam (DRE) of the|

| | |anal canal and distal rectum, anoscopic examination, and proctoscopic examination. No anorectal source of pain |

| | |is identified. |

| | |Description of Procedure |

| | |Under anesthesia (general, spinal, or epidural), a complete examination of the perianal skin, anal verge, anal |

| | |canal, and rectum is performed. This includes visual inspection of the perineal skin, DRE of the anal canal and|

| | |distal rectum (a sweep of the entire coccyx and at least half of the sacrum), anoscopic examination, and |

| | |proctoscopic examination. No anorectal source of pain is identified. |

|[pic] |

|46020 |  |Clinical Example (46020) |

| | |An adult patient develops a fistulo-in-ano following drainage of a perirectal abscess. At the time of surgical |

| | |treatment of the fistula, the surgeon elects to proceed with placement of a seton instead of fistulotomy or |

| | |other surgical methods. Clinical circumstances such as complex or high fistulas, presence of inflammatory bowel|

| | |disease or other mitigating factors can influence such a decision. The placement of the seton can be considered|

| | |definitive treatment or in some instances can set the stage for a subsequent surgery. |

| | |Description of Procedure (46020) |

| | |With the patient under appropriate anesthesia, the perianal region is prepped and draped in a sterile fashion. |

| | |A combination of digital rectal exam, anoscopy, and passage of fistula probes determines the internal and |

| | |external openings of the fistula as well as its relationship to the anal sphincter. The examination reveals a |

| | |long fistula tract with an external opening 2 cm from the anal verge and an internal opening 1 cm proximal to |

| | |the anorectal ring. As the fistulotomy would sacrifice all of the sphincter mechanism, and there is too much |

| | |induration for an endo anal flap, the decision is then made to place a seton. |

| | |The probe is used to guide a non-absorbable material such as a silk suture or silastic vascular tape through |

| | |the fistula tract. The seton can then be tied down in place. |

|[pic] |

|46505 |  |Clinical Example |

| | |A 38-year-old woman presents with a history of bright red rectal bleeding and pain with every bowel movement. |

| | |She has a posterior midline fissure that has failed treatment with topical creams and nitroglycerin ointment. |

| | |Treatment of the fissure by injection of chemodenervation agent (eg, botulinum toxin) is performed to |

| | |temporarily relax the internal anal sphincter, allow healing of the fissure, and minimize the complication of |

| | |fecal incontinence associated with a surgical sphincterotomy. |

| | |Description of Procedure |

| | |Under anesthesia, a digital rectal exam and anoscopic evaluation are performed. Forty units of botulinum toxin |

| | |are injected in divided doses at the posterior midline and both lateral quadrants of the intersphincteric area.|

|[pic] |

|46706 |  |Clinical Example (46706) |

| | |The patient is a 24-year-old female with an anterior fistula-in-ano from a peri-rectal abscess. After |

| | |considering the alternatives, the patient and the surgeon opt for treatment of the fistula by fibrin glue |

| | |application. This was chosen to minimize the complications of fecal incontinence and rectovaginal fistula |

| | |associated with anterior division of the anal sphincter muscle. |

| | |Description of Procedure (46706) |

| | |The patient is brought to the OR and given a spinal anesthetic. The patient is then positioned on the operating|

| | |table in either lithotomy position or prone jack-knife position. She is checked for adequate padding. The |

| | |perineum is prepped and draped in a sterile fashion. Digital rectal exam is performed. Anoscopic evaluation is |

| | |performed. A probe is passed from the internal fistula opening to the outer opening. After establishing the |

| | |course of the tract, all granulation tissue is curetted away. Utilizing a flexible catheter, a bead of fibrin |

| | |glue is placed at the internal fistula opening. A stream of fibrin glue is utilized to fill the fistula tract. |

| | |Dry dressing is applied. |

|[pic] |

|46710 |  |Clinical Example |

| | |A 35-year-old woman presents with passage of stool through the vagina. Her history includes a prior |

| | |proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. Crohn’s disease has been considered. |

| | |At operation, she undergoes a transperineal mobilization of the pouch with advancement and re-anastomosis. |

| | |Description of Procedure |

| | |Under general anesthesia, the distal pouch is mobilized for 6 to 10 cm. If residual anal canal mucosa is |

| | |present, a completion mucosectomy is performed. An operating anoscope is inserted, and the level of the |

| | |anastomosis is defined. An epinephrine-containing solution is injected below the level of the previous |

| | |anastomosis. Cautery is used to circumferentially dissect the pouch immediately proximal to the dentate line. |

| | |This is deepened to the internal sphincter that is defined and protected with great care. Hemostasis is |

| | |meticulous with cautery. Dissection proceeds proximally. The previous anastomosis is reached and dissection |

| | |continues past this point, generally for a distance of 6 to 10 cm until the pouch has been circumferentially |

| | |mobilized. For cases with a pouch-vaginal or anastomosis-vaginal fistula, this dissection has divided the |

| | |fistula tract. Attention is turned to the vaginal or perineal end of the tract, which is excised and debrided, |

| | |before being closed with one or more layers of meticulously placed absorbable sutures. The distal end of the |

| | |mobilized pouch is trimmed, excising the anal transitional zone or fistula site. Great attention is made to |

| | |avoid making the pouch too short or rendering it ischemic. The new distal margin of the pouch is sutured |

| | |circumferentially to the dentate line as a new hand-sewn ileo-anal anastomosis. Hemostasis is assessed for, and|

| | |obtained, at each stage of the procedure. |

|[pic] |

|46712 |  |Clinical Example |

| | |A 35-year-old woman presents with passage of stool through the vagina. Her history includes a prior |

| | |proctocolectomy and ileal pouch-anal anastomosis for ulcerative colitis. Crohn’s disease has been considered. |

| | |At operation, she undergoes a transperineal and transabdominal mobilization of the pouch with advancement and |

| | |re-anastomosis. |

| | |Description of Procedure |

| | |The patient is placed under general anesthesia in the perineolithotomy position. The abdomen is opened through |

| | |a lower midline incision and dissection is performed to mobilize the pelvic reservoir from the sacrum, the |

| | |lateral pelvic walls, and then from the vagina. Complete mobilization of the pelvic pouch is performed to the |

| | |level of the anastomosis. After this is completed, attention is turned to the perineal area. An |

| | |epinephrine-containing solution is injected below the level of the previous anastomosis. Cautery is used to |

| | |circumferentially dissect the pouch immediately proximal to the dentate line. This is deepened to the internal |

| | |sphincter that is defined and protected with great care. Hemostasis is meticulous with cautery. Dissection |

| | |proceeds proximally. This is carried up to the level of the abdominal dissection. This divides any fistula |

| | |tracts. The old pouch is brought into the abdomen and assessed for viability. If the old pouch is viable, it is|

| | |returned to the pelvis, ensuring it is not under too much tension, and sewn to the anal canal. If the old pouch|

| | |was not salvaged, a new neo-pelvic reservoir is constructed and sewn to the anal canal. When this is completed,|

| | |attention is returned to the abdominal incision and a temporary loop ileostomy is created. All wounds are |

| | |closed as appropriate. |

|[pic] |

|46947 |  |Clinical Example (46947) |

| | |A 36-year-old female presents with grade III, prolapsing, internal hemorrhoids that have failed non-operative |

| | |management. After the decision is made to operate, the surgeon reviews all the previous laboratory and |

| | |endoscopic studies, and informed consent is obtained. At operation, she undergoes a stapled hemorrhoidopexy. |

| | |Postoperative visits are conducted as necessary during the 90-day global period to assure normal recovery and |

| | |the absence of complications. |

| | |Description of Procedure (46947) |

| | |A progressive anal dilation is performed, and a circular anoscope is inserted into the anus. A purse-string |

| | |suture anoscope is inserted through the circular anoscope. A circumferential purse-string suture is placed into|

| | |the mucosa and submucosa only. A digital vaginal examination is performed to confirm that the posterior vaginal|

| | |wall is not incorporated into the purse-string suture. Once the vaginal exam is completed, the purse-string |

| | |suture is gently tightened to draw the redundant rectal mucosa into the lumen of the rectum. An opened stapler |

| | |is inserted through the circular anoscope, and the anvil is passed through the purse-string suture. The |

| | |purse-string suture is tied around the shaft of the stapler. The suture threader is used to pull the free ends |

| | |of the suture through lateral channels of the stapler housing. The stapler is tightened. The vagina is once |

| | |again examined to confirm that the posterior vaginal wall is not incorporated into the stapler. The stapler is |

| | |fired and held closed for one minute to assist hemostasis. The head of the stapler is opened, and the stapler |

| | |and circular anoscope are removed together. The specimen is removed from the stapler and inspected by the |

| | |surgeon to verify that a complete circumferential excision of tissue was obtained. A digital examination |

| | |confirms that the staple line is circumferential. The purse-string anoscope or a retractor is then inserted |

| | |into the anus to inspect for bleeding at the staple line. Local anesthetic may be injected for post-operative |

| | |analgesia. |

|[pic] |

|47133 |  |Clinical Example (47133) |

| | |In a previously healthy 30-year-old, non-obese, brain-dead, automobile accident victim, who had a moderate |

| | |elevation of blood alcohol level on admission, the retrieval surgeon assesses the liver visually, by palpation,|

| | |and decides to biopsy, which is satisfactory. Coordination between the other organ teams is provided for. The |

| | |dissection of the hilum, the coronary ligaments, and preservation of an accessary left gastric artery are done.|

| | |The biliary tract is flushed. The inferior epigastric/portal vein and the aorta are dissected and prepared for |

| | |flushing. Cannulation and flushing with vena cava venting are carried out. The hilum dissection is completed |

| | |with care to avoid damage to accessory arteries. The remaining attachments with the cava are cut, and the liver|

| | |is removed and packaged. |

| | |After the trip back to the transplanting hospital, on the back table the vena cavae are dissected and tested |

| | |for leaks. The protal vein is dissected, cannulated for later flushing, and tested for leaks. The artery is |

| | |dissected, with care to preserve the accessory left. |

| | |Description of Procedure (47133) |

| | |The brain-dead, ventilated donor is positioned, prepped, and drapped. Exploration of the abdomen through a |

| | |midline incision extending cephalad from the pubis through the sternum and diaphragming is performed as |

| | |necessary, and manual palpation of intra-abdominal viscera is done to rule out unanticipated masses, abcesses, |

| | |etc. Dissection is performed of all attachments to the liver so that the liver is fully mobilized and attached |

| | |only by the suprahepatic vena cava, infrahepatic vena cava, portal vein and celiac artery trunk (look for |

| | |accessory or anomalous hepatic arteries). The common hepatic duct is dissected to the head of the pancreas; |

| | |heparinize the patient and cannulate the infrarenal aorta and cannulate the inferior mesenteric vein; apply |

| | |occluding vascular clamps to the suprahepatic aorta and flush both cannulas with cold preservation solution |

| | |while applying cold topical rinse solution; divide the portal vein, hepatic artery, common bile duct, and |

| | |inferior vena cava above and below the liver; remove the common iliac artery and its bifurcation branches and a|

| | |segment of external iliac vein for possible use in reconstructing the liver's vasculature; reexamine the liver |

| | |on the back table and package it in sterile fashion with vessels in preservation solution in ice for transport |

| | |and procure additional lymph nodes from small bowel mesentery as needed for completion of crossmatching. |

|[pic] |

|47140 |  |Clinical Example (47140) |

| | |A willing volunteer living-donor has been identified for this infant. In this particular case, it is a parent |

| | |whose blood type is compatible, who has been evaluated and been found not to have any medical or psychosocial |

| | |conditions that would contraindicate living donation, is free from coercion, and has been given every |

| | |opportunity to decline the procedure. The anatomical data on the donor liver reveals no vascular or biliary |

| | |anatomical variance that would preclude the use of the left lateral segment (Couinaud segments II and III). The|

| | |volume of the left lateral segment is measured radiologically as 120 cc 3, equivalent roughly to 120 gm of |

| | |liver tissue [graft to body weight ratio (GBWR) is 1.2%-must exceed 0.8%]. Therefore, the left lateral segment |

| | |is considered to be the graft of choice for the recipient. No hepatic steatosis is identified. To the best of |

| | |the transplant team's knowledge, there is no financial compensation planned and the risks of the procedure have|

| | |been thoroughly covered by the transplant team. |

| | |Once a decision has been made to proceed, the surgeon reviews laboratory and x-ray/imaging studies to plan the |

| | |operative approach, discusses the procedure with the patient and his/her family, and obtains informed consent. |

| | |At operation, the liver is mobilized appropriately and a careful examination is made of the entire abdomen and |

| | |liver to rule out any pathology that might contraindicate living donation. A donor hepatectomy, with |

| | |preparation and maintenance of allograft, left lateral segment only (segments II and III) is performed. |

| | |Postoperative care of the donor includes all necessary hospital and office visits through the 90-day global |

| | |period. |

| | |Description of Procedure (47140) |

| | |A skin incision is made consisting of bilateral subcostal incisions extended to the xiphoid in the midline. The|

| | |anterior abdominal wall is carefully divided. The peritoneum is entered. The round and falciform ligaments are |

| | |divided. The self-retaining mechanical retractor is secured to the operating room table and the various |

| | |attachments are utilized and exposure obtained for the hepatic mobilization and resection. A thorough |

| | |exploration of the area around the liver is undertaken, including palpation and visualization of the left |

| | |lateral segment. The abdominal contents are examined for any evidence of pathology. The left triangular |

| | |ligament is taken down, exposing the left hepatic vein. Any adhesions present are taken down by sharp and blunt|

| | |dissection. The porta hepatis is isolated and encircled with a Penrose drain. The left hepatic artery is |

| | |identified within the porta hepatis and is dissected free of the surrounding tissues and looped with a vessel |

| | |loop. |

| | |The gastrohepatic ligament is taken down and great care is taken to identify any potential aberrant left |

| | |hepatic arteries within the ligament. If an artery is found, the aberrant left hepatic artery is meticulously |

| | |dissected back to the junction with the left gastric artery. The left lateral segment is reflected anteriorly |

| | |and the ligamentum venosum is transected. The round ligament is carefully dissected away from segment IV of the|

| | |liver in the recess of Rex and all comeback vessels and bile ducts are transected in this plane. Dissection is |

| | |carried down to the left portal vein as the falciform remnant enters the portal vein. The left portal vein is |

| | |dissected and encircled and great care is taken not to injure the portal bifurcation. Short caudate branches of|

| | |the left portal vein are divided. The left bile duct is identified within the liver parenchyma, preferably |

| | |after the segment IV duct has entered. The left hepatic duct is transected sharply within the liver parenchyma.|

| | |There are often multiple bile ducts and these need to be carefully identified and transected within the liver |

| | |parenchyma aiming to preserve vascular supply to the bile duct and great care is taken not to injure the |

| | |remaining bile duct. The left hepatic vein is carefully dissected and, if possible, encircled within the liver |

| | |parenchyma. Intraoperative ultrasound is undertaken to locate the junction of the left and middle hepatic |

| | |veins. The ultrasound dissector is then grasped and the presumed area for resection is marked with a cautery. |

| | |The ultrasound dissector is then used to outline the area for dissection. Individual vessels and bile ducts are|

| | |identified in the depths of the ultrasonic dissection and ligated carefully with suture and divided. Hemostasis|

| | |within the liver is secured, and suture is used as necessary to repair vessels which one wishes to preserve. |

| | |The harmonic scalpel may be used in thin areas of the liver. Hemostasis is secured in both raw surfaces making |

| | |certain that there are no bile leaks. |

| | |The argon beam coagulator may be utilized continuously on the raw surface of the liver to stop minimal oozing |

| | |in an effort to prevent blood transfusion in an otherwise healthy donor, thus achieving meticulous hemostasis |

| | |while taking care not to coagulate bile ducts. Once the parenchymal transection is completed and in |

| | |coordination with the recipient's procedure, appropriate vascular clamps are applied to the left portal vein, |

| | |left hepatic artery, and left hepatic vein and the left lateral segment is removed. This previous step requires|

| | |two additional assistants who will prepare and preserve the left lateral segment organ donation, including |

| | |perfusion with cold preservation solution while the vascular and biliary stumps are carefully oversewn by the |

| | |primary surgeon in the donor. The left portal vein, left hepatic artery and left hepatic veins, and left bile |

| | |duct(s) is(are) oversewn with suture in turn. The artery is doubly ligated with suture. A careful check of the |

| | |raw surface is carried out, assuring hemostasis and the absence of new bile leaks. The abdominal cavity is |

| | |copiously irrigated with antibiotic-laden solution. One closed-suction drain is placed in the immediate |

| | |vicinity of the resection towards the cut edge of the liver. The position of the nasogastric tube is checked. |

| | |Perioperative antibiotics are given preoperatively, and are repeated as necessary. Wound towels and the |

| | |retractor are removed. The abdominal wall is closed in layered fashion. The skin is closed in the usual |

| | |fashion. |

|[pic] |

|47141 |  |Clinical Example (47141) |

| | |One of the child's parents is available as a potential living donor. The parent's blood type is compatible. The|

| | |parent has been evaluated and been found to not have any medical or psychosocial conditions that would |

| | |contraindicate living donation, is free from coercion, and has been given every opportunity to decline the |

| | |procedure. The anatomical data on the donor liver reveals no vascular or biliary anatomical variance that would|

| | |preclude the use of the left lobe (Couinaud segments II, III, and IV). The volume of the left lateral segment |

| | |is measured radiologically as 350 cc3, equivalent roughly to 350 gm of liver tissue [graft to body weight ratio|

| | |(GBWR) is 1.0%-must exceed 0.8%]. The left lateral segment (segments II and III) measure 170 cc3 (0.5%), which |

| | |does not provide adequate liver mass for the child. Therefore, the left lobe is considered to be the graft of |

| | |choice for this particular recipient. No hepatic steatosis was identified. To the best of the transplant team's|

| | |knowledge, there is no financial compensation planned and the risks of the procedure have been thoroughly |

| | |explained by the transplant team to the parent. Although the patient is listed as a status 1 and despite |

| | |mandatory regional sharing, there is concern by the transplant team and the child's parents that a suitable |

| | |organ will not be identified and procured before the onset of irreversible brain damage secondary to cerebral |

| | |edema. Since the potential donor has been preemptively evaluated and approved, the decision is made to proceed |

| | |urgently with living donor liver transplantation. It is assumed that if, in the process of preparing the donor |

| | |for hepatectomy, a suitable cadaveric donor is in fact identified and the time interval required to procure the|

| | |organ is reasonable, the living donor procedure will be abandoned in favor of a cadaveric transplant. |

| | |Once a decision has been made to proceed, the surgeon reviews laboratory and x-ray/imaging studies to plan the |

| | |operative approach, discusses the procedure with the patient and his/her family, and obtains informed consent. |

| | |At operation, the liver is mobilized appropriately and a careful examination is made of the entire abdomen and |

| | |liver to rule out any pathology that might contraindicate living donation. A donor hepatectomy, with |

| | |preparation and maintenance of allograft, total left lobectomy (segments II, III and IV) is performed. |

| | |Postoperative care of the donor includes all necessary hospital and office visits through the 90-day global |

| | |period. |

| | |Description of Procedure (47141) |

| | |A skin incision is made consisting of bilateral subcostal incisions extended to the xiphoid in the midline. The|

| | |anterior abdominal wall is carefully divided. The peritoneum is entered. The round and falciform ligaments are |

| | |divided. The self-retaining mechanical retractor is secured to the operating room table and the various |

| | |attachments are utilized and exposure obtained for the hepatic mobilization and resection. A thorough |

| | |exploration of the area around the liver is undertaken, including palpation and visualization of the left lobe.|

| | |The abdominal contents are examined for any evidence of pathology. The left triangular ligament is taken down, |

| | |exposing the left and middle hepatic veins. Any adhesions present are taken down by sharp and blunt dissection.|

| | |The porta hepatis is isolated and encircled with a Penrose drain. The left hepatic artery is identified within |

| | |the porta hepatis and is dissected free of the surrounding tissues and looped with a vessel loop. The |

| | |gastrohepatic ligament is taken down and great care is taken to identify any potential aberrant left hepatic |

| | |arteries within the ligament. If an artery is found, the aberrant left hepatic artery is meticulously dissected|

| | |back to the junction with the left gastric artery. Dissection is carried down to the left portal vein. The left|

| | |portal vein is meticulously dissected and encircled and great care is taken not to injure the portal |

| | |bifurcation. Short caudate branches of the left portal vein are divided. If the caudate lobe is included with |

| | |the left lobe, the caudate veins are identified and the major ones spared for reimplantation. The left bile |

| | |duct is identified at the base of segment IV. A cholecystectomy is performed and a cystic duct cholangiogram |

| | |catheter inserted into the cystic duct for fluoroscopic cholangiography. The biliary anatomy is confirmed with |

| | |cholangiography. |

| | |The left hepatic duct is transected sharply away from the main confluence. There are often multiple bile ducts |

| | |and these need to be carefully identified and transected within the liver parenchyma aiming to preserve |

| | |vascular supply to the bile duct and great care is taken not to injure the remaining bile duct. The left and |

| | |middle hepatic veins are carefully dissected and, if possible, encircled within the liver parenchyma. |

| | |Intraoperative ultrasound is undertaken to locate the junction of the left and middle hepatic veins. The |

| | |ultrasound dissector is then grasped and the presumed area for resection is marked with a cautery. The |

| | |ultrasound dissector is then used to outline the area for dissection (Cantlie's line - major hepatic fissure). |

| | |Individual vessels and bile ducts are identified in the depths of the ultrasonic dissection and ligated |

| | |carefully with suture and divided. Hemostasis within the liver is secured and prolene is used as necessary to |

| | |repair vessels which one wishes to preserve. The harmonic scalpel is used in thin areas of the liver. |

| | |Hemostasis is secured in both raw surfaces making certain that there are no bile leaks. The argon beam |

| | |coagulator is utilized continuously on the raw surface of the liver to stop minimal oozing in an effort to |

| | |prevent blood transfusion in an otherwise healthy donor thus achieving meticulous hemostasis while taking care |

| | |not to coagulate bile ducts. Once the parenchymal transection is completed and in coordination with the |

| | |recipient's procedure, appropriate vascular clamps are applied to the left portal vein, left hepatic artery, |

| | |and left hepatic vein and the left lobe is removed. This requires two additional assistants who will prepare |

| | |and preserve the left lobe including perfusion with cold preservation solution while the vascular and biliary |

| | |stumps are carefully oversewn in the donor. The left portal vein, left hepatic artery and left and middle |

| | |hepatic veins are oversewn with Prolene. The artery is doubly ligated with suture and the left bile duct(s) is |

| | |(are) oversewn with Prolene. A careful check of the raw surface is carried out, looking for meticulous |

| | |hemostasis and the absence of new bile leaks. A completion cholangiogram is performed to document the integrity|

| | |of the remaining bile duct system and to check for leaks. The catheter is removed and the cystic duct is doubly|

| | |ligated. The abdominal cavity is copiously irrigated with antibiotic-laden solution. One closed-suction drain |

| | |is placed in the immediate vicinity of the resection towards the cut edge of the liver. The position of the |

| | |nasogastric tube is checked. Perioperative antibiotics are given preoperatively, but are repeated as necessary,|

| | |depending on time intraoperatively; thus if a first-generation cephalosporin is used, a redosing occurs at 2 |

| | |hours following the initial dose. Wound towels and the retractor are removed. The abdominal wall is closed in |

| | |layered fashion with meticulous attention to hemostasis. The skin is closed in the usual fashion. |

|[pic] |

|47142 |  |Clinical Example (47142) |

| | |The patient's brother has volunteered to be a living donor. This is a healthy 35-year-old male with no |

| | |significant past medical history. His blood type is compatible. He has been evaluated and been found not to |

| | |have any medical or psychosocial conditions that would contraindicate living donation, is free from coercion, |

| | |and has been given every opportunity to decline the procedure. The anatomical data on the donor liver reveals a|

| | |few vascular and biliary anatomical variances, including a trifurcation of the portal vein, as well as a |

| | |trifurcation of the bile duct. (Two other potential donors have been evaluated and ruled out for medical and |

| | |anatomical reasons.) The volume of the right lobe is measured radiologically as 860 cc3, equivalent roughly to |

| | |860 gm of liver tissue (graft to body weight ratio (GBWR) is 1.2%-must exceed 0.8%). The left lobe (segments |

| | |II, III, and IV) measures 420 cc3 (0.6%) and, therefore, the left lobe does not provide adequate liver mass for|

| | |the patient. Therefore, the right lobe is considered to be the graft of choice for this particular recipient. |

| | |No hepatic steatosis was identified. To the best of the transplant team's knowledge, there is no financial |

| | |compensation planned and the risks of the procedure have been thoroughly covered by the transplant team. |

| | |Once a decision has been made to proceed, the surgeon reviews laboratory and x-ray/imaging studies to plan the |

| | |operative approach, discusses the procedure with the patient and his/her family, and obtains informed consent. |

| | |At operation, the liver is mobilized appropriately and a careful examination is made of the entire abdomen and |

| | |liver to rule out any pathology that might contraindicate living donation. A donor hepatectomy, with |

| | |preparation and maintenance of allograft, total right lobectomy (segments V, VI, VII and VIII) is performed. |

| | |Postoperative care of the donor includes all necessary hospital and office visits through the 90-day global |

| | |period. |

| | |Description of Procedure (47142) |

| | |A skin incision is made consisting of bilateral subcostal incisions extended to the xiphoid in the midline. The|

| | |anterior abdominal wall is carefully divided. The peritoneum is entered. The round and falciform ligaments are |

| | |divided. The self-retaining mechanical retractor is secured to the operating room table and the various |

| | |attachments are utilized and exposure obtained for the hepatic mobilization and resection. A thorough |

| | |exploration of the area around the liver is undertaken, including palpation and visualization of the right |

| | |lobe. The abdominal contents are examined for any evidence of pathology. The right triangular, right coronary, |

| | |and right hepatorenal ligaments are taken down, exposing the "bare area" which is then dissected to the |

| | |inferior vena cava. Any adhesions present are taken down by sharp and blunt dissection. The porta hepatis is |

| | |isolated and encircled with a Penrose drain. The right hepatic artery is identified within the porta hepatis |

| | |and is dissected free of the surrounding tissues and looped with a vessel loop. A cholecystectomy is performed |

| | |and a cystic duct cholangiogram catheter inserted into the cystic duct for fluoroscopic cholangiography. The |

| | |biliary anatomy is confirmed with cholangiography. Dissection is carried down to the right portal vein. The |

| | |right portal vein is dissected and encircled and great care is taken not to injure the portal bifurcation. |

| | |Short caudate branches of the right portal vein are divided. The right bile duct(s) is(are) identified by |

| | |lowering the hilar plate. The right hepatic duct is transected sharply within the liver parenchyma. There are |

| | |often multiple bile ducts and these need to be carefully identified and transected within the liver parenchyma |

| | |aiming to preserve vascular supply to the bile duct and great care is taken not to injure the remaining bile |

| | |duct. |

| | |The caudate lobe is mobilized from the inferior vena cava by dividing all caudate and accessory hepatic veins. |

| | |These are individually ligated. The right hepatic vein is carefully dissected and, if possible, encircled |

| | |within the liver parenchyma. Intraoperative ultrasound is undertaken to locate the junction of the right and |

| | |middle hepatic veins. The ultrasound dissector is then grasped and the presumed area for resection is marked |

| | |with a cautery. The ultrasound dissector is then used to outline the area for dissection along Cantlie's line |

| | |(major hepatic fissure). Individual vessels and bile ducts are identified in the depths of the ultrasonic |

| | |dissection and ligated carefully with suture and divided. Hemostasis within the liver is secured and Prolene is|

| | |used as necessary to repair vessels which one wishes to preserve. Hepatic veins draining segments V and VIII |

| | |are spared for future reimplantation. Hemostasis is secured in both raw surfaces making certain that there are |

| | |no bile leaks. The argon beam coagulator is utilized continuously on the raw surface of the liver to stop |

| | |minimal oozing in an effort to prevent blood transfusion in an otherwise healthy donor thus achieving |

| | |hemostasis while taking care not to coagulate bile ducts. Once the parenchymal transection is completed and in |

| | |coordination with the recipient's procedure, appropriate vascular clamps are applied to the right portal vein, |

| | |right hepatic artery, and right hepatic vein and the right lobe is removed. This requires two additional |

| | |assistants who will prepare and preserve the right lobe including perfusion with cold preservation solution |

| | |while the vascular and biliary stumps are carefully oversewn in the donor. The right portal vein, right hepatic|

| | |artery, and right hepatic vein are oversewn with Prolene in turn. The artery is doubly ligated with suture. The|

| | |right bile duct(s) is (are) oversewn with Prolene. A careful check of the raw surface is carried out, looking |

| | |for hemostasis and the absence of new bile leaks. A completion cholangiogram is performed to document the |

| | |integrity of the remaining bile duct system and to check for leaks. The catheter is removed and the cystic duct|

| | |is doubly ligated. The abdominal cavity is copiously irrigated with antibiotic-laden solution. One |

| | |closed-suction drain is placed in the immediate vicinity of the resection towards the cut edge of the liver. |

| | |The position of the nasogastric tube is checked. Perioperative antibiotics are given preoperatively, but are |

| | |repeated as necessary, depending on time intraoperatively; thus if a first-generation cephalosporin is used, a |

| | |redosing occurs at 2 hours following the initial dose. Wound towels and the retractor are removed. The |

| | |abdominal wall is closed in layered fashion with attention to hemostasis. The skin is closed in the usual |

| | |fashion. |

|[pic] |

|47143 |  |Clinical Example (47143) |

| | |A cadaver whole liver graft that has been procured with cold preservation and maintained cold is received at |

| | |the transplant recipient site of service and requires preparation prior to transplantation. Standard backbench |

| | |preparation, including a cholecystectomy and dissection of surrounding soft tissues to prepare the vena cava, |

| | |portal vein, hepatic artery, and common bile duct for implantation, is performed. |

| | |Description of Procedure (47143) |

| | |The whole liver graft is received in a sterile container and is maintained in cold preservation solution. The |

| | |surgeon requests and confirms that a sterile backbench is set up in the operating room, with appropriate |

| | |instruments for the backbench dissection. An appropriate recipient has been identified. The correct |

| | |identification process is carried out to make sure that the liver graft is being allocated to the right |

| | |recipient. The surgeon must make the appropriate arrangements with the operating room and staff to allow for |

| | |sterile dissection of the organ in coordination with the recipient procedure. The surgeon scrubs and gowns. The|

| | |liver is removed from the sterile container and placed on a sterile table, on ice, while bathing in cold |

| | |preservation solution. The liver graft is inspected to be certain that it is grossly intact and that its |

| | |appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, dissection and removal of surrounding soft tissues are |

| | |carried out. The retrohepatic vena cava is identified and stay sutures are placed in both the supra- and |

| | |infra-hepatic aspects of the cava to allow for appropriate dissection. The left triangular ligament, as well as|

| | |the remaining coronary ligaments, are dissected free of the supra hepatic cava. Phrenic veins are identified |

| | |and suture-ligated as necessary on both the right and left sides. The dissection is continued caudad and the |

| | |adrenal vein is identified and ligated. The adrenal gland is then freed from the bare area and this dissection |

| | |is continued by dividing the right triangular ligament. At this point, the cava is tested for leaks by placing |

| | |a vascular clamp at both the upper and lower ends in sequence and injecting preservation solution into the cava|

| | |under pressure. Once the cava is prepared for implantation, if a "piggy-back" caval anastomosis is planned, the|

| | |posterior surface of the cephalad end of the donor cava is cleared adequately to allow sufficient cava to sew |

| | |to on either side of a longitudinal posterior caval slit. This caval slit is created by dividing the posterior |

| | |aspect of the cava from the suprahepatic caval orifice caudad for 3-4 cm to allow an adequate orifice for a |

| | |triangulated anastomosis with the recipient cava. |

| | |Attention is now focused on the porta hepatis. The celiac axis is identified and, using meticulous dissection, |

| | |the splenic, left gastric and gastroduodenal arteries are identified and ligated. Next, the portal vein is |

| | |dissected free of surrounding soft tissues, inspected for holes and prepared for implantation. The common bile |

| | |duct is then identified and dissected away from surrounding soft tissues taking care not to devascularize the |

| | |duct. A cholecystectomy is performed by identifying and ligating the cystic artery and the cystic duct, and |

| | |dissecting the gallbladder away from the gallbladder fossa using sharp dissection. |

| | |The liver graft is kept cold in anticipation of transplantation. If necessary, the liver graft is repackaged in|

| | |a sterile fashion and maintained cold prior to transplantation. |

|[pic] |

|47144 |  |Clinical Example (47144) |

| | |A cadaver whole liver graft that has been procured with cold preservation and maintained cold is received at |

| | |the transplant recipient site of service and requires preparation prior to transplantation. There are two |

| | |transplant recipients scheduled to receive partial graft transplants. Standard backbench preparation, including|

| | |a cholecystectomy and dissection of surrounding soft tissues to prepare the vena cava, portal vein, hepatic |

| | |artery, and common bile duct for implantation, is performed. Additionally, an ex vivo trisegment split is |

| | |performed on the whole liver graft to prepare a left lateral segment graft (segments II and III) and a right |

| | |trisegment graft (segments I and IV through VIII) for transplantation into two recipients. |

| | |Description of Procedure (47144) |

| | |The whole liver graft is received in a sterile container and is maintained in cold preservation solution. The |

| | |surgeon requests and confirms that a sterile backbench is set up in the operating room, with appropriate |

| | |instruments for the backbench dissection. Appropriate recipients have been identified. The correct |

| | |identification process is carried out to make sure that the liver graft is being allocated to the correct |

| | |recipients. The surgeon must make the appropriate arrangements with the operating room staff to allow for |

| | |sterile dissection of the organ in coordination with both recipient procedures. The surgeon scrubs and gowns. |

| | |The whole liver is removed from the sterile container and placed on a sterile table, on ice, while bathing in |

| | |cold preservation solution. The liver graft is inspected to be certain that it is grossly intact and that its |

| | |appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, dissection and removal of surrounding soft tissues are |

| | |carried out. The retrohepatic vena cava is identified and stay sutures are placed in both the supra- and |

| | |infra-hepatic aspects of the cava to allow for appropriate dissection. The left triangular ligament, as well as|

| | |the remaining coronary ligaments, are dissected free of the supra hepatic cava. Phrenic veins are identified |

| | |and suture-ligated as necessary on both the right and left sides. The dissection is continued caudad and the |

| | |adrenal vein is identified and ligated. The adrenal gland is then freed from the bare area and this dissection |

| | |is continued by dividing the right triangular ligament. At this point, the cava is tested for leaks by placing |

| | |a vascular clamp at both the upper and lower ends in sequence and injecting preservation solution into the cava|

| | |under pressure. Once the cava is prepared for implantation, if a "piggy-back" caval anastomosis is planned, the|

| | |posterior surface of the cephalad end of the donor cava is cleared adequately to allow sufficient cava to sew |

| | |to on either side of a longitudinal posterior caval slit. This caval slit is created by dividing the posterior |

| | |aspect of the cava from the suprahepatic caval orifice caudad for 3-4 cm to allow an adequate orifice for a |

| | |triangulated anastomosis with the recipient cava. |

| | |Attention is now focused on the porta hepatis. The celiac axis is identified and using meticulous dissection, |

| | |the splenic, left gastric and gastroduodenal arteries are identified and ligated. Next, the portal vein is |

| | |dissected free of surrounding soft tissues, inspected for holes and prepared for implantation. The common bile |

| | |duct is then identified and dissected away from surrounding soft tissues taking care not to devascularize the |

| | |duct. A cholecystectomy is performed by identifying and ligating the cystic artery and the cystic duct, and |

| | |dissecting the gallbladder away from the gallbladder fossa using sharp dissection. |

| | |Next, attention is turned to splitting the whole graft into two partial grafts. The left hepatic vein is |

| | |dissected free of the liver at its origin and transected sharply. The defect in the cava is repaired with a |

| | |layer of fine (6-0) monofilament suture. The left portal structures are inspected and identified. The left |

| | |hepatic artery is transected either beyond the bifurcation with the right hepatic artery or beyond a |

| | |significant branch to segment IV, depending on the existing arterial anatomy. The arterial stump is oversewn in|

| | |the main hepatic artery with a layer of fine (6-0) monofilament suture, making sure not to compromise the lumen|

| | |of the main hepatic artery. Alternatively, the right hepatic artery is cut at the bifurcation with the left, |

| | |and the stump of the right hepatic artery is oversewn, leaving the celiac trunk with the left lateral segment. |

| | |The round ligament is identified and the "come-back" vessels to segment IV are meticulously divided between |

| | |ligatures until the left portal vein is identified. The left portal vein is dissected free from the surrounding|

| | |soft tissues, ligating and dividing caudate branches as necessary. The left portal vein is transected at the |

| | |bifurcation and the stump is oversewn with fine (6-0) monofilament suture. Alternatively, the right portal vein|

| | |is transected and its stump oversewn, leaving the main portal vein with the left lateral segment. A small probe|

| | |is inserted into the main bile duct and the location of the right and left ducts is determined. If necessary, a|

| | |cholangiogram is obtained using fluoroscopy. The left duct is transected at the desired level (alternatively, |

| | |the right duct is transected) and the stump oversewn with fine (6-0) Prolene. The parenchyma of the liver is |

| | |now dissected along the plane of the falciform ligament aiming towards the Rex fissure, ligating all visible |

| | |tubular structures encountered with silk ligatures until the left lateral segment (segments II and III) is |

| | |completely separated (split) from the remaining liver (segments I and IV through VIII-right trisegment). |

| | |Both grafts are perfused with cold preservation solution looking for obvious leaks in the parenchyma which are |

| | |oversewn where necessary. The two grafts are packaged separately in cold preservation solution and kept cold in|

| | |anticipation of transplantation. If necessary, the liver grafts are repackaged in a sterile fashion and |

| | |maintained cold prior to transplantation. |

|[pic] |

|47145 |  |Clinical Example (47145) |

| | |A cadaver whole liver graft that has been procured with cold preservation and maintained cold is received at |

| | |the transplant recipient site of service and requires preparation prior to transplantation. There are two |

| | |transplant recipients scheduled to receive partial graft transplants. Standard backbench preparation, including|

| | |a cholecystectomy and dissection of surrounding soft tissues to prepare the vena cava, portal vein, hepatic |

| | |artery, and common bile duct for implantation, is performed. Additionally, a backbench lobe split is performed |

| | |on the whole liver graft to prepare a left lobe graft (segments II, III, and IV) and a right lobe graft |

| | |(segments I and V through VIII) for transplantation into two recipients. |

| | |Description of Procedure (47145) |

| | |The whole liver graft is received in a sterile container and is maintained in cold preservation solution. The |

| | |surgeon requests and confirms that a sterile backbench is set up in the operating room, with appropriate |

| | |instruments for the backbench dissection. Appropriate recipients have been identified. The correct |

| | |identification process is carried out to make sure that the liver graft is being allocated to the correct |

| | |recipients. The surgeon must make the appropriate arrangements with the operating room staff to allow for |

| | |sterile dissection of the organ in coordination with both recipient procedures. The surgeon scrubs and gowns. |

| | |The whole liver is removed from the sterile container and placed on a sterile table, on ice, while bathing in |

| | |cold preservation solution. The liver graft is inspected to be certain that it is grossly intact and that its |

| | |appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, dissection and removal of surrounding soft tissues are |

| | |carried out. The retrohepatic vena cava is identified and stay sutures are placed in both the supra- and |

| | |infra-hepatic aspects of the cava to allow for appropriate dissection. The left triangular ligament, as well as|

| | |the remaining coronary ligaments, are dissected free of the supra hepatic cava. Phrenic veins are identified |

| | |and suture-ligated as necessary on both the right and left sides. The dissection is continued caudad and the |

| | |adrenal vein is identified and ligated. The adrenal gland is then freed from the bare area and this dissection |

| | |is continued by dividing the right triangular ligament. At this point, the cava is tested for leaks by placing |

| | |a vascular clamp at both the upper and lower ends in sequence and injecting preservation solution into the cava|

| | |under pressure. Once the cava is prepared for implantation, if a "piggy-back" caval anastomosis is planned, the|

| | |posterior surface of the cephalad end of the donor cava is cleared adequately to allow sufficient cava to sew |

| | |to on either side of a longitudinal posterior caval slit. This caval slit is created by dividing the posterior |

| | |aspect of the cava from the suprahepatic caval orifice caudad for 3-4 cm to allow an adequate orifice for a |

| | |triangulated anastomosis with the recipient cava. |

| | |Attention is now focused on the porta hepatis. The celiac axis is identified, and using meticulous dissection, |

| | |the splenic, left gastric, and gastroduodenal arteries are identified and ligated. Next, the portal vein is |

| | |dissected free of surrounding soft tissues, inspected for holes and prepared for implantation. The common bile |

| | |duct is then identified and dissected away from surrounding soft tissues taking care not to devascularize the |

| | |duct. A cholecystectomy is performed by identifying and ligating the cystic artery and the cystic duct, and |

| | |dissecting the gallbladder away from the gallbladder fossa using sharp dissection. |

| | |Next, attention is turned to splitting the whole graft into two partial grafts. The left and middle hepatic |

| | |veins will be dissected free of the liver at their origin and will be transected sharply. The defect in the |

| | |cava will be repaired with a layer of fine monofilament suture. Next, the left portal structures will be |

| | |inspected and identified. The left hepatic artery is transected beyond the bifurcation with the right hepatic. |

| | |The arterial stump will be oversewn in the main hepatic artery with a layer of fine monofilament suture, making|

| | |sure not to compromise the lumen of the main hepatic artery. Alternatively, the right hepatic artery is cut at |

| | |the bifurcation with the left, and the stump of the right hepatic artery is oversewn, leaving the celiac trunk |

| | |with the left lobe. The left portal vein is dissected free from the surrounding soft tissues, ligating and |

| | |dividing caudate branches as necessary. The left portal vein is transected at the bifurcation and the stump is |

| | |oversewn with fine monofilament suture. Alternatively, the right portal vein is transected and its stump |

| | |oversewn, leaving the main portal vein with the left lobe. A small probe is inserted into the main bile duct |

| | |and the location of the right and left ducts is determined. If necessary, a back table cholangiogram is |

| | |obtained using fluoroscopy. The left duct is transected at the desired level (alternatively, the right duct is |

| | |transected) and the stump oversewn with fine suture material. The parenchyma of the liver is now dissected |

| | |along Cantlie's line (major fissure), ligating all visible tubular structures encountered with silk ligatures |

| | |until the left lobe (segments II, III, and IV) is completely separated (split) from the right lobe (segments I |

| | |and V through VIII). |

| | |Both grafts are perfused with cold preservation solution looking for obvious leaks in the parenchyma which are |

| | |oversewn where necessary. The two grafts are packaged separately in cold preservation solution and kept cold in|

| | |anticipation of transplantation. If necessary, the liver grafts are repackaged in a sterile fashion and |

| | |maintained cold prior to transplantation. |

|[pic] |

|47146 |  |Clinical Example (47146) |

| | |The patient is a liver graft recipient whose portal vein is thrombosed (non-usable) and a venous extension is |

| | |necessary on the donor, liver, allograft, portal vein. Under loupe magnification, an anastomosis between a |

| | |conduit (either the common or external iliac arteries) and the portal vein is performed on the donor allograft.|

| | |Description of Procedure (47146) |

| | |In the case of portal vein thrombosis in the recipient, a venous extension may be needed on the donor portal |

| | |vein. On ice, with continuous bathing in cold preservation solution, a segment of donor iliac vein with |

| | |matching diameter to the portal vein (either common or external iliac vein) is anastomosed end-to-end to the |

| | |portal vein. This anastomosis is performed with fine monofilament suture. The liver graft is kept cold in |

| | |anticipation of transplantation. If necessary, the liver graft is repackaged in a sterile fashion and |

| | |maintained cold prior to transplantation. |

|[pic] |

|47147 |  |Clinical Example (47147) |

| | |The right, hepatic artery of a liver allograft is aberrant or injured (lacerated) and continuity between the |

| | |celiac axis and the vessel is necessary. Under loupe magnification, an arterial anastomosis is performed on the|

| | |patient to reconstruct the right hepatic artery on the donor allograft. |

| | |Description of Procedure (47147) |

| | |On ice, with continuous bathing in cold preservation solution, an end-to-end or end-to-side arterial |

| | |anastomoses between the right hepatic artery and the celiac axis is performed using either running or |

| | |interrupted, fine monofilament suture under loupe magnification between either the superior mesenteric artery |

| | |or the replaced (or injured) right, hepatic artery, and either the splenic artery stump, or the gastroduodenal |

| | |artery stump. Depending on the anatomy of the donor, other techniques for arterial reconstruction may be |

| | |applied. The liver graft is kept cold in anticipation of transplantation. If necessary, the liver graft is |

| | |repackaged in a sterile fashion and maintained cold prior to transplantation. |

|[pic] |

|47370 |  |Clinical Vignette Example (47370) |

| | |The patient is a 31-year-old man who underwent a right colon resection for adenocarcinoma one year ago. At that|

| | |time, he had positive lymph nodes and two palpable liver metastases. Following surgery, he received systemic |

| | |chemotherapy with an initial decrease in the size of liver tumors. CEA levels were not elevated prior to |

| | |surgery or at any subsequent time during his treatment. After one year of treatment, the tumors increased in |

| | |size and two additional separate lesions were visible on spiral CT scan of the abdomen. All four lesions were |

| | |confirmed on ultrasound examination and were felt to be superficial and accessible by laparoscopy. |

| | |Description of Procedure (47370) |

| | |In the operating room and under general anesthesia, the patient was prepped and draped. All laparoscopic and RF|

| | |ablation equipment was hooked up and confirmed to be in working order by the surgeon. The surgeon performed a |

| | |diagnostic laparoscopy and there was no evidence of extrahepatic tumors. The liver was fully mobilized. The |

| | |surgeon used a linear array laparoscopic ultrasound probe to examine all 8 hepatic segments. There were two |

| | |separate tumors seen in the right lobe anteriorly and superiorly, and two lesions in the lateral segment of the|

| | |left lobe of the liver. The largest lesion was biopsied under ultrasound guidance. Using the laparoscopic |

| | |ultrasound image and the standard laparoscopic image as a guide, the radiofrequency thermal ablation device was|

| | |placed within the first lesion. RF energy heated an area of tissue to 100 degrees centigrade (monitored by |

| | |thermocouples within the device) and the temperature was maintained at that level for ten minutes. |

| | |When the ablation cycle was complete, the "cool down temperature" was monitored for an additional minute to |

| | |insure the entire lesion had been adequately heated. Each subsequent tumor was treated in the same manner, with|

| | |the largest tumor requiring three overlapping ablations to ensure that the necessary margin of normal liver had|

| | |been ablated around the tumor. A total of six ablation cycles were performed in the treatment of the four |

| | |tumors identified by intraoperative ultrasound. Hard copies were made of the sonogram images of each ablated |

| | |lesion, documenting adequate margins of destruction. The liver was examined for any sign of bleeding and then |

| | |the laparoscopic canulas were removed and the CO2 gas was allowed to escape from the abdominal cavity. The |

| | |small incisions were sutured closed and the patient was taken to the post-anesthesia recovery room. The total |

| | |operative time was four hours. |

|[pic] |

|47371 |  |Clinical Example (47371) |

| | |The patient is a 44-year-old man who underwent a colon resection for adenocarcinoma one and one-half years ago.|

| | |Following the left colon surgery, he received systemic chemotherapy. After six months of treatment, the |

| | |patient's carcinoembryogenic antigen (CEA) began to rise. CT imaging of the liver reveals three lesions along |

| | |the anterior, inferior surface of the right lobe of the liver. All three lesions were confirmed on ultrasound |

| | |examination and were felt to be superficial and accessible by laparoscopy. The lesions measure 4 cm, 2.0 cm, |

| | |and 2.5 cm in diameter. The patient undergoes laparoscopy and cryosurgical ablation of all three liver tumors. |

| | |NOTE: The ultrasound guidance, supervision, and interpretation are separately reportable. |

|[pic] |

|47379 |  |Clinical Example (47379) |

| | |The patient is a 70-year-old man who, 11 years ago, underwent sigmoid colectomy for an adenocarcinoma. He |

| | |recently developed a recurrent lesion for which the sigmoid colon as well as the left kidney required excision.|

| | |He was also noted to have liver metastases and was treated with several cycles of 5FU. The lesions have not |

| | |responded to the chemotherapy and he has been referred for ablation of his hepatic tumors. |

| | |Description of Procedure (47379) |

| | |The patient is sedated intravenously. An adult colonoscope is introduced through the patient's colostomy site |

| | |and passed to the mid-transverse colon where there is an obstructing neoplasm. The endoscope can not be |

| | |advanced through the lesion. The procedure is performed using fluoroscopic guidance. Using a standard 5 Fr |

| | |biliary catheter and a 0.035" guidewire, the catheter is advanced beyond the stricture. The guidewire is |

| | |removed and water-soluble contrast is injected through the catheter to delineate the length of the stricture. |

| | |The guidewire is reinserted and the catheter is withdrawn. Over the guidewire and through the endoscope, a 20 |

| | |mm internal diameter by 90-mm long expandable metal stent is deployed across the stricture using both |

| | |endoscopic and fluoroscopic guidance. The endoscope is then withdrawn. With sedation and manipulation, the |

| | |treatment session takes approximately 40 minutes. |

|[pic] |

|47380 |  |Clinical Example (47380) |

| | |An 82-year-old gentleman was diagnosed with colon cancer in May of 1994 and underwent a right hemi-colectomy at|

| | |that time. He had a Dukes C2 lesion with positive lymph nodes. He was recently seen in follow-up and found to |

| | |have an elevated CEA of 34. A CT scan revealed two hepatic metastases in right lobe of the liver and one in the|

| | |medial segment of the left lobe of the liver. The two lesions in the right lobe were 3 cm and 2 cm |

| | |respectively. The lesion in the left lobe was 3.5 cm. These findings were confirmed by ultrasound. The |

| | |remainder of the metastatic workup revealed no other spread in the abdomen, retroperitoneum, lung, bone, or |

| | |brain. A recent follow-up colonscopy was also negative for recurrent cancer. Because of the bilaterality and |

| | |multiplicity of the lesions, the surgeon did not feel surgical resection was appropriate, and moreover, he felt|

| | |that radiofrequency thermal ablation was most appropriate. The surgeon obtained consents. The patient underwent|

| | |an exploratory laparotomy. No extra-hepatic disease was found. All three lesions were ablated with |

| | |radiofrequency thermal technique using sonographic guidance and confirmation of lesion destruction. |

| | |Description of Procedure (47380) |

| | |The patient was prepped and draped in a sterile fashion, and a Foley catheter inserted. A bilateral subcostal |

| | |incision is made. A thorough manual and visual exploration of the abdomen, peritoneum, and retroperitoneum is |

| | |performed. Appropriate biopsies are performed based on the findings, and the tissue is sent to the pathologist |

| | |for frozen section examination. No extra-hepatic metastatic deposits are found. Upon visualizing the liver, the|

| | |patient had two metastases in the right lobe of the liver and one lesion in the medial segment of the left |

| | |lobe. A tru-cut needle biopsy of one lesion is performed confirming a mucin-producing metastatic |

| | |adenocarcinoma. The 7.5 mHz intraoperative ultrasound probe was draped out, activated and adjusted. The above |

| | |lesions were identified. Permanent copies of these sonograms were printed. The right and left lobes of the |

| | |liver were then mobilized by taking down the right and left triangular ligaments and the falciform ligament. |

| | |Using a hand-held 7.5 mHz ultrasound probe, the lesions in the liver are carefully mapped out. Under direct |

| | |guidance with the assistance of the ultrasound probe, the radiofrequency needle was inserted individually in |

| | |each of the lesions. The lesions were heated to a temperature of 100 degrees C for five minutes. The two |

| | |lesions of 3 cm and 3.5 cm, diameter each required two heatings, and the smaller lesion only required one, for |

| | |a total of 5 ablation cycles. The heat ablation was monitored with real-time ultrasound, and hard copies of the|

| | |sonograms were obtained confirming adequate margins of tissue ablation. The rest of the abdominal cavity was |

| | |examined for bleeding. The abdomen was then irrigated. The sponge, needle, and instrument count were reconciled|

| | |by the nursing staff. The abdoman was closed in layers. The skin is carefully closed with a skin stapler. The |

| | |total operative time was 4 hours. |

|[pic] |

|47381 |  |Clinical Vignette (47381) |

| | |A 65-year-old gentleman was diagnosed with colon cancer in 1999 had a sigmoid colon resection at that time. He |

| | |had a Dukes C2 lesion with positive lymph nodes. He was recently seen in follow-up and found to have an |

| | |elevated CEA of 34. A CT scan revealed two hepatic metastases in the liver; one in the medial segment of the |

| | |left lobe of the liver and one in the posterior segment of the right lobe of the liver. The lesion in the right|

| | |lobe was 4.5 cm., and the lesion in the left lobe was 3.5 cm. These findings were confirmed by ultrasound. The |

| | |remainder of the metastatic workup revealed no other spread in the abdomen, retroperitoneum, lung, bone, or |

| | |brain. A recent follow-up colonscopy was also negative for recurrent cancer. Because of the bilaterally and |

| | |multiplicity of the lesions, the surgeon did not feel surgical resection or ablation was appropriate. The |

| | |surgeon obtained consents. The patient underwent an exploratory laparotomy. No extra-hepatic disease was found.|

| | |An additional 1.5 cm. lesion was found in the anterior segment of the right lobe of the liver. All three |

| | |lesions were ablated with cryosurgical technique using sonographic guidance and confirmation of lesion |

| | |destruction. |

| | |Description of Procedure (43781) |

| | |The patient was prepped and draped in a sterile fashion, and a Foley catheter inserted. A bilateral subcostal |

| | |incision is made. A thorough manual and visual exploration of the abdomen, peritoneum, and retroperitoneum is |

| | |performed based on the findings, and the tissue is sent to the pathologist for frozen-section examination. No |

| | |extra-hepatic metastatic deposits are found. Upon visualizing the liver, patient had two metastases in the |

| | |right lobe of the liver and one lesion in the medial segment of the left lobe. A tru-cut needle biopsy of one |

| | |lesion is performed confirming a mucin-producing metastatic adenocarcinoma. The 7.5 mHz intraoperative |

| | |ultrasound probe was draped out, activated and adjusted. The above lesions were identified. Permanent copies of|

| | |these sonograms were printed. The right and left lobes of the liver were then mobilized by taking down the |

| | |right and left triangular ligaments and the falciform ligament. Using a hand-held 7.5 mHz ultrasound probe, the|

| | |lesions in the liver were carefully mapped out. Under direct guidance with the assistance of the ultrasound |

| | |probe, two 5 mm cryosurgical probes were placed in the larger lesion in the posterior right liver. Both probes |

| | |were used simultaneously, using a 15 minute freeze cycle, a 10-minute thaw cycle, and an additional 15-minute |

| | |freeze cycle. Cryosurgical ablation was monitored with real-time ultrasound, and hard copies of the sonograms |

| | |were obtained confirming adequate margins of tissue ablation. The anterior lesion in the right liver lobe was |

| | |ablated using a single 5 mm probe, again with ultrasound documentation of the adequacy of the ice-ball |

| | |formation and of obtaining at least 10 mm margins of ice around the lesion. The 15-10-15 minute |

| | |freeze-thaw-freeze cycles were used again. Similarly, the lesion in the left liver lobe was ablated using a 10 |

| | |mm probe, similar freeze thaw cycles and with ultrasound guidance and documentation. On removal of the 10 mm |

| | |probe, the liver parenchyma cracked and brisk bleeding ensued. This was controlled with the application of |

| | |thrombin-soaked gelfoam and liver sutures. The rest of the abdominal cavity was examined for bleeding. The |

| | |abdomen was then irrigated. The sponge, needle, and instrument counts were reconciled by nursing staff. The |

| | |abdominal wound was closed in layers. The skin was carefully closed with a skin stapler. The total operative |

| | |time was 4 hours. |

|[pic] |

|47382 |  |Clinical Vignette (47382) |

| | |A 73-year-old man with colon cancer developed two metastatic lesions to the liver. Lesions were 2 cm x 2 cm and|

| | |4 cm x 4 cm. Because the lesions were not surgically resectable due to their location, the patient's oncologist|

| | |referred him for evaluation for radiofrequency (RF) ablation. The patient was evaluated by the treating |

| | |physician, and the lesions were determined to be amenable to percutaneous RF ablation. |

| | |Description of Procedure (47382) |

| | |After imaging localization of the lesion (coded separately), local anesthesia is injected and a small incision |

| | |is made to facilitate RF needle electrode placement. The RF needle electrode is placed into the lesion. RF |

| | |power is applied until satisfactory core heating is achieved. Overlapping ablations are performed as needed to |

| | |assure complete tumor necrosis and satisfactory margins. After satisfactory necrosis, the RF needle is |

| | |withdrawn to the liver capsule and cauterization is performed to achieve hemostasis along the needle tract. |

| | |After adequate hemostasis of the first lesion, the additional lesion is treated in turn using the same process.|

|[pic] |

|48550 |  |Clinical Example (48550) |

| | |The patient is brain-dead and on life support, and is to be used as a multiple organ donor, including a heart, |

| | |lung, and liver and kidneys in addition to the pancreas. A cruciate incision, extending from the sternal notch |

| | |to the pubis and from the right to the left flank, is used to expose all organs. The pancreas and liver are |

| | |mobilized together as the initial maneuvers. The portal vein, hepatic artery and bile duct are dissected in the|

| | |porta-hepatis and the gastro-duodenal artery ligated. The hepatic artery is freed from the pancreas to its |

| | |origin at the celiac axis. The origin of the splenic artery is identified. The left gastric artery is ligated. |

| | |The celiac and superior mesenteric arteries are isolated at their origins from the aorta. A Feuer maneuver is |

| | |performed mobilizing the duodenum. Following incision of the suspensory ligaments of the liver and as the |

| | |thoracic organs are clamped and removed, the aorta and inferior mesenteric vein are infused with synthetic |

| | |solution. The duodenum is stapled and divided at the pylorus and at the ligament of Treitz. The splenic artery |

| | |is divided at its origin and the portal vein is transected midway between the pancreas and liver, and the |

| | |celiac axis at its origin, allowing the liver to be removed. The superior mesenteric artery is divided at its |

| | |origin allowing the pancreas to be removed. The pancreas is reflushed with synthetic solution on the back table|

| | |and prepared for preservation or for immediate transplantation. |

| | |Description of Procedure (48550) |

| | |Procedure includes positioning, prep, and drape of the patient, exploration of the donor through a midline |

| | |incision from xyphoid to pubis with cruciate incisions as necessary, and manually evaluating the |

| | |intra-abdominal viscera. The gastrocolic ligament is opened to expose the pancreas, and the vascular anatomy of|

| | |the liver is assessed to recognize a possible accessory or anomalous right hepatic artery. The porta hepatis is|

| | |ligated, and the common bile duct is identified and ligated adjacent to the duodenum and divided. Next, the |

| | |common hepatic artery is identified, and dissected back towards the celiac trunk including dissection and |

| | |vessel looping of the splenic artery. Dissection of the portal vein is performed, and a generous Kocher |

| | |maneuver is done to mobilize the head of the pancreas. The nasogastric (NG) tube is positioned through the |

| | |pylorus into the duodenum and antifungal and antibiotic agents are infused. The NG tube is pulled back into the|

| | |stomach and a stapler is used to staple the portion of the duodenum just distal to the pylorus as well as the |

| | |very proximal jejunum distal to the ligament of Treitz. The ligament attachments are taken down between the |

| | |spleen and the abdominal wall, colon, and kidney, and the tail of the pancreas is mobilized. The mesocolon is |

| | |then dissected and the middle colonic vessels identified. The superior mesenteric arterial cascade distal to |

| | |the pancreatic uncinate is also identified. The patient is heparinized and the infrarenal aorta and inferior |

| | |mesenteric vein are cannulated. Vascular clamps are applied to the suprahepatic aorta and the infrarenal aorta |

| | |and inferior mesenteric vein are flushed with cold preservation solution. A topical cold solution is applied, |

| | |and the amount of flushing of the pancreas through the splenic artery and superior mesenteric artery is |

| | |controlled. The portal vein is divided, as well as the splenic artery and superior mesenteric artery. The |

| | |middle colonic vessel is also divided, either with the stapler or individual suture ligatures. The small bowel |

| | |mesenteric vascular arcade is also divided in a similar manner (stapler or individual suture ligatures). The |

| | |pancreaticoduodenal allograft is removed, leaving the spleen intact, and the donor common iliac, external |

| | |iliac, and internal iliac arteries and veins are procured. The physician reexamines the pancreaticoduodenal |

| | |allograft on the "back table," and this allograft is packaged with vessels in preservation solution in ice for |

| | |transport. Additional lymph nodes from small bowel mesentery are procured as needed for completion of |

| | |crossmatching, and the physician closes the cadaver donor incision. |

|[pic] |

|48551 |  |Clinical Example (48551) |

| | |A cadaver donor pancreas allograft that has been procured with cold preservation and maintained cold is |

| | |received at the transplant recipient site of service. Standard backbench preparation, including dissection of |

| | |the allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of |

| | |mesenteric vessels, and Y-graft arterial anastomoses from the iliac artery to the superior mesenteric artery |

| | |and to the splenic artery, is performed. |

| | |Description of Procedure (48551) |

| | |The pancreas graft is received in a sterile container and is maintained in cold preservation solution. The |

| | |surgeon requests and confirms that a sterile backbench is set up in the operating room, with appropriate |

| | |instruments for the backbench dissection. An appropriate recipient has been identified. The correct |

| | |identification process is carried out to make sure that the pancreas graft is being allocated to the right |

| | |recipient. The surgeon must make the appropriate arrangements with the operating room and staff to allow for |

| | |sterile dissection of the organ in coordination with the recipient procedure. The surgeon scrubs and gowns. The|

| | |pancreas is removed from the sterile container and placed on a sterile table, on ice, while bathing in cold |

| | |preservation solution. The pancreas graft is inspected to be certain that it is grossly intact and that its |

| | |appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, a splenectomy is performed by meticulously ligating and |

| | |dividing the splenic vessels at the hilum of the spleen, taking care not to injure the tail of the pancreas. |

| | |Next, the duodenum is opened longitudinally across from the Sphincter of Oddi and washed clean of sulcus to |

| | |locate the position of the sphincter. A catheter may be inserted into the common bile duct and passed through |

| | |the sphincter to confirm sphincter location. Once the sphincter is located, the duodenum is shortened from both|

| | |the pyloric end and the distal end. The feeding (mesenteric) vessels are carefully ligated and divided |

| | |individually as the duodenum is dissected away from the pancreas distally. Proximally, the dissection is |

| | |extended to remove the pylorus. Once the duodenum is trimmed to the desired length (12-14 cm), both ends are |

| | |stapled and the ends are then oversewn with a non-absorbable suture for reinforcement. The common bile duct is |

| | |ligated after the catheter is withdrawn. Next, attention is focused on the middle colic vessels, which must be |

| | |securely ligated at the base of the transverse mesocolon with either suture ligatures or a staple line. This is|

| | |followed by either individual or mass suture ligation and/or stapling of the superior mesenteric vessels at the|

| | |root of small bowel mesentery. A Y-graft is then constructed from the junction of the external and internal |

| | |(hypogastric) iliac arteries of the donor. An arterial anastomosis is constructed first between one of the Y |

| | |limbs to the superior mesenteric artery (end-to-end), and a second anastomosis between the second limb of the Y|

| | |and the splenic artery (end-to-end). These anastomoses are completed with fine monofilament suture under loupe |

| | |magnification. |

| | |The pancreas is kept cold in anticipation of transplantation. If necessary, the pancreas is repackaged in a |

| | |sterile fashion and maintained cold prior to transplantation. |

|[pic] |

|48552 |  |Clinical Example (48552) |

| | |The portal vein on the pancreas allograft is short and requires an extension graft prior to transplantation in |

| | |the patient. Under loupe magnification, an anastomosis between a conduit (either the common or external iliac |

| | |vein) and the portal vein is performed on the allograft. |

| | |Description of Procedure (48552) |

| | |On ice, with continuous bathing in cold preservation solution, a segment of donor, iliac vein with matching |

| | |diameter to the portal vein (either common or external iliac vein) is anastomosed end-to-end to the portal |

| | |vein. The anastomosis is performed with fine, monofilament suture under loupe magnification. |

|[pic] |

|49322 |  |A 30-year-old woman presented 2 months ago with complaints of left-lower-quadrant pain for the preceding week. |

| | |Examination and ultrasound demonstrated a large left adnexal mass that appeared to be a simple ovarian cyst |

| | |without signs of malignancy. She was observed. A repeat ultrasound performed 2 months after initial |

| | |presentation and following a normal menses demonstrates a persistent cyst that had not changed in size. |

|[pic] |

|49323 |  |A 66-year-old man is 18 months post-operative radical retropubic prostatectomy and bilateral pelvic |

| | |lymphadenectomy for the treatment of localized prostate cancer. He has recently developed pelvic pain and |

| | |urinary urgency and frequency. Ultrasound reveals a large lymphocele. |

|[pic] |

|49324 |  |Clinical Example (49324) |

| | |A 51-year-old female with end-stage renal disease due to diabetic nephropathy needs to initiate dialysis |

| | |therapy. The patient has a previous surgical history of Cesarean section and open cholecystectomy. She is |

| | |referred for placement of a peritoneal dialysis catheter, and a laparoscopic approach is selected. |

| | |Description of Procedure (49324) |

| | |A skin incision is made and carried through the subcutaneous tissues. Hemostasis is obtained with suture or |

| | |cautery. The midline fascia, usually below the umbilicus, is exposed to either side of the midline and incised |

| | |vertically in the midline. Stay sutures are placed in the fascia on either side of the midline. The peritoneum |

| | |is opened under direct vision and a trocar is placed. The side stay sutures are attached to the winding posts |

| | |of the trocar. The abdomen is then insufflated with carbon dioxide. Physiologic changes are monitored at this |

| | |time. |

| | |The appropriate camera is inserted, and the assistant is instructed as to how to hold the camera, where the |

| | |focus is, and to make certain of the orientation of the camera. A thorough exploration of the abdominal cavity |

| | |is undertaken visually prior to placing the other trocars. Under direct vision, with the camera viewing |

| | |placement of the other ports, local anesthesia is injected and a trocar is placed in the right upper quadrant |

| | |immediately adjacent to the midline. Two additional ports are then placed on the anterior axillary line of the |

| | |right upper quadrant. The liver is retracted appropriately, and the other trocars are used to perform as |

| | |detailed an exploratory laparoscopy as possible, viewing the small bowel, colon, stomach, spleen where |

| | |possible, and pelvic organs. At this time, adhesions may be lysed sharply and/or bluntly. |

| | |Laparoscopic exploration is performed to identify a clear space to which the peritoneal dialysis catheter will |

| | |be directed. A sleeve or port conduit is inserted through the same or different abdominal wall puncture site to|

| | |provide a channel for insertion of the peritoneal dialysis catheter. After the intraperitoneal catheter segment|

| | |is inserted, the extraperitoneal portion is tunneled subcutaneously from the abdominal wall insertion location |

| | |to a skin exit site. Flow function of the catheter is tested. If bleeding is encountered, electrocautery or |

| | |hemostatic agents are utilized to achieve hemostasis. |

| | |The other individual trocars are withdrawn under direct laparoscopic vision, making certain that there is no |

| | |bleeding. The umbilical trocar is removed, carbon dioxide is allowed to escape from the abdomen, and the |

| | |fascial defect at the umbilicus, and possibly the upper midline, are closed with interrupted sutures. The |

| | |fascial stay sutures are either removed or tied to each other. Local anesthetic is injected to all four trocar |

| | |sites. The subcutaneous tissue is approximated with interrupted sutures to eliminate a dead space. The skin |

| | |incisions are closed in subcuticular fashion. Sponge, needle, and instrument counts are obtained and confirmed |

| | |prior to closure. |

|[pic] |

|49325 |  |Clinical Example (49325) |

| | |A 46-year-old female utilizing continuous cyclic peritoneal dialysis as renal replacement therapy develops |

| | |inflow and outflow discomfort with slow and incomplete dialysate drainage. An abdominal radiograph demonstrates|

| | |displacement of her peritoneal dialysis catheter tip out of the pelvis into the right midabdominal region. The |

| | |patient elects to undergo laparoscopic revision of the catheter. |

| | |Description of Procedure (49325) |

| | |A skin incision is made and carried through the subcutaneous tissues. Hemostasis is obtained with suture or |

| | |cautery. The midline fascia, usually below the umbilicus, is exposed to either side of the midline and incised |

| | |vertically in the midline. Stay sutures are placed in the fascia on either side of the midline. The peritoneum |

| | |is opened under direct vision and a trocar is placed. The side stay sutures are then attached to the winding |

| | |posts of the trocar. The abdomen is then insufflated with carbon dioxide. Physiologic changes are monitored at |

| | |this time. |

| | |The appropriate camera is inserted, and the assistant is instructed as to how to hold the camera, where the |

| | |focus is, and to make certain of the orientation of the camera. A thorough exploration of the abdominal cavity |

| | |is undertaken visually prior to placing the other trocars. Under direct vision, with the camera viewing |

| | |placement of the other ports, local anesthesia is injected and a trocar is placed in the right upper quadrant |

| | |immediately adjacent to the midline. Two additional ports are then placed on the anterior axillary line of the |

| | |right upper quadrant. The liver is retracted appropriately, and the other trocars are used to perform as |

| | |detailed an exploratory laparoscopy as possible, viewing the small bowel, colon, stomach, spleen where |

| | |possible, and pelvic organs. |

| | |Laparoscopic exploration is performed to identify the source of catheter dysfunction. Omentopexy, omentectomy, |

| | |resection of epiploic appendices, or salpingectomy (reported separately) may be required to restore catheter |

| | |function and prevent recurrence of obstruction. Removing intraluminal obstructing material (eg, fibrin clots or|

| | |retained tissue fragments) and redirecting the tubing tip into a position of good flow function are performed. |

| | |The port devices are removed, surgical wounds are repaired, and dressings applied. Flow function of the |

| | |catheter is tested. If bleeding is encountered, electrocautery or hemostatic agents are utilized to achieve |

| | |hemostasis. The other individual trocars are then withdrawn under direct laparoscopic vision, making certain |

| | |that there is no bleeding. The umbilical trocar is removed, carbon dioxide is allowed to escape from the |

| | |abdomen, and the fascial defect at the umbilicus, and possibly the upper midline, are closed with interrupted |

| | |sutures. The fascial stay sutures are either removed or tied to each other. Local anesthetic is injected to all|

| | |four trocar sites. The subcutaneous tissue is approximated with interrupted sutures to eliminate a dead space. |

| | |The skin incisions are closed in subcuticular fashion. Sponge, needle, and instrument counts are obtained and |

| | |confirmed prior to closure. |

|[pic] |

|49326 |  |Clinical Example (49326) |

| | |A 59-year-old male with end-stage renal disease from diabetic nephropathy is undergoing peritoneal dialysis and|

| | |has developed problems with inflow and outflow, which is thought to be related to omental wrapping. At the time|

| | |of the laparoscopy, redundant, thin, filmy omentum is noted to fill the pelvis and lies in juxtaposition of the|

| | |coiled tip of the implanted dialysis catheter, causing partial occlusion. Laparoscopic omentopexy is selected |

| | |to reduce omental trapping of the peritoneal dialysis catheter. |

| | |Description of Procedure (49326) |

| | |Through a laparoscopic working port, forceps or a similar device is inserted into the peritoneal cavity to |

| | |grasp the omentum and displace it into the upper abdomen. The greater omentum is displaced from the pelvis into|

| | |the upper peritoneal cavity, where it is attached to the posterior aspect of the anterior abdominal wall or, |

| | |alternatively, attached to an upper abdominal structure such as the falciform ligament of the liver. The |

| | |omental fixation is accomplished using one of several techniques including but not limited to: placing a |

| | |U-stitch with a suture passing needle inserted through a separate incision; direct laparoscopic suturing with |

| | |intracorporal or extracorporal knot tying; or through the use of a laparoscopic tacking device. The omental |

| | |fixation process typically requires a small skin incision for the suture passing needle or a second |

| | |laparoscopic working port for the insertion of suturing or tacking instruments. |

|[pic] |

|49419 |  |Clinical Example (49419) |

| | |A 42-year-old woman with stage IIIC ovarian cancer undergoes initial surgery followed by multi-agent |

| | |chemotherapy, after which a second-look laparotomy reveals microscopic foci of residual carcinoma limited to |

| | |the peritoneal cavity. The patient is counseled about treatment options and is advised to undergo |

| | |intraperitoneal chemotherapy administration. To accomplish this procedure, the patient is advised that she will|

| | |need to have an intraperitoneal catheter inserted with a subcutaneous reservoir. |

| | |Description of Procedure |

| | |A 6- to 7-cm incision is made in the upper abdomen. The incision is carried down to the peritoneum, and the |

| | |peritoneal cavity is entered. Dissection of bowel and adhesions may be required to achieve a completely open |

| | |peritoneal cavity. A subcutaneous pocket is created on top of the rectus fascia. The Portacath is then sutured |

| | |to the rectus fascia. The Portacath is filled with heparinized saline. The catheter of the Portacath is then |

| | |tunneled into the peritoneal cavity lateral to the fascia and peritoneal incision. The Portacath is arranged in|

| | |a manner that will allow it to have free flow into the peritoneal cavity. The incision in the peritoneum and |

| | |rectus fascia and skin are then closed in layers. |

|[pic] |

|49435 |  |Clinical Example (49435) |

| | |A 48-year-old morbidly obese female (body mass index = 46.6) with end-stage renal disease needs to initiate |

| | |dialysis therapy. In addition to her obesity, the patient has several risk factors for peritoneal dialysis |

| | |catheter infection, including stress urinary incontinence necessitating wearing an adult diaper and chronic |

| | |intertrigo below an abdominal pannus. The surgeon elects to shift the catheter exit site from the abdominal |

| | |wall to a parasternal site that will reduce the risk of infection as well as provide improved visibility of the|

| | |catheter site to the patient. This extension procedure is performed at the time of the peritoneal dialysis |

| | |catheter insertion into the peritoneal cavity. |

| | |Description of Procedure (49435) |

| | |After the abdominal catheter component is inserted (49421, 49324), the extension component (presternal or |

| | |parasternal segment) is implanted by advancing a tunneling device (eg, a vascular tunneler) on the surface of |

| | |the abdominal and thoracic fascia (retromammary) from the abdominal insertion incision to an upper chest |

| | |incision (level of 2nd or 3rd intercostal space), and pulling the extension tube through the subcutaneous path.|

| | |The extension tube and/or abdominal catheter segments are trimmed to the appropriate lengths based upon |

| | |preoperative measurements. A connector is inserted to join the two tubing components. Ligatures are applied to |

| | |secure the joint. The joined catheter segment is pulled up into the subcutaneous tunnel. The extension tube is |

| | |then tunneled from the upper chest incision to the designated presternal skin exit site with appropriate |

| | |positioning of one or more attached catheter cuffs to complete the insertion procedure. |

|[pic] |

|49436 |  |Clinical Example (49436) |

| | |A 26-year-old male with chronic renal failure elects early placement of a subcutaneously embedded peritoneal |

| | |dialysis catheter. Eleven months later, his renal function suddenly declines and he is experiencing uremic |

| | |symptoms. The embedded subcutaneous segment of the catheter is urgently exteriorized. The patient immediately |

| | |begins full-dose peritoneal dialysis without a break-in period and successfully avoids the need for vascular |

| | |catheter placement and temporary hemodialysis. |

| | |Description of Procedure (49436) |

| | |The interval retrieval procedure is performed by making a small incision at or adjacent to the scar marking the|

| | |designated exit site. The catheter is identified by blunt dissection and delivered through the incision. The |

| | |external limb is pulled from the subcutaneous tract, the occluded end of the catheter is removed, the tubing is|

| | |irrigated, and the appropriate connections are attached, such as an adapter, transfer set, and cap. Typically, |

| | |the catheter is immobilized at the exit site with sterile adhesive strips and covered with a dressing. Suture |

| | |repair of the wound is performed if the catheter was exited through the skin by tunneling it to an adjacent |

| | |site separate from the exteriorizing incision. Dressings are applied to complete the procedure. |

|[pic] |

|49904 |  |Clinical Example (49904) |

| | |A 67-year-old man developed a sternal wound infection two weeks after open-heart surgery for coronary artery |

| | |bypass. He is referred to the plastic surgeon for repair of the sternal wound defect following two extensive |

| | |debridement procedures by the thoracic surgeon. The plastic surgeon reviews the patient's medical history and |

| | |laboratory values, examines the sternal wound, chest, and abdomen, and confers with the referring thoracic |

| | |surgeon. After the surgeon discusses the present problem and treatment alternatives with the patient and his |

| | |family, the patient chooses to proceed with an omental flap reconstruction of the sternal wound defect. |

| | |Description of Procedure (49904) |

| | |At operation, the patient is prepared for general anesthesia. The abdomen and chest are prepped with prep |

| | |solution and sterile draping is done. The abdomen is entered through an upper midline incision that extends to |

| | |just below the umbilicus. The skin, subcutaneous layer, and linea alba of the midline fascia are incised. The |

| | |peritoneum is incised and the abdominal cavity is entered. A nasogastric tube is inserted and its position is |

| | |checked from within the abdomen. After a brief exploration of the abdominal organs, attention is turned to |

| | |assessing the omentum and its vessel pattern. By temporary digital occlusion of the left and right |

| | |gastroepiploic vessels and Doppler flow measurements, a determination is made as to which vessels are dominant |

| | |and which vessel pedicle would provide the best omental flap length, arc of rotation, and robust vascular |

| | |supply. The omentum is carefully lifted up from the colon, and any adhesions are isolated and sharply divided |

| | |while protecting the viscus from which they are liberated. After the omentum is freed, its attachment to the |

| | |transverse colon is isolated and carefully divided. Care is taken to avoid injury to the middle colic vessels |

| | |within the transverse mesocolon. Small blood vessels are individually clamped and ligated with fine silk ties. |

| | |The short vessels between the gastroepiploic arch and the greater curvature of the stomach are individually |

| | |clamped and ligated close to the gastric serosa. The omentum is lifted from the abdomen and over the chest to |

| | |ascertain its reach. To provide more length, the left gastroepiploic vessels are divided at a convenient point |

| | |along the greater curvature, without entering the region of the splenic hilum. Dissection at an area of the |

| | |anterior diaphragm is enlarged to allow passage of the omental flap into the sternal wound without tension. The|

| | |omental flap is transposed into the chest. It is carefully placed so as to fill the sternal defect in all |

| | |directions. Care is taken to ensure that the omental pedicle is lying unobstructed and without compression and |

| | |does not cause tethering of the right gastroepiploic vessels, which could cause gastric outlet obstruction or |

| | |vascular compromise. The omental flap is secured to the surrounding structures with several interrupted sutures|

| | |of 3-0 Vicryl. A Jackson-Pratt drain is placed over the flap and is brought out through a separate exit wound |

| | |and anchored to the skin with a 2-0 silk suture. The abdominal peritoneum is closed with 2-0 Vicryl and the |

| | |fascia is closed with 1-0 PDS suture. The skin of both the recipient and donor sites is closed with interrupted|

| | |and running subcuticular 3-0 Vicryl sutures. The wounds are cleansed and sterile dressings are applied. The |

| | |patient is taken to the recovery area. |

|[pic] |

|50250 |  |Clinical Example |

| | |A 59-year-old female with intermittent nausea and vomiting undergoes an abdominal computed tomography that |

| | |reveals an incidental 2.5-cm solid mass of the anterior midpole of the right kidney. The patient has chronic |

| | |renal failure with a baseline creatinine of 3.2. The patient is referred to a urologist and focal cryoablation |

| | |of the mass is decided upon in order to preserve renal function. Since the patient has undergone multiple prior|

| | |abdominal procedures, an open approach is selected. The patient receives usual follow-up care in the hospital |

| | |and office during the 90-day global period. |

| | |Description of Procedure |

| | |A 16 F Foley catheter is placed in the bladder and the patient is placed in the flank position. A flank |

| | |incision is made, the 11th or 12th rib is resected, and the mass is exposed. The kidney is mobilized, the |

| | |ureter is identified, and fatty tissue is dissected from the kidney. A cryosurgical probe is inserted into the |

| | |mass. Ultrasound may be used to monitor the freeze depth. A second freeze is performed. Meticulous hemostasis |

| | |is carried out and drains are placed. The incision is closed in layers. |

|[pic] |

|50300 |  |Clinical Example (50300) |

| | |The patient is brain-dead or is on life support. |

| | |Description of Procedure (50300) |

| | |A long, xiphoid to pubis incision is used to expose the organs to be removed. Careful dissection prepares both |

| | |kidneys and a long segment of the ureters. The kidneys are removed with all major vessels attached (ie, aortic |

| | |cuff and vena cava). The renal grafts are then prepared for preservation or for immediate transplantation. |

|[pic] |

|50320 |  |Clinical Example (50320) |

| | |The donor is a healthy, related sibling/parent/child of a patient suffering from chronic renal failure. |

| | |Description of Procedure (50320) |

| | |Through a generous flank/abdominal incision, the kidney is removed and is carefully dissected with particular |

| | |attention being paid to the renal and ureteral blood supply. A long length of ureter (level of iliac artery) is|

| | |dissected. The renal artery and vein are dissected to their origins (aorta and vena cava, respectively). After |

| | |removal, the kidney is perfused and readied for immediate transplantation. |

|[pic] |

|50323 |  |Clinical Example (50323) |

| | |A cadaver whole renal graft that has been procured with cold preservation and maintained cold is received at |

| | |the transplant recipient site of service and requires preparation prior to transplantation. Standard backbench |

| | |dissection and removal of perinephric fat, diaphragmatic, and retroperitoneal attachments, excision of adrenal |

| | |gland, and preparation of renal vein(s), renal artery(ies), and ureter(s), ligating branches, as necessary, is |

| | |performed. |

| | |Description of Procedure (50323) |

| | |The renal graft is received in a sterile container and is maintained in cold preservation solution. The surgeon|

| | |requests and confirms that a sterile backbench is set up in the OR, with appropriate instruments for the |

| | |backbench dissection. An appropriate recipient has been identified. The correct identification process is |

| | |carried out to make sure that the renal graft is being allocated to the right recipient. The surgeon must make |

| | |the appropriate arrangements with the operating room and staff to allow for sterile dissection of the organ in |

| | |coordination with the recipient procedure. The surgeon scrubs and gowns. The renal graft is removed from the |

| | |sterile container and placed on a sterile table, on ice, while bathing in cold preservation solution. The renal|

| | |graft is inspected to be certain that it is grossly intact and that its appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, the aortic cuff is first identified in order to |

| | |determine the presence or absence of aberrant renal arteries. The renal vein(s) is (are) then identified. The |

| | |adrenal and gonadal veins are identified, ligated and divided. Gerota's fascia and the perinephric adipose |

| | |tissue is removed carefully avoiding capsular injuries, and identifying and sparing aberrant renal arteries |

| | |that enter the kidney directly. The renal artery(ies) is(are) dissected clear of surrounding soft tissues. The |

| | |adrenal gland is identified and gently dissected away from the upper pole of the kidney. The ureter(s) is(are) |

| | |inspected and trimmed free of retroperitoneal structures and fat avoiding skeletonization of the ureter to |

| | |ensure adequate blood supply. |

| | |The renal graft is then re-perfused with cold preservation solution and kept cold in anticipation of |

| | |transplantation. If necessary, the renal graft is repackaged in a sterile fashion and maintained cold prior to |

| | |transplantation. |

|[pic] |

|50325 |  |Clinical Example (50325) |

| | |A living donor renal allograft is received at the transplant recipient site of service in a sterile container, |

| | |maintained in cold preservation solution. Standard backbench dissection and removal of perinephric fat and |

| | |preparation of renal vein(s), renal artery(ies), and ureter(s), ligating branches, as necessary, is performed. |

| | |Description of Procedure (50325) |

| | |The renal graft is received in a sterile container and is maintained in cold preservation solution. The surgeon|

| | |requests and confirms that a sterile backbench is set up in the OR, with appropriate instruments for the |

| | |backbench dissection. An appropriate recipient has been identified. The correct identification process is |

| | |carried out to make sure that the renal graft is being allocated to the right recipient. The surgeon must make |

| | |the appropriate arrangements with the operating room and staff to allow for sterile dissection of the organ in |

| | |coordination with the recipient procedure. The surgeon scrubs and gowns. The renal graft is removed from the |

| | |sterile container and placed on a sterile table, on ice, while bathing in cold preservation solution. The renal|

| | |graft is inspected to be certain that it is grossly intact and that its appearance is acceptable. |

| | |With continuous bathing in cold preservation solution, the aortic cuff is first identified in order to |

| | |determine the presence or absence of aberrant renal arteries. The renal vein(s) is(are) then identified. |

| | |Gerota's fascia and the perinephric adipose tissue is removed carefully avoiding capsular injuries, and |

| | |identifying and sparing aberrant renal arteries that enter the kidney directly. The renal vein(s), renal |

| | |artery(ies), and ureter(s) are prepared for implantation, ligating branches as necessary. |

| | |The renal graft is then re-perfused with cold preservation solution and kept cold in anticipation of |

| | |transplantation. If necessary, the renal graft is repackaged in a sterile fashion and maintained cold prior to |

| | |transplantation. |

|[pic] |

|50327 |  |Clinical Example (50327) |

| | |The renal vein of a right, renal allograft from a deceased donor is short and thin, and requires elongation |

| | |prior to transplantation in the patient. A backbench, vena cava, extension graft or vein patch (venoplasty) is |

| | |performed on the allograft. |

| | |Description of Procedure (50327) |

| | |On ice, with continuous bathing in cold preservation solution, the renal, vein, extension graft is constructed |

| | |in continuity with the renal vein by using a vascular stapler across the vena cava both above and below the |

| | |renal vein(s), so that a tube of cava can serve as the extension graft. This requires two applications of the |

| | |stapler and oversewing of the staple lines for reinforcement, as necessary. If the superior aspect of the cava |

| | |is short and cannot accommodate a staple line without compromising the lumen of the renal vein(s), a venoplasty|

| | |is required; a triangulated vein patch is used to cover the deficit by using two suture lines of fine |

| | |monofilament suture in the superior aspect of the extension. |

|[pic] |

|50328 |  |Clinical Example (50328) |

| | |Two renal end arteries are present on a renal allograft. Backbench, arterial anastomosis, either end-to-end or |

| | |side-to-side, is performed on the allograft to create a single arterial lumen for transplantation. |

| | |Description of Procedure (50328) |

| | |Work is performed on ice, with continuous bathing in cold preservation solution. The main renal artery is kept |

| | |attached to the aortic patch of the donor, and if the ostia of the aberrant artery is greater than 1.0 cm |

| | |apart, the aortic patch is shortened by cutting out a redundant portion of aortic patch and reconstituting |

| | |continuity with a single layer of fine monofilament suture. Alternatively, the aberrant artery is reimplanted |

| | |onto the main renal artery either end-to-side or side-to-side forming a single arterial lumen for |

| | |transplantation in the patient. |

|[pic] |

|50329 |  |Clinical Example (50329) |

| | |Double ureters are present on a renal allograft. Backbench, ureteral anastomosis is performed on the allograft |

| | |creating a ureteroureterostomy, so that there will be one ureteral orifice for the transplantation |

| | |ureteroneocystostomy anastomosis (transplantation work is reported separately). |

| | |Description of Procedure (50329) |

| | |On ice, with continuous bathing in cold preservation solution, the ureters are joined distally by a |

| | |side-to-side ureteral anastomosis with running absorbable monofilament. |

|[pic] |

|50382 |  |Clinical Example |

| | |An 80-year-old with a chronic indwelling double-J ureteral stent placed for ureteral obstruction is seen after |

| | |a failed attempt to exchange the stent was made via cystoscopy. The stent was inadvertently fractured, with the|

| | |distal end removed at cystoscopy, and is now inaccessible from a urethral approach. It is, therefore, elected |

| | |to retrieve and exchange the stent percutaneously from a transnephric approach. |

| | |Description of Procedure |

| | |The physician orders medication for conscious sedation. A small skin incision is made after infiltration of the|

| | |skin and subcutaneous tissues with 1% lidocaine of the selected entry site. A needle is introduced into the |

| | |appropriate renal calyx with the help of imaging guidance to ensure appropriate needle positioning. The |

| | |physician injects contrast once the needle is in place, and fluoroscopy is used to confirm position and to |

| | |identify relevant anatomy. A guidewire is introduced into the renal pelvis, the needle is removed, and the |

| | |tract is serially dilated to the appropriate diameter. A guidewire is introduced into the renal pelvis again, |

| | |this time followed by a sheath placement over the wire into the renal pelvis. A safety guidewire is introduced |

| | |into the bladder, traversing the ureter under fluoroscopic imaging guidance with periodic contrast injection. |

| | |Under fluoroscopic guidance, a snare device is negotiated into the renal pelvis through the sheath and used to |

| | |grasp the proximal end of the indwelling stent, and the stent is partially pulled out through the sheath. Once |

| | |the proximal end of the indwelling stent has been externalized, it is cannulated with a guidewire, which is |

| | |maneuvered past the side holes into the ureter. The old ureteral stent is removed completely over the |

| | |guidewire, leaving the guidewire in place in the bladder. The physician confirms the length of the replacement |

| | |stent. The replacement stent is advanced over the wire until the distal loop is in the bladder. (If balloon |

| | |dilation of the ureter is necessary for stent passage, this is separately reportable.) The distal loop is |

| | |deployed. Once the stent position is confirmed to be satisfactory, the wire is withdrawn, allowing the proximal|

| | |loop to reform in the renal pelvis. The guide, sheath, and safety wire are removed. Images are obtained |

| | |documenting the final stent position. |

|[pic] |

|50384 |  |Clinical Example |

| | |A 75-year-old male with chronic ureteral obstruction has been maintained for 2 years with a chronic indwelling |

| | |ureteral stent. However, the patient now has end-stage renal disease and no urine output, and it is elected to |

| | |remove the ureteral stent. An attempt to remove the stent cystoscopically has failed, with removal of the |

| | |distal portion of the catheter but retention of the proximal and ureteral portions after the stent was |

| | |inadvertently fractured. The patient is referred, therefore, for percutaneous removal of the indwelling stent. |

| | |Description of Procedure |

| | |The physician orders medication for conscious sedation. A small skin incision is made after infiltration of the|

| | |skin and subcutaneous tissues with 1% lidocaine of the selected entry site. The physician introduces a needle |

| | |into the appropriate renal calyx, using imaging guidance to ensure appropriate needle positioning. He or she |

| | |injects contrast once the needle is in place, and fluoroscopy is used to confirm the position and to identify |

| | |relevant anatomy. A guidewire is introduced into the renal pelvis, the needle is removed, and the tract is |

| | |serially dilated to the appropriate diameter. A guidewire is introduced into the renal pelvis again, this time |

| | |followed by a sheath placement over the wire into the renal pelvis. A safety guidewire is introduced into the |

| | |bladder, traversing the ureter under fluoroscopic imaging guidance with periodic contrast injection. Next, |

| | |under fluoroscopic guidance, a snare device is negotiated into the renal pelvis through the sheath and used to |

| | |grasp the proximal end of the indwelling stent, and the stent is pulled out through the sheath, maintaining |

| | |wire position in the bladder. Once the proximal end of the indwelling stent has been externalized, it is |

| | |cannulated with a guidewire, which is then maneuvered past the side holes into the ureter. The old ureteral |

| | |stent is removed completely over the guidewire. The guidewire(s) and sheath are removed. A sterile dressing is |

| | |applied. |

|[pic] |

|50387 |  |Clinical Example |

| | |A 64-year-old male with a current right transnephric single-piece internal/ external (tube hub accessible at |

| | |the patient’s flank) capped ureteral stent presents for routine fluoroscopically guided catheter exchange. |

| | |Description of Procedure |

| | |The physician infiltrates the skin and subcutaneous tissues with 1% lidocaine at the catheter entry site. |

| | |Contrast may be injected into the catheter to assess anatomy and to help with subsequent positioning of both |

| | |pigtails of the new stent. The suture fixing the proximal pigtail in position is cut, and a selective guidewire|

| | |is introduced through the hub of the stent and advanced through the stent into the bladder. Fluoroscopy is used|

| | |to help maneuver the wire through the catheter lumen; the guidewire often is difficult to position due to |

| | |multiple side holes in the catheter. Once the guidewire has exited the distal end hole of the stent, the |

| | |indwelling catheter is removed over the guidewire and discarded. A new nephroureteral stent is advanced over |

| | |the wire with diameter and length chosen to fit the patient’s anatomy. Once in the bladder, the guidewire is |

| | |partially removed to allow formation of the distal loop within the bladder. Fluoroscopic assessment of the |

| | |proximal portion of the catheter is done to be certain that the proximal pigtail will reform within the renal |

| | |pelvis. Once the catheter is appropriately positioned, the guidewire is removed, and the suture is pulled to |

| | |cinch the proximal pigtail in position. Minor adjustments to the catheter position are performed to decrease |

| | |patient discomfort from the catheter tip poking into the wall of the bladder or renal collecting system. |

| | |Contrast may be injected to ensure appropriate positioning and functioning of the new catheter. Once final |

| | |adjustments are made, the catheter site is dressed appropriately. It may be sutured to the skin. The catheter |

| | |may be capped to internal drainage or a drainage bag may be attached for partial external drainage. An image is|

| | |obtained documenting final catheter position for the patient record. |

|[pic] |

|50389 |  |Clinical Example |

| | |A 62-year-old male with bladder carcinoma had a left internal ureteral stent placed 5 days earlier via |

| | |transnephric approach. A nephrostomy catheter had been left in place due to moderate bleeding at the time of |

| | |the stent placement. He now presents for removal of the nephrostomy catheter under fluoroscopic guidance to |

| | |avoid displacing the previously placed ureteral stent. |

| | |Description of Procedure |

| | |Contrast is injected through the indwelling nephrostomy catheter, confirming that the ureteral stent is in |

| | |place and functioning. A note is made that no large thrombus is present in the collecting system. The skin site|

| | |is anesthetized with local anesthetic. The suture fixing the nephrostomy pigtail in position is released, and a|

| | |wire is carefully introduced through the indwelling nephrostomy catheter into the collecting system. This |

| | |maneuver is watched fluoroscopically to be certain that the nephrostomy catheter pigtail and/or retention |

| | |suture do not hook the proximal pigtail of the double-J stent. Adjustments are made with fluoroscopic guidance |

| | |to ensure that the ureteral stent is not dislodged as the nephrostomy catheter is pulled out over the wire. |

| | |Once the nephrostomy catheter is out, a permanent image of the final ureteral stent position is made for the |

| | |patient’s record. A thick sterile dressing is applied to the flank site. |

|[pic] |

|50391 |  |Clinical Example (50391) |

| | |A 58-year-old male with a solitary kidney has known 0.5 cm papillary tumor involving the medial aspect of the |

| | |renal pelvis with associated hydronephrosis. A prior nephrostomy tube had been placed two weeks ago for renal |

| | |drainage. After a lengthy discussion of options, a decision is made to utilize infusion of BCG into the right, |

| | |renal pelvis to destroy the cancer and prevent tumor reoccurrence. BCG is instilled into the renal pelvis via |

| | |the established nephrostomy tube. One amp of BCG is mixed with normal saline. |

| | |Description of Procedure (50391) |

| | |The patient is positioned in the flank position. The field is sterilized, prepared, and draped. Under |

| | |fluoroscopic guidance, the position of the previously placed nephrostomy tube is confirmed. Then the |

| | |anti-neoplastic agent (eg, BCG) is prepared per protocol. The irrigant is poured into a syringe connected to |

| | |the nephrostomy tube. The patient is kept in this position for an appropriate time. Then the fluid is allowed |

| | |to drain from the kidney and disposed of according to OSHA protocol. Finally, the nephrostomy tube is |

| | |reconnected to the drainage system. |

|[pic] |

|50541 |  |A 55-year-old woman is seen with a history of left flank discomfort of 4 to 5 years' duration. The fullness in |

| | |the flank is never sharp but persists most of the time and is an aggravation in her life. An examination |

| | |reveals a soft mass in the left flank. Subsequent ultrasound demonstrates two large posterior renal cysts. A CT|

| | |examination confirms no internal mass lesions and the patient's urine demonstrates no red blood cells. The |

| | |patient is apprised of the findings and is given the options of watchful waiting, surgical exploration, or |

| | |laparoscopic decortication of the cysts. She is actively employed and wishes to minimize her sick-leave time |

| | |and she chooses the laparoscopic approach. |

|[pic] |

|50542 |  |Clinical Example (50542) |

| | |A 59-year-old male has a routine abdominal CT performed for evaluation of abdominal pain. The CT demonstrates |

| | |gallstones; however, an incidental 2-cm solid mass consistent with a renal cell carcinoma is discovered |

| | |involving the posterior hilum of the left kidney. Due to the size and location of the tumor, it is elected to |

| | |proceed with laparoscopic ablation. |

| | |Description of Procedure (50542) |

| | |The patient is taken to the operating room, positioned, padded, and secured to the operating table in a |

| | |modified left flank position. His left flank is prepped and draped in the normal sterile fashion. A |

| | |pneumoperitoneum is achieved in the standard manner and three trocars are placed: a trocar above the umbilicus,|

| | |another trocar lateral to the rectus muscle half way between the umbilicus and ribcage, and a another trocar |

| | |halfway between the umbilicus and xiphoid. All trocars are placed under direct vision and secured to the skin |

| | |with sutures. The laparoscope is placed into the abdominal cavity through the port. Utilizing sharp dissection,|

| | |the colon is reflected medially. The left kidney is identified and dissected away from the Gerota's fascia. The|

| | |renal artery and vein are identified and freed up. Once the kidney is free, an ultrasound probe is utilized and|

| | |demonstrates a solitary lesion at the posterior hilum consistent with the CT scan. The ablation device is |

| | |deployed into the lesion, under ultrasound guidance, and the tumor is ablated in two cycles of up to 90 watts |

| | |power. Once the lesion appears to be completely ablated, the device is removed. A small drain is placed in the |

| | |retroperitoneum on the left side and sutured to the skin. All bleeding points are thoroughly coagulated. The |

| | |trocar sites are removed and closed with sutures after all gas has been removed from the abdomen. The skin is |

| | |closed with sutures and sterile adhesive strips. |

|[pic] |

|50543 |  |Clinical Example (50543) |

| | |A 49-year-old female is noted to have microscopic hematuria on a routine visit to her internist and is referred|

| | |to a urologist for further evaluation. An abdominal CT is performed which demonstrates a 3.0-cm solid mass |

| | |consistent with a renal cell carcinoma involving the lower pole of her right kidney. Because of the size and |

| | |location of the tumor, it is elected to perform a nephron-sparing procedure via a laparoscopic approach. |

| | |Description of Procedure (50543) |

| | |The patient is taken to the operating room and positioned in the modified right flank position. She is |

| | |adequately padded and taped to the table and the flank is prepped and draped in a sterile fashion. A |

| | |pneumoperitoneum is achieved and then three trocars are placed: a trocar roughly 6 cm above the umbilicus in |

| | |the midline, a trocar two finger breadths off the xiphoid in the midline, and a trocar at the level of the |

| | |first trocar in the midclavicular line. All trocars are placed under direct vision and secured to the skin with|

| | |sutures. The liver is retracted anteriorly by placing a port to the left of the midline, halfway between the |

| | |midline trocars. A paddle retractor is used to retract the liver anteriorly. Then the peritoneum over the |

| | |kidney is circumscribed and using blunt and sharp dissection the kidney is dissected out within the Gerota's |

| | |fat. Inspection of the kidney confirms a pedunculated 3-cm solid mass originating from the lower pole that is |

| | |easily visualized. The renal artery and vein are dissected free by fulgurating lymphatic channels in the hilum.|

| | |There are two renal arteries and one renal vein. The ureter is preserved and the periureteric tissue is |

| | |preserved. The surface of the kidney is scored and bulldog clamps are placed on the arteries and veins. The |

| | |tumor is excised, placed in the lap sac and removed. Biopsies are taken of the base of the kidney resection |

| | |margin and frozen sections are reported as negative. The tumor is also sent for frozen section and good margins|

| | |are also confirmed. All blood vessels are sutured. The collecting system is seen and closed with |

| | |figure-of-eight sutures. A beam coagulator is used to fulgurate the parenchyma. Fibrin glue is applied over |

| | |where the collecting system is closed and over the hilum of the incision. Pledgets are placed in the base and |

| | |then the capsule is reapproximated with sutures. The bulldogs are removed. Total ischemic time is 25 minutes. |

| | |The kidney pinks up nicely and papaverine is placed on the arteries. There appears to be good perfusion at the |

| | |end of the procedure. A drain is placed through a lateral stab incision and placed posterior to the kidney and |

| | |sutured to the skin with a suture. Prior to leaving the abdomen, the abdomen is inspected for bleeding, with no|

| | |bleeding being noted. The trocar sites are closed with sutures. All trocars are removed under direct vision. |

| | |All gas is removed prior to removing the last trocar. The skin is closed with sutures and sterile adhesive |

| | |strips. |

|[pic] |

|50544 |  |A 22-year-old college student presents noting that when she drinks alcohol, she has right flank pain. |

| | |Evaluation with an IVP demonstrates a right ureteropelvic junction obstruction. Renal imaging reveals 40% |

| | |function on the right side with markedly delayed drainage after Lasix administration. This also reproduces the |

| | |pain. The options for treatment are discussed including endoscopic incision, open pyeloplasty and laparoscopic |

| | |pyeloplasty. She elects for laparoscopic pyeloplasty. |

|[pic] |

|50545 |  |Clinical Example (50545) |

| | |A 32-year-old woman is found to have a 3 cm renal cell carcinoma in the lower pole of the left kidney, |

| | |discovered on CT scan for suspected gallbladder disease. The gallbladder was found to be normal. The patient |

| | |wishes if at all possible to avoid a large scar and elects a laparoscopic radical nephrectomy. |

| | |Description of Procedure (50545) |

| | |Either an intra- or extra- peritoneal approach is used. The abdomen is insufflated with CO2 and four operating |

| | |ports are placed. The left colon is taken down at the white line and reflected medially, the kidney is |

| | |mobilized inside of Gerota's fascia (leaving a layer of fat over the kidney). The ureter and renal vessels are |

| | |identified and ligated. Lymph node bearing tissue along the aorta is removed as a separate specimen. The upper |

| | |pole of the kidney is carefully dissected off of the spleen and the kidney is now entirely free within the |

| | |abdomen. Two of the laparoscopic ports are connected by a 5 cm incision and the kidney is removed. The wound |

| | |and the laparoscopic incisions are closed. |

|[pic] |

|50546 |  |Clinical Example (50546) |

| | |A 45-year-old man presents with headaches and dizzy spells and is found to have an elevated blood pressure of |

| | |156/110. Subsequent work-up demonstrates a small contracted left kidney with renal vein renin which lateralizes|

| | |to the left. A glucoheptanate renal scan demonstrates 97% function on the right and 3% function on the left |

| | |kidney. Attempts at blood pressure control with medical therapy are partially successful but the patient |

| | |remains symptomatic. The options are: increasing his drug regimen to three anti-hypertensive agents; open |

| | |surgical removal; or laparoscopic surgical removal. These are outlined for the patient, who chooses the |

| | |laparoscopic means of repair. A renal vein renin confirms that the patient's BP elevation was due to |

| | |renovascular cause. |

|[pic] |

|50547 |  |Clinical Example (50547) |

| | |A male or female without major medical problems consents to donate a kidney to a relative or close acquaintance|

| | |with renal failure. Following an extensive medical and psychosocial evaluation confirming the health of the |

| | |prospective donor, the donor is accepted for the procedure. The laparoscopic procedure is associated with |

| | |decreased pain, length-of-stay, and morbidity in comparison to those of the traditional open procedure. |

| | |Description of Procedure (50547) |

| | |The patient is under general anesthesia. The abdomen is insufflated with CO2. Four ports are placed. The left |

| | |colon is reflected, the spleen is reflected, the renal vessels are isolated to the aorta, the ureter is divided|

| | |at the iliac vessel, the kidney is completely freed up. A 6 cm incision for extraction of the kidney is made |

| | |near the umbilicus, the renal artery and vein are stapled, the kidney is placed in a large retrieval bag and |

| | |gently pulled out through the extraction incision. The incisions for the four ports and extraction are closed. |

|[pic] |

|50548 |  |Clinical Example (50548) |

| | |A 48-year-old woman presents with a history of gross hematuria. Her work up includes an IVP and retrograde |

| | |pyelogram which demonstrates a transitional cell cancer at the right renal pelvis. The patient's left kidney is|

| | |normal and urine cytologies are positive for carcinoma. The options of open verus laparoscopic |

| | |nephroureterectomy are presented and she chooses the laparoscopic approach. |

|[pic] |

|50562 |  |Clinical Example (50562) |

| | |A 69-year-old female with a solitary left kidney is referred to a urologist for gross painless hematuria. An |

| | |intravenous pyelogram (IVP) demonstrates a papillary filling defect involving the medial aspect of the renal |

| | |pelvis just above the ureteropelvic junction (UPJ). A voided cytology is positive for transitional cell |

| | |carcinoma and confirms the neoplastic nature of the visualized lesion. Because the patient has only one kidney |

| | |and the tumor involves the renal pelvis, it is elected to endoscopically resect the tumor. |

| | |Description of Procedure (50562) |

| | |The patient is taken to the operating room and placed in the left flank position. The field is sterilized, |

| | |prepped, and draped. Under fluoroscopic guidance the left kidney is identified and a percutaneous guidewire |

| | |placed into the left renal pelvis. A percutaneous tract is then established and segmentally dilated to accept |

| | |an appropriate resectoscope. Renal endoscopy is performed with a flexible nephroscope and confirms a low-grade |

| | |papillary transitional cell cancer on the medial wall of the renal pelvis. The nephroscope is removed and a |

| | |resectoscope is then passed into the renal pelvis. The tumor is carefully resected, being careful not to |

| | |perforate the thin wall of the renal pelvis or injure the renal pedicle. The tumor is then irrigated out of the|

| | |pelvis with an evacuator and all bleeding points fulgurated. The resectoscope is removed and a temporary |

| | |nephrostomy tube is placed to allow for drainage. The tube is secured to the patient's skin with a suture. |

|[pic] |

|50592 |  |Clinical Example |

| | |A 76-year-old man with poor cardiac function and history of previous open-heart surgery has a 3.0-cm enhancing |

| | |solid renal mass that was incidentally found as a result of a computed tomography scan performed due to the |

| | |patient’s complaint of abdominal pain. The patient’s comorbidities rule out open total or partial nephrectomy |

| | |as too risky. The patient is referred for percutaneous renal tumor ablation. |

| | |Description of Procedure |

| | |The physician supervises the start of an IV and the administration of 0.625 mg intravenous droperidol. He or |

| | |she oversees equipping of the room, positioning of the patient, and dispersing of electrodes (ground pads) and |

| | |skin temperature sensors. The physician obtains and interprets the initial localization image (included in |

| | |76362, 76394, or 76940, separately reportable) for selection of the site for initial electrode placement. The |

| | |physician supervises as the nurse administers a dose (or doses) of IV conscious sedation, which typically is 50|

| | |µgs fentanyl and 1 mg midazolam. A small incision is made to facilitate radio frequency (RF) needle electrode |

| | |placement. A 17-gauge, internally cooled radiofrequency needle electrode is introduced into the center of the |

| | |lesion under imaging guidance (imaging included in 76362, 76394, or 76940) to avoid organs and major blood |

| | |vessels. Needle tip location is confirmed using the imaging guidance (imaging included in 76362, 76394, or |

| | |76940). The physician applies RF power as many times as needed until satisfactory core heating is achieved. |

| | |Intratumoral temperature is monitored before and after each treatment (based on the type of radio frequency |

| | |ablation device used) to confirm the completion of the treatment. The physician repeats the process for |

| | |overlapping ablations as needed to ensure complete tumor necrosis and satisfactory margins. The RF electrode is|

| | |withdrawn after satisfactory necrosis, and the physician cauterizes to achieve hemostasis along the needle |

| | |tract. The incision sites are cleaned and sterile adhesive dressings are applied. |

|[pic] |

|50945 |  |A 26-year-old woman presents with a history of UTI infections that were treated medically as a child. She had |

| | |no work-up at the time and now has a VCUG that demonstrates grade III reflux in her (small) right kidney. |

| | |Glucoheptanate renal scan demonstrates 5% function in that kidney and 95% on the left. The left kidney has no |

| | |scars. The creatinine clearance is 80 mL/min. The patient is a single mother caring for two children and cannot|

| | |afford to miss a lot of work. The options of open vs laparoscopic nephroureterectomy are presented, and the |

| | |patient chooses the laparoscopic approach. |

|[pic] |

|50947, |  |Clinical Example (50947, 50948) |

|50948 | |A 10-year-old girl with recurrent UTIs is found to have grade III left sided vesicoureteral reflux. Because of |

| | |breakthrough UTIs and recurrent left pyelonephritis, ureteral implant is recommended. The parents have elected |

| | |for a laparoscopic rather than an open procedure. |

| | |Description of Procedure (50947) |

| | |A periumbilical incision is made in a circumferential direction inferior to the umbilicus. Dissection is |

| | |carried down just inferior to the umbilicus to enter the peritoneal cavity. A disposable trocar and laparoscope|

| | |are introduced and the abdomen insufflated. Next, three 5 mm instrument ports are introduced. Once these parts |

| | |are placed, dissection is carried out to mobilize the ureter just proximal to the broad ligament and down to |

| | |the ureterovesical junction. A detrusor incision is made along the left lateral aspect of the bladder in a |

| | |direction such that the ureter could lie in a nonkinking position into the trough. Toward the latter part of |

| | |the dissection, a small opening is made into the bladder mucosa. The ureter is laid in the detrusor trough. At |

| | |the most distal port of the dissection, the ureter is anastomosed to the detrusor edges using dexon sutures. |

| | |Once this is done, the detrusor trough is sequentially closed from distal to proximal until the hiatus is |

| | |closed. |

| | |A cystoscope is inserted into the bladder and a 4 French ureteral catheter is advanced up the left ureter. |

| | |Under laparoscopic vision, the catheter is seen to slide up the ureter with ease. A urethral catheter is placed|

| | |and all scopes are removed. All abdominal wounds are closed and the patient is taken to the recovery room. |

|[pic] |

|51720 |  |Clinical Example (51720) |

| | |A 72-year-old male is 4-weeks postoperative from a transurethral resection of a noninvasive transitional |

| | |carcinoma of the bladder. He is a candidate for bladder cancer therapy. |

| | |Description of Procedure (51720) |

| | |Following the guidelines for the reconstitution and administration of the anticarcinogenic agent, a gown, |

| | |gloves, protective eyewear, and a face mask are worn. The bladder is catheterized and drained of urine, the |

| | |anticarcinogenic agent is placed in the bladder, and the catheter is removed. The catheter, gown, gloves, mask,|

| | |and all equipment used are disposed of in accordance with regulations. The patient is asked to position himself|

| | |periodically on his right side, left side, abdomen, and back to make sure that all areas of the bladder are |

| | |treated during the course of 2 hours. The patient then voids all of the material from his bladder into the |

| | |toilet. |

|[pic] |

|51798 |  |Clinical Example (51798) |

| | |A 70-year-old man complains of progressive decrease in force of urinary flow, urgency, frequency, and nocturia |

| | |times five. As a part of his urologic evaluation a residual urine volume needs to be determined. With the |

| | |patient supine on the exam table a dedicated ultrasound machine is used to measure the residual urine |

| | |immediately after the patient voids. The residual urine volume is measured at 655 mL, therefore the patient is |

| | |asked to go to the bathroom again to try to empty more completely. He is then rescanned and the urine volume is|

| | |measured at 608 mL. |

| | |Description of Procedure (51798) |

| | |The patient's abdominal area is palpated to identify the pubic bone, and ultrasound jelly is applied to the |

| | |suprapubic area. The suprapubic area is repeatedly scanned, typically three to six times. If the volume is |

| | |high, the patient is asked to void again and the procedure is repeated. The jelly is cleaned off of the |

| | |patient's abdominal area. |

|[pic] |

|51990 |  |A 55-year-old woman with genuine stress urinary incontinence has failed medical therapy and wears 4 to 5 pads a|

| | |day. Urodynamic testing demonstrates a compliant bladder without uninhibited contractions and good detrusor |

| | |activity. She has tried Kegel exercises without success. |

|[pic] |

|51992 |  |A 55-year-old woman with genuine stress urinary incontinence has failed medical therapy and wears 4 to 5 pads a|

| | |day. Urodynamic testing demonstrates a compliant bladder without uninhibited contractions and good detrusor |

| | |activity. She has tried Kegel exercises without success. |

|[pic] |

|52001 |  |Clinical Example (52001) |

| | |A 65-year-old male presents to the emergency room with lower abdominal pain and voiding small amounts of |

| | |grossly bloody urine with clots. On physical examination, his bladder is tender and distended. Several urethral|

| | |catheters are placed; however, they rapidly obstruct secondary to clots. Due to inadequate bladder drainage, |

| | |the patient is taken to the OR. |

| | |Description of Procedure (52001) |

| | |After anesthetic is administered, a cystoscope is passed into the bladder and reveals diffuse prostatic |

| | |bleeding with massive clots within the bladder. The cystoscope is removed. A resectoscope is passed into the |

| | |bladder and the clots are evacuated with an evacuator. Inspection of the bladder shows no residual clots, |

| | |stones, or tumors. The resectoscope is removed and a catheter is inserted to provide continuous bladder |

| | |irrigation and tamponade any prostatic bleeding. After observation for 15 minutes, the irrigate appears clear |

| | |and flows freely. The patient is taken to the recovery room. |

|[pic] |

|52341 |  |Clinical Example (52341) |

| | |A 58-year-old man with left flank pain. Studies demonstrate a left hydronephrosis with a lower ureteral |

| | |stricture. The patient elects endoscopic rather than open surgical treatment. |

| | |Description of Procedure (52341) |

| | |The patient is in the dorsal lithotomy position. The cystoscope is introduced through the urethra into the |

| | |bladder. The ureteral orifice is visualized. A guidewire is passed up the ureter. Fluoroscopy is used |

| | |throughout the procedure. A high pressure balloon is passed over the guidewire to the strictured area and |

| | |inflated. After an appropriate length of time the balloon is deflated and removed. A Foley catheter is placed. |

|[pic] |

|52342 |  |Clinical Example (52342) |

| | |A 58-year-old man with left flank pain. Studies demonstrate a left hydronephrosis with a ureteral pelvic |

| | |junction obstruction. The patient elects endoscopic rather than open surgical treatment. |

|[pic] |

|52343 |  |Clinical Example (52343) |

| | |A 56-year-old man has intermittent severe left flank pain. Studies demonstrate a dilated upper pole calyx with |

| | |stenosis of the infundibulum. He elects endoscopic rather than open surgical treatment. |

| | |Description of Procedure (52343) |

| | |The patient is in the dorsal lithotomy position. The cystoscope is introduced through the urethra into the |

| | |bladder. The ureteral orifice is visualized. Fluoroscopy is used throughout the procedure. A guidewire is |

| | |passed up the ureter and into the dilated upper pole calyx. A high-pressure balloon is passed over the |

| | |guidewire through the stenosed infundibulum and inflated. After an appropriate length of time the balloon is |

| | |deflated and removed. A Foley catheter is placed. |

|[pic] |

|52344 |  |Clinical Example (52344) |

| | |A 58-year-old man with left flank pain. Studies demonstrate a left hydronephrosis with a lower ureteral |

| | |stricture. The patient elects endoscopic rather than open surgical treatment. |

| | |Description of Procedure (52344) |

| | |The patient is in the dorsal lithotomy position. The ureteroscope is passed through the urethra to the bladder |

| | |and then into the ureter. The stricture is visualized and a guidewire is passed through the lumen of the |

| | |stricture. The laser is used to incise the narrowed area. There is no bleeding. The instruments are removed and|

| | |a Foley catheter is placed. |

|[pic] |

|52345 |  |Clinical Example (52345) |

| | |A 21-year-old woman has a history of increasing left flank pain, noted especially after drinking several beers.|

| | |Studies demonstrate a left UPJ obstruction. The patient elects ureteroscopic treatment of the obstruction |

| | |instead of an open pyeloplasty. |

| | |Description of Procedure (52345) |

| | |The patient is placed in the dorsal lithotomy position. The ureteroscope is passed through the urethra to the |

| | |bladder and then into the ureter. The ureteroscope is gradually passed up the ureter, over the iliac vessels |

| | |and into the upper ureter. The pinpoint opening of the UPJ is visualized. A guidewire is placed. The laser |

| | |fiber is positioned and the strictured area is treated successfully. The area is carefully inspected, there is |

| | |no bleeding. The instruments are removed. |

|[pic] |

|52346 |  |Clinical Example (52346) |

| | |A 56-year-old man has intermittent severe left flank pain. Studies demonstrate a dilated upper pole calyx with |

| | |stenosis of the infundibulum. He elects endoscopic rather than open surgical treatment. |

| | |Description of Procedure (52346) |

| | |The patient is in the dorsal lithotomy position. The ureteroscope is inserted through the urethra, into the |

| | |bladder and then into the ureter. The ureteroscope is then passed slowly up the ureter, over the iliac vessels |

| | |and into the renal pelvis. The obstructed infundibulum is identified and a guidewire is passed through the |

| | |small opening and coiled into the dilated calyx. A laser fiber is introduced and the opening is carefully |

| | |enlarged. Bleeding is minimal. The instruments are removed. |

|[pic] |

|52347 |  |Clinical Example (52347) |

| | |A 22-year-old male undergoes an infertility evaluation and is found to have a low volume ejaculate with |

| | |oligasthenospermia and a low pH. Transrectal ultrasound demonstrates fibrosis of the distal ejaculatory ducts |

| | |with distention of the seminal vesicles all the way to the veru montanem consistent with ejaculatory duct |

| | |obstruction. |

| | |Description of Procedure (52347) |

| | |After anesthetic is administered, a 21 French cystoscope is passed into the bladder and reveals diffuse |

| | |prostatic bleeding with massive clots within the bladder. The cystoscope is removed. A 28 French resectoscope |

| | |is passed into the bladder and the clots evacuated with an Ellik evacuator. Inspection of the bladder shows no |

| | |residual clots, stones or tumors. The scope is removed and a 22 French three-way Foley catheter is inserted to |

| | |provide continuous bladder irrigation and tamponade any prostatic bleeding. After observation for 15 minutes, |

| | |the irrigate appears clear and flows freely and the patient is taken to the recovery room. |

|[pic] |

|52354 |  |Clinical Example (52354) |

| | |A 59-year-old male presents with a two-day history of gross, painless hematuria. An IVP demonstrates an area of|

| | |narrowing in the left mid-ureter. A urine cytology is suspicious for transitional cell cancer. |

| | |Description of Procedure (52354) |

| | |The patient is taken to the OR and, after adequate anesthesia is achieved, a cystoscope is passed into the |

| | |bladder. Inspection of the bladder with 30 and 70 degree lenses reveals normal mucosa. A guidewire is then |

| | |passed up the left ureter to the region of the narrowing and the cystoscope is removed. A semi-rigid |

| | |ureteroscope is passed over the guidewire into the bladder. Utilizing the wire as a guide, the ureteroscope is |

| | |then passed through the left orifice and up the left ureter to the level of the narrowing. The area of |

| | |narrowing is identified and appears suspicious for possible cancer. The guidewire is removed and the |

| | |ureteroscopic biopsy forceps passed through the ureteroscope to the level of the lesion. A biopsy is taken and |

| | |the biopsy forceps removed. A small electrocautery electrode is passed up to the biopsy site and the site |

| | |fulgurated. The ureteroscope is removed and the bladder is emptied. The patient is taken to the recovery room. |

|[pic] |

|52355 |  |Clinical Example (52355) |

| | |A 48-year-old male with a solitary left kidney presents with intermittent gross hematuria for several weeks. An|

| | |intravenous pyelogram (IVP) demonstrates a 1-cm filling defect in the left renal pelvis. A urine cytology test |

| | |is positive for transitional cell cancer. |

| | |Description of Procedure (52355) |

| | |The patient is taken to the OR and, after adequate anesthesia is achieved, a cystoscope is passed into the |

| | |bladder. Inspection of the bladder with 30 and 70 degree lenses reveals normal mucosa. A guidewire is passed up|

| | |the left ureter into the left renal pelvis. The cystoscope is removed and a semi-rigid ureteroscope is passed |

| | |over the guidewire into the bladder. Utilizing the wire as a guide, the ureteroscope is then passed through the|

| | |left orifice and up the left ureter to the level of the left renal pelvis. The cancer is identified and the |

| | |guide wire removed. A contact laser fiber is passed through the ureteroscope into the renal pelvis. Utilizing a|

| | |holmium laser power source, the tumor is vaporized at its base. The mass is then removed with a grasping |

| | |forceps. The edges are then lasered, vaporizing all margins. The laser fiber is pulled back 1 mm from the base |

| | |and lasering is continued to coagulate the base. Further inspection demonstrates that the lesion is fully |

| | |resected down to the muscle of the renal pelvis. The base of the lesion is inspected and there is no evidence |

| | |of bleeding. The laser fiber is retracted and the ureteroscope is removed. The bladder is emptied and the |

| | |patient is taken to the recovery room. |

|[pic] |

|52647 |  |Clinical Example |

| | |A 70-year-old male has severe, obstructive symptoms secondary to BPH. |

| | |Description of Procedure |

| | |During cystoscopic examination under anesthesia, a 25-gram obstructive prostate is noted. A right-angle laser |

| | |fiber is passed into the prostatic fossa through a continuous-flow resectoscope and laser energy is delivered |

| | |for 90 seconds to each of four quadrants and to the median lobe. The procedure is approximately 30 minutes in |

| | |duration. A suprapubic tube may be inserted prior to the procedure or a Foley catheter inserted following the |

| | |procedure. The procedure is performed on an ambulatory basis or for a 1-day stay. The patient returns to the |

| | |office on the fifth postoperative day and the Foley catheter is removed or the patient is instructed to turn |

| | |the valve on the suprapubic tube to initiate a voiding trail. He may be placed on an intermittent catheter |

| | |until successful voiding begins, a process that may take up to 2 weeks. Though not common for all, some |

| | |patients may also require placement of a suprapubic tube. |

|[pic] |

|52648 |  |Clinical Example |

| | |A 75-year-old male has severe, obstructive symptoms secondary to BPH. |

| | |Description of Procedure |

| | |During cystoscopic examination under anesthesia, a 65-gram obstructive prostate is noted. A right-angle laser |

| | |fiber is passed into the prostate fossa through a continuous-flow resectoscope with the delivery of laser |

| | |energy for 45 seconds at a time. Prostate tissue is vaporized at 20 different points within the prostatic |

| | |fossa, ultimately creating a resected cavity similar to a transurethral resection of the prostate. After |

| | |completion of the laser procedure, a resectoscope sheath may be inserted transurethrally to resect debris and |

| | |remaining prostate tissue. The procedure is approximately an hour in duration. A catheter is placed and the |

| | |patient is discharged on the second postoperative day. He returns to the office on the fifth postoperative day |

| | |and his catheter is removed with a voiding trail. Though not common for all, some patients may also require |

| | |placement of a suprapubic tube. |

|[pic] |

|53440 |  |Clinical Example (53440) |

| | |A 62-year-old male status post radical retropubic prostatectomy has a 1-year history of severe urinary |

| | |incontinence uncontrolled by medication. He currently soaks five pads per day and is embarrassed by his |

| | |incontinence. Urodynamic studies reveal external sphincteric dysfunction. The patient is advised that there are|

| | |two methods of treatment for his incontinence: a sling procedure or an artificial sphincter. He elects to have |

| | |a sling procedure. |

| | |Description of Procedure (53440) |

| | |The patient is placed in the lithotomy position and a catheter passed into the bladder. First, a transverse |

| | |incision is made in the suprapubic area and carried down to the rectus fascia. The rectus fascia is opened and |

| | |the retropubic space entered. Then a second U-shaped perineal incision is made in the perineum under the |

| | |scrotum and carried down to the bulbospongiosus muscle. The urethra is carefully dissected and the retropubic |

| | |space is entered on both sides lateral to the urethra. A ligature passer is used to traverse the retropubic |

| | |space through the incision from above, perforating the endopelvic fascia and exiting in the perineum on the |

| | |left of the urethra. A sling graft (fascia or synthetic) is soaked and placed under the urethra. One end of the|

| | |sling is attached to the ligature passer and then pulled up through the endopelvic fascia into the retropubic |

| | |space on the left side. The ligature passer is then passed again from above, this time exiting on the right of |

| | |the urethra. The other side of the sling is then pulled up through the retropubic space on the right. The sling|

| | |is seated underneath the urethra and the tension is adjusted to provide support but not obstruction. The |

| | |perineal wound is closed in a layered fashion. The abdominal fascia is closed with a suture. The sling sutures |

| | |are tunneled through the inferior leaf of the rectus fascia and tied down firmly over the closed rectus fascia.|

| | |The subcutaneous and skin layers are then closed. |

|[pic] |

|53442 |  |Clinical Example (53442) |

| | |A 70-year-old male had a periurethral prolene sling placed 8 months ago for post-radical prostatectomy urinary |

| | |incontinence. He now presents with swelling and pain in the perineal region and pyuria. An office cystoscopy |

| | |reveals erosion of the sling into the urethra. Removal of the sling is planned. |

| | |Description of Procedure (53442) |

| | |The patient is placed in the lithotomy position and a catheter placed into the bladder. A perineal incision is |

| | |made under the scrotum and carried down to the bulbospongiosus muscles. The urethra and surrounding sling are |

| | |identified. The sling is freed up from the surrounding urethra, being careful not to further injure the urethra|

| | |or its vasculature. The sling is then mobilized laterally at its exit through the endopelvic fascia and into |

| | |the retropubic space. A second incision is then made suprapubically and the abdominal ends of the sling are |

| | |identified. The sling is mobilized through the abdominal fascia into the retropubic space from above. The sling|

| | |is then removed by pulling it downward from the perineal wound. The urethral erosion is debrided and closed |

| | |with interrupted sutures. The abdominal and perineal wounds are irrigated with antibiotic solution and |

| | |individually closed with sutures. A drain is placed in the perineum and the abdominal wound before closure is |

| | |complete. |

|[pic] |

|53444 |  |Clinical Example (53444) |

| | |The patient is a 65-year-old male, status post radical retropubic prostatectomy with subsequent postoperative |

| | |urinary incontinence. Primary workup leads to the implantation of a urinary sphincter, which remains in place |

| | |for five years functioning adequately. Over the last six months, the patient's incontinence has been |

| | |progressively worse. The incontinence is mainly related to stress induced activities. Exam reveals incontinence|

| | |without sphincter activated. With sphincter activated, the incontinence is worse. There is no evidence of edema|

| | |or erythema around the sphincteric components. The device cycles well. |

| | |Description of Procedure (53444) |

| | |A Foley catheter is placed. With the patient in lithotomy position an incision is made over the cuff at the |

| | |level of the bulbous urethra. The urethral cuff is delicately mobilized. The cuff and tubing are freed from |

| | |urethra. The tubing is clamped. The old cuff is removed. The urethral diameter is measured. Two new cuffs are |

| | |selected and delicately placed around the atrophied urethra. Connections are made to the existing tubing. The |

| | |system is activated and tested. The bladder is filled and leakage is tested with the two cuffs. The wound is |

| | |irrigated throughout with an antibiotic spray. The wound is closed in the usual fashion. |

|[pic] |

|53445 |  |Clinical Example (53445) |

| | |The patient is a sixty-five-year-old male, status post radical retropublic porstatectomy with subsequent |

| | |postoperative urinary incontinence. Primary workup leads to the implantation of a urinary sphincter, which |

| | |remained in place for five years with adequate functioning. Over the last six months, however, the patient's |

| | |incontinence has been progressively worse. The incontinence is mainly related to stress-induced activities. |

| | |Exam reveals incontinence without sphincter activation. With the sphincter activated, the incontinence is |

| | |worse. There is no evidence of edema or erythema around the sphincteric components. The device cycles well. |

| | |Description of Procedure (53445) |

| | |A perineal incision is created and the initial cuff is identified. A secondary cuff is placed (either distally |

| | |or proximally) and connected to the pressure system through a Y-connector setup. The system is activated and |

| | |antegrade perfusion profilometry is tested, which demonstrates adequate resistance at the reservoir pressure |

| | |set point. The incision is closed. |

|[pic] |

|53446 |  |Clinical Example (53446) |

| | |The patient is a middle-aged male, status post radical retropubic prostatectomy, who developed |

| | |post-prostatectomy incontinence. An artificial urinary sphincter was placed for incontinence. The patient has |

| | |now had an indwelling prosthesis for approximately five years. There has been a slow recrudescence of the |

| | |stress incontinence with activity. The patient desires sphincter removal due to loss of manual dexterity |

| | |necessary to operate pump and need for nocturnal deactivation of the device because of detrusor overactivity |

| | |occurring in the nocturnal timeframe. Exam reveals the sphincter prosthesis to be well-seated and to cycle |

| | |poorly. There was demonstrable stress incontinence with device fully inflated. With the pump activated, there |

| | |is further increased incontinence. |

| | |Description of Procedure (53446) |

| | |A Foley catheter is placed. With the patient in lithotomy position, an incision is made and urethral cuff is |

| | |delicately mobilized. The cuff and tubing are freed from urethra. The patient is repositioned supine and |

| | |re-prepped and draped. An infra-pubic incision is made. Electrocautery dissection is done to avoid cutting the |

| | |tubing. The rectus muscles are opened and reservoir is removed. The scrotal pouch is dissected and the pump |

| | |activation-deactivation valve is removed. The wound is irrigated. Closure is done in usual fashion. |

|[pic] |

|53447 |  |Clinical Example (53447) |

| | |The patient is a 60-year-old male, status post radical retropubic prostatectomy, for confined disease, who had |

| | |an artificial urinary sphincter subsequently placed one year postoperatively. Five years postoperative, the |

| | |patient experienced increased incontinence. Incontinence is apparently stress related without evidence of a |

| | |significant urgency component. There is no evidence of hematuria or urinary tract infection. Exam reveals a |

| | |sphincter prosthesis with demonstrable stress incontinence without activation of the device. With activation, |

| | |incontinence is worse. The sphincter cycles well without evidence of decompression. |

| | |Description of Procedure (53447) |

| | |A Foley catheter is placed. With the patient in lithotomy position, a perineal incision is made and the |

| | |urethral cuff is delicately mobilized. The cuff and tubing are freed from the urethra. A new cuff is very |

| | |carefully placed around the urethra. The new tubing is placed alongside the old tubing through the inguinal |

| | |ring. The patient is repositioned supine and re-prepped and draped. An infra-pubic incision is made. |

| | |Electrocautery dissection is done to avoid cutting the tubing. The rectus muscles are opened and reservoir is |

| | |removed. The scrotal pouch is dissected and the pump/activation-deactivation system is removed. The wound and |

| | |prosthetic components are irrigated throughout the procedure with antibiotic solution spray. A new reservoir is|

| | |placed beneath rectus muscles, space is closed. A new pump/activation-deactivation system is placed. The system|

| | |is filled with fluid and connections are made. The system is tested. The wound is irrigated. Closure is done in|

| | |usual fashion. |

|[pic] |

|53448 |  |Clinical Example (53448) |

| | |The patient is a 62-year-old male, who is status post sphincter implantation for post-prostatectomy |

| | |incontinence two years ago. The patient subsequently developed edema and erythema of the scrotum. Exam reveals |

| | |some scrotal edema and skin fixation. The sphincter pump is notable, palpated, and apparently fixed to the |

| | |skin. The patient has a low-grade fever, but is not systemically toxic. |

| | |Description of Procedure (53448) |

| | |A Foley catheter is placed. With the patient in lithotomy position incision is made and the urethral cuff is |

| | |delicately mobilized. The cuff and tubing are freed from the urethra. The area is debrided as necessary. The |

| | |wound is irrigated with antibiotic solution. Jackson-Pratt drains are placed for irrigation with antibiotic |

| | |solution. A new cuff is very carefully placed around the urethra. The new tubing is placed alongside the old |

| | |tubing through the inguinal ring. The perineal incision is closed. The patient is repositioned supine and |

| | |re-prepped and draped. An infra-pubic incision is made. Electrocautery dissection is done to avoid cutting the |

| | |tubing. The rectus muscles are opened and the reservoir is removed. The scrotal pouch is dissected and the |

| | |pump/activation-deactivation system is removed. The wound and prosthetic components are irrigated throughout |

| | |the procedure with antibiotic solution spray. The entire wound is irrigated with 10 liters of antibiotic |

| | |solution. A new reservoir is placed beneath the rectus muscles, and the space is closed. A new |

| | |pump/activation-deactivation system is placed. The system is filled with fluid and connections are made. The |

| | |system is tested. The wound is irrigated. Closure is done in the usual fashion. |

| | |A new reservoir is placed beneath the rectus muscles. Jackson-Pratt drains (3.2 mm round) are placed in |

| | |appropriate areas for postoperative irrigation with antibiotic solutions and drainage. The subcutaneous tissues|

| | |are closed. The drains are brought out through separate stab wounds and sutured in place. The wound is closed |

| | |in the usual fashion. |

|[pic] |

|53449 |  |Clinical Example (53449) |

| | |The patient is a 60-year-old male, status post radical retropubic prostatectomy, for confined disease, who had |

| | |an artificial urinary sphincter subsequently placed one year postoperatively. Five years postoperative, the |

| | |patient has experienced increased incontinence. Incontinence is apparently stress related without evidence of a|

| | |significant urgency component. There is no evidence of hematuria or urinary tract infection. Exam reveals a |

| | |sphincter prosthesis with demonstrable stress incontinence without activation of the device. With activation, |

| | |incontinence is worse. The sphincter cycles well without evidence of decompression. |

| | |Description of Procedure (53449) |

| | |The patient is taken to surgery and the sphincter prosthesis is exposed initially through an inguinal approach,|

| | |which exposes the sphincter reservoir. This may or may not be associated with a secondary incision in the |

| | |perineum to approach the cuff. The area of tubing fracture and/or leak is noted. If reservoir related, the |

| | |reservoir is replaced. If tubing fracture or connection break is noted, these materials are replaced. The |

| | |system is refilled and tested at the time of surgery with antegrade profusion profilometry and/or other methods|

| | |to ensure adequate cycling of the sphincteric prosthesis. The surgical incisions are closed. |

|[pic] |

|53500 |  |Clinical Example (53500) |

| | |A 62-year-old female is seen at her one year follow-up visit for a previous bladder neck suspension. She has |

| | |developed progressive urinary obstructive symptoms including decreased force of stream, straining to void and |

| | |double voiding. She also has worsening urgency and urge incontinence. Work up demonstrates significant bladder |

| | |outlet obstruction secondary to urethral scarring and fibrosis. |

| | |Description of Procedure (53500) |

| | |An appropriate vaginal incision is made and the periurethral and vesicovaginal space is dissected. This |

| | |requires careful and tedious dissection to avoid excess blood loss and further compromise of the urethra and |

| | |bladder neck. Dissection is performed anterior and posterior to the urethra including lysis and removal of |

| | |associated fibrous tissue until the urethra has been freed from the surrounding structures. The dissection |

| | |requires mobilization of the urethra bilaterally. Careful hemostasis is essential. The incision is closed |

| | |either primarily or in layers depending on the integrity of the urethra following release of the fibrosis. |

|[pic] |

|53853 |  |Clinical Example (53853) |

| | |The patient is a 65-year-old male complains of the frequent and urgent need to urinate while producing only a |

| | |scant and weak flow. A PSA test was not remarkable. A transrectal ultrasound revealed an enlarged prostate. The|

| | |patient has been informed about various treatment options. |

| | |Description of Procedure (53853) |

| | |Anesthetic gel is placed into the urethra. The water-induced thermotherapy treatment catheter is introduced |

| | |into the urethra and bladder. The bladder-locating catheter balloon is inflated with air. The water-induced |

| | |thermotherapy tip stylet is removed. The catheter is taped to the patient's leg . The pump is activated which |

| | |circulates the 60 degree C water through the catheter and treatment balloon positioned in the prostate. |

| | |Additional water is injected into the treatment balloon. The system console and the patient are monitored for a|

| | |45-minute treatment cycle. The treatment catheter position is checked at regular intervals. The air is deflated|

| | |from the locating balloon and the treatment balloon and treatment catheter are removed. A Foley catheter is |

| | |placed at the end of the procedure. |

|[pic] |

|54150 |  |Clinical Example (54150) |

| | |The parents of a 2-day-old male request an elective circumcision prior to home discharge from the normal |

| | |newborn nursery. The risks, benefits, and alternatives of the procedure are discussed with the parents who |

| | |elect to proceed with the procedure. They are particularly concerned that discomfort and pain be controlled |

| | |during the procedure. A penile nerve block (either dorsal or ring block) is discussed with the family as the |

| | |most appropriate and effective form of anesthesia. |

| | |Description of Procedure (54150) |

| | |The physician injects the dorsal nerve bundle and does a complete circumferential penile blockade with local |

| | |anesthetic. The patient is observed. The patient is then strapped to a papoose board and reprepped. The |

| | |foreskin ring is forcefully dilated with a hemostat and then reduced to the shaft of the penis. All |

| | |foreskin-glans adhesions are taken down with a tear duct probe and all smegma concretions are removed. |

| | |Reprepping is accomplished and the foreskin is placed over the glans. One of three clamps is selected and |

| | |inserted through the foreskin riding over the glans. The constricting circular ring is placed over the foreskin|

| | |and screwed down to compress and devascularize the foreskin. The device is left in place until |

| | |devascularization occurs. The devascularized foreskin is then excised with a scalpel, the ring device is |

| | |removed, and the penis dressed. |

|[pic] |

|54162 |  |Clinical Example (54162) |

| | |The patient is a 4-year-old boy who is noted to have a curved erection and an unusual appearing penis. Upon |

| | |careful inspection, it is noted that the foreskin has been incompletely excised and multiple skin bridges |

| | |attach the left side of the glans penis to the penile shaft skin. |

| | |Description of Procedure (54162) |

| | |The patient is prepped and draped under general anethesia and a local anesthetic block is administered for |

| | |post-op pain control. Using loop magnification, multiple adhesions are freed up and smegma and debris are |

| | |removed. The skin bridge is incised. Closure of the now separated skin bridge is done in Heinke-Mikulicz |

| | |fashion to ensure that there will be no postoperative chordee (curvature) with erection. Bleeders are |

| | |coagulated. Any remaining foreskin is carefully excised. Ointment, Adaptic and a gauze dressing is applied. |

|[pic] |

|54163 |  |Clinical Example (54163) |

| | |The patient is a 4-year-old boy is noted to have a curved erection and an unusual appearing penis. Upon careful|

| | |inspection it is noted that the foreskin has been incompletely excised and multiple skin bridges attach the |

| | |left side of the glans penis to the penile shaft skin. |

| | |Description of Procedure (54163) |

| | |The patient is given a general anesthetic. The penis is prepped and draped. A local anesthetic block is |

| | |administered for post op pain control. Using loop magnification, multiple adhesions are freed up between the |

| | |incompletely excised foreskin and the glans penis; smegma is removed. The skin bridges are incised, and |

| | |bleeders are coagulated. The remaining foreskin is excised with scissors. Multiple absorbable sutures are |

| | |placed to reapproximate the penile shaft skin to the mucous membrane. A sterile dressing is applied. |

|[pic] |

|54164 |  |Clinical Example (54164) |

| | |The patient is a 28-year-old man circumcised at birth, who reports painful tearing and bleeding from the |

| | |frenulum of the penis when having intercourse. Conservative measures have failed. Even after prolonged periods |

| | |of abstinence, the bleeding recurs when having intercourse. |

| | |Description of Procedure (54164) |

| | |The patient is placed under anesthesia, as this procedure is very painful. Using loop magnification, adhesions |

| | |around the frenulum are freed. The scar tissue is excised, and bleeders are coagulated. The frenular tissue is |

| | |reapproximated so as to relieve the tension and to allow stretching of the tissue. A sterile dressing is |

| | |applied. |

|[pic] |

|54406 |  |Clinical Example (54406) |

| | |A 74-year-old diabetic male had an inflatable multi-component penile prosthesis placed 14 years ago. The |

| | |prosthesis is somewhat uncomfortable, he is no longer sexually active and wants the prosthesis removed. He does|

| | |not want it replaced. |

| | |Description of Procedure (54406) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. The corpora cavernosa are exposed. |

| | |Lateral corporotomies are made. Each prosthesis (right and left) is carefully removed. The proximal corpus |

| | |cavernosum on each side is probed and checked for remaining rear-tip extenders. The pump is removed from the |

| | |scrotum. |

| | |The rectus muscles are divided and the reservoir is removed. The rectus muscles are closed. Throughout the |

| | |procedure the operative field is irrigated with antibiotic solution. |

| | |The subcutaneous tissues are closed. Drains are brought out through separate stab wounds and sutured in place. |

| | |The wound is closed in usual fashion. |

|[pic] |

|54408 |  |Clinical Example (54408) |

| | |A 68-year-old man with severe peripheral vascular disease had an inflatable multi-component penile prosthesis |

| | |placed 14 months ago. The right cylinder has buckled and slipped back from the glans penis. Repair of this |

| | |problem is scheduled. |

| | |Description of Procedure (54408) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. Dissection is done entirely with |

| | |electro-cautery so as not to cut the prosthesis and tubing. A herniation of the right cylinder is noted through|

| | |the old corporotomy incision causing a buckling of the right prosthesis. The prosthesis is removed from the |

| | |right cylinder and seen to be in good working order. The prosthesis is replaced into normal position. The |

| | |defect in the corpus cavernosum is carefully repaired giving a good, strong closure over the prosthesis. The |

| | |prosthesis is pumped and deflated to make sure it works properly. The wound is irrigated throughout the |

| | |procedure with antibiotic spray. The corporotomies are closed. |

| | |The wound is irrigated and closed in usual fashion. |

|[pic] |

|54410 |  |Clinical Example (54410) |

| | |The patient is a 77-year-old man who had a multi-component inflatable penile prosthesis placed 11 years ago. |

| | |When having vigorous intercourse two days ago he heard a "pop" and suddenly lost his erection. On exam the |

| | |prosthesis will not inflate when compressing the scrotal pump. An x-ray confirms loss of fluid from the system.|

| | |The patient is anxious to correct the problem as soon as possible. Removal of all old components and |

| | |replacement with all new components of a multi-component inflatable penile prosthesis is planned. |

| | |Description of Procedure (54410) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. Dissection is done entirely with the |

| | |electro-cautery so as not to cut the prosthesis and tubing. Fluid from the prosthesis is noted tracking along |

| | |the tubing. The tubing is traced to the cylinders in the corpora cavernosa. Longitudinal corporotomies are |

| | |made. Both cylinders are delivered into the wound. The right cylinder is noted to have a crack at the level of |

| | |the tubing exit. A leak in the system is identified at the tubing exit from the cylinder. Tubing is divided |

| | |from both cylinders. New measurements of the corporal length are made. Appropriate new penile prosthesis |

| | |cylinders are selected and opened. New connections to the old tubing are made and the system is carefully |

| | |refilled with fluid to the exact amount necessary. The prostheses are pumped and deflated to make sure they |

| | |work properly. |

| | |The prostheses are then replaced in the corpora. Rear tip extenders are added as necessary. The wound is |

| | |irrigated throughout the procedure with antibiotic spray. |

| | |The corporotomies are closed. The wound is irrigated and closed in usual fashion. |

|[pic] |

|54411 |  |Clinical Example (54411) |

| | |The patient is a 67-year-old man who had an inflatable self-contained penile prosthesis placed four months ago.|

| | |His penis has become swollen, red and tender. He has a low-grade fever. After appropriate testing, he is found |

| | |to have an infected prosthesis. If the prosthesis is removed and not replaced, the corporal bodies will scar |

| | |making future placement of a prosthesis difficult, if not impossible. Removal of the prosthesis and replacement|

| | |through an infected field is planned. |

| | |Description of Procedure (54411) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. The corpora cavernosa are exposed. |

| | |Lateral corporotomies are made. Each prosthesis (right and left) is carefully removed. The proximal corpus |

| | |cavernosum on each side is probed and checked for remaining rear tip extenders. The corporotomies and entire |

| | |wound are irrigated with 10 liters of a saline solution containing antibiotics for a total of 20 minutes. The |

| | |length of each corpus cavernosum from the ischial tuberosity to the glans penis is carefully measured. An |

| | |appropriately sized prosthesis is selected and opened. The corpora are re-dilated to the proper diameter. The |

| | |prosthesis is inserted, an insertion tool and insertion suture may be utilized. Rear tip extenders are added as|

| | |necessary. The prosthesis is checked for fit. Jackson-Pratt drains (3.2 mm round) are placed in appropriate |

| | |areas for postoperative irrigation with antibiotic solutions and drainage. |

| | |The corporotomies are closed with absorbable suture. Throughout the procedure the operative field is irrigated |

| | |with antibiotic spray. The subcutaneous tissues are closed. |

| | |Drains are brought out through separate stab wounds and sutured in place. The wound is closed in usual fashion.|

|[pic] |

|54415 |  |Clinical Example (54415) |

| | |The patient is a 65-year-old man who had a semi-rigid penile prosthesis placed 16 years ago. He now has some |

| | |discomfort in the penis and is no longer sexually active. He wants the prosthesis removed. He does not want a |

| | |new prosthesis. |

| | |Description of Procedure (54415) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. The corpora cavernosa are exposed. |

| | |Lateral corporotomies are made. Each prosthesis (right and left) is carefully removed. The proximal corpus |

| | |cavernosum on each side is probed and checked for remaining rear tip extenders. The corporotomies are |

| | |irrigated. |

| | |The corporotomies are closed with running absorbable suture. The wound is irrigated and closed in usual |

| | |fashion. |

|[pic] |

|54416 |  |Clinical Example (54416) |

| | |The patient is taken to the operating room and given an anesthetic. An infra-pubic incision is made. The tunica|

| | |albuginea is exposed and corporotomies are made. The prostheses are both removed. Measurements are taken and |

| | |new prostheses are selected. On the left side, the distal portion of the corpus is tight and will not accept |

| | |the prosthesis. The distal left corpus is blindly cut with a scissors and then dilated carefully so as not to |

| | |perforate into the urethra. The new prostheses are placed and the corporotomies are closed. The wound is |

| | |closed. |

| | |Description of Procedure (54416) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. The corpora cavernosa are exposed. |

| | |Lateral corporotomies are made. Each prosthesis (right and left) is carefully removed. The proximal corpus |

| | |cavernosum on each side is probed and checked for remaining rear tip extenders. The corporotomies are |

| | |irrigated. The length of each corpus cavernosum from the ischial tuberosity to the glans penis is carefully |

| | |measured. An appropriately sized prosthesis is selected and opened. The corpora are re-dilated to the proper |

| | |diameter. The prosthesis is inserted, an insertion tool and insertion suture may be utilized. Rear tip |

| | |extenders are added as necessary. The prosthesis is checked for fit. The corporotomies are closed with |

| | |absorbable suture. Throughout the procedure the operative field is irrigated with antibiotic spray. The |

| | |subcutaneous tissues are closed. The wound is closed in usual fashion. |

|[pic] |

|54417 |  |Clinical Example (54417) |

| | |The patient is a 67-year-old man who had a multi-component inflatable penile prosthesis placed five months ago.|

| | |Over the past month he has developed low-grade fevers, penile swelling, mild erythema of the penis and scrotum,|

| | |scrotal aching and generalized pelvic discomfort. Two days ago a red area at the left aspect of his infra-pubic|

| | |incision opened and pus drained out. After appropriate exam and testing it is determined that his prosthesis is|

| | |infected. If the infected prosthesis is removed, the "dead space" will scar, making future placement of a new |

| | |prosthesis difficult, if not impossible. Salvage of the prosthesis through an infected field is planned. |

| | |Description of Procedure (54417) |

| | |A Foley catheter is placed. A transverse infra-pubic incision is made. The corpora cavernosa are exposed. |

| | |Lateral corporotomies are made. Each prosthesis (right and left) are carefully removed. The proximal corpus |

| | |cavernosum on each side is probed and checked for remaining rear tip extenders. The corporotomies and entire |

| | |wound are irrigated with 10 liters of a saline solution containing antibiotics for a total of 20 minutes. The |

| | |length of each corpus cavernosum from the ischial tuberosity to the glans penis is carefully measured. An |

| | |appropriately sized prosthesis is selected and opened. The corpora are re-dilated to the proper diameter. The |

| | |prosthesis is inserted, an insertion tool and insertion suture may be utilized. Rear tip extenders are added as|

| | |necessary. The prosthesis is checked for fit. A new pump is selected and placed in the scrotum. A new reservoir|

| | |is placed beneath the rectus muscles. Pump and reservoir spaces are copiously irrigated. Jackson-Pratt drains |

| | |(3.2 mm round) are placed in appropriate areas for post operative irrigation with antibiotic solutions and |

| | |drainage. The corporotomies are closed with absorbable sutures. The rectus muscles are reapproximated. |

| | |Throughout the procedure the operative field is irrigated with antibiotic spray. The subcutaneous tissues are |

| | |closed. Drains are brought out through separate stab wounds and sutured in place. The wound is closed in the |

| | |usual fashion. |

|[pic] |

|54512 |  |Clinical Example (54512) |

| | |A 32-year-old man has a firm, painless 2 cm mass palpable in the right scrotum. The history is unremarkable. |

| | |Tumor markers are negative. Ultrasound is inconclusive, but does show a solid mass adjacent to the testicle. |

| | |Scrotal exploration through a groin incision is planned with frozen section and possible orchiectomy or |

| | |excision of extraparenchymal lesion as may be indicated. |

| | |Description of Procedure (54512) |

| | |Local anesthesia with 0.25% Marcaine is instilled along the intended incision line. A right groin incision is |

| | |made, the external oblique fascia is opened, the ileoinguinal nerve is preserved, the cord is mobilized and a |

| | |Penrose drain tourniquet is placed around the cord; more 0.25% Marcaine is instilled into the cord. The |

| | |testicle is then delivered out of the scrotum and into the wound, still attached to the cord. Towels are used |

| | |to isolate the testis. The tunica vaginalis is opened and the testis and epididymus are palpated and visually |

| | |inspected. A 2 cm firm, fleshy mass is adjacent to the epididymus. Biopsies are taken for frozen section. The |

| | |frozen section returns as a "benign adenomatoid tumor." The mass is then totally excised. Hemostasis is |

| | |achieved. The testis is replaced in normal position. The tourniquet is removed and the wound is irrigated and |

| | |closed. A sterile dressing is applied. |

|[pic] |

|54522 |  |Clinical Example (54522) |

| | |A 28-year-old man has a firm, painful 2 cm mass palpable in the right testicle. There is a history of an |

| | |athletic injury to the right testicle several years ago. Tumor markers are normal. Ultrasound is inconclusive, |

| | |but does show a mass on the anterior surface of the testicle with calcification. Scrotal exploration through a |

| | |groin incision is planned with frozen section and possible orchiectomy or partial orchiectomy as may be |

| | |indicated. |

| | |Description of Procedure (54522) |

| | |Local anesthesia is instilled along the intended incision line. A right groin incision is made, the external |

| | |oblique fascia is opened, the ileoinguinal nerve is preserved, the cord is mobilized and a Penrose drain |

| | |tourniquet is placed around the cord; more anesthetic is instilled into the cord. The testicle is the delivered|

| | |out of the scrotum and into the wound still attached to the cord. Towels are used to isolate the testis. The |

| | |tunica vaginalis is opened and the testis and epididymus are palpated and visually inspected. A 2 cm gritty |

| | |plaque like area is noted. Biopsies are taken for frozen section. The frozen section returns as a "benign |

| | |calcified pseudotumor of the tunica albuginea." The abnormal area is then totally excised. Hemostasis is |

| | |achieved; the tunica albuginea (testicular capsule) is closed with multiple interrupted vertical mattress |

| | |sutures. The testis is replaced in normal position. The tourniquet is removed and the wound is irrigated and |

| | |closed. A sterile dressing is applied. |

|[pic] |

|54692 |  |A 2-year-old boy presents with a right undescended testis. The mother reports that the child has never had a |

| | |palpable testis and was fullterm at birth. Physical examination reveals a closed inguinal ring on the right. |

| | |The left testis does not appear hypertrophied. |

|[pic] |

|55550 |  |A typical patient is a young adult male with or without infertility, who has a varicocele. |

|[pic] |

|55866 |  |Clinical Example (55866) |

| | |A 48-year-old male with a PSA of 3.5 undergoes a prostate biopsy which reveals Gleason 7 adenocarcinoma of both|

| | |lobes. He is counseled on the risks and benefits of surgery versus radiation and chooses laparoscopic radical |

| | |prostatectomy. |

| | |Description of Procedure (55866) |

| | |The patient is taken to the operating room and placed in the modified lithotomy position. The lower abdomen is |

| | |prepped and draped in the standard fashion. A pneumoperitoneum is achieved in the standard fashion and four |

| | |trocars are placed. The laparoscope is introduced and attention is turned to first dissecting the seminal |

| | |vesicles and vas deferens. The peritoneum at the reflection point of the anterior rectum and posterior bladder |

| | |is incised. The vas deferens is identified on each side and then divided. The seminal vesicles are carefully |

| | |dissected out using the harmonic scalpel to divide all bleeding vessels until the structures are completely |

| | |freed. The space just posterior to the seminal vesicles is dissected in order to open Denonvilliers fascia, |

| | |thereby revealing a pre-rectal fat plane. |

| | |Attention is then turned to complete mobilization of the opening of the peritoneum and mobilization of the |

| | |bladder. The median umbilical ligaments and urachus are divided close to the umbilicus. Careful blunt |

| | |dissection is used to reflect the bladder away from the abdominal wall. This exposes the endo-pelvic fascia. |

| | |The fat overlying the endo-pelvic fascia is then cleared off and the endo-pelvic fascia is incised bilaterally |

| | |to free the prostate away from the lateral pelvic side wall. The dorsal vein complex is developed and suture |

| | |ligated. The bladder neck is then opened. The catheter is removed and a curved urethral sound is placed to aid |

| | |in traction of the prostate. This allows identification of the posterior bladder neck, which is then carefully |

| | |dissected away from the base of the prostate. The area of the pedicles of the prostate is then taken down. The |

| | |tissue is opened overlying the seminal vesicles, these structures are then withdrawn into the area of |

| | |dissection and used as traction. Both lateral pedicles are then taken down, up to the level near the apex. The |

| | |dorsal vein complex is then divided. Careful sharp dissection is used around the apex of the prostate. The |

| | |prostate is rocked back and forth and dissection continues along the lateral pedicle plane to define the apex |

| | |of the prostate posteriorly. The urethra is then identified and sharp dissection is used to divide the anterior|

| | |and posterior urethra and the rectourethralis muscle. |

| | |Then the final attachments are undone and the specimen is withdrawn in the endo-cath sac. Hemostasis is |

| | |assured. The vesicourethral anastomosis is performed with interrupted suture. A catheter is placed through the |

| | |anastomosis. A drain is placed through one of the abdominal side ports. All of the four trocar sites are |

| | |inspected, and all surgical sites are inspected at 5 mm Hg pressure before removing the trocars under direct |

| | |vision. |

|[pic] |

|55873 |  |Clinical Example (55873) |

| | |A 62-year-old man with clinically localized prostate cancer, having considered all available treatment options,|

| | |has elected to have cryosurgical ablation of the prostate. |

|[pic] |

|55876 |  |Clinical Example (55876) |

| | |A 68-year-old male was referred to his urologist for a prostate-specific antigen of 6.8. He underwent |

| | |transrectal ultrasound and biopsy of his prostate, which revealed one core of Gleason score 6 adenocarcinoma of|

| | |the prostate. His urologist discussed the alternatives of definitive treatment and the patient elected to |

| | |receive intensity modulated radiation therapy. After consulting with the radiation oncologist, it is decided |

| | |that the patient will have fiducial seeds placed to facilitate the localization of the prostate during |

| | |treatment to avoid contiguous organ injury. |

| | |Description of Procedure (55876) |

| | |The physician takes time to identify the patient. The patient is positioned on his left side (for a |

| | |right-handed urologist) and draped. A digital rectal exam is repeated and the anus is dilated. A transrectal |

| | |ultrasound probe is inserted into the rectum and the prostate is visualized in the transverse and sagittal |

| | |planes. (Ultrasound guidance is reported separately.) Local anesthetic injection is performed both at the base |

| | |and at the apex of the gland to achieve an adequate peripheral nerve block, and at the the perineum to allow a |

| | |cutaneous block for needle introduction. Utilizing ultrasound needle guidance, four preloaded gold fiducial |

| | |markers are introduced and implanted bilaterally at the base and apex of the prostate. The positions of the |

| | |base seeds are confirmed for appropriate distance from the base and the apex. The transrectal probe is removed |

| | |and transrectal pressure is applied. The patient leaves the procedure room in good condition. |

|[pic] |

|56820 |  |Clinical Example (56820) |

| | |A 44-year-old female presents with a one-year history of vulvar irritation and itching. She has a past history |

| | |of human papilloma virus (HPV) changes to Pap smear and has previously undergone cryotherapy of the cervix. Her|

| | |family physician has tried antifungal as well as antibiotic cream preparations and yet her symptoms persist. |

| | |She presents now for further evaluation of the vulva to exclude the process. |

| | |Description of Procedure (56820) |

| | |Colposcopic examination is performed employing a 5% acetic acid staining of the entire vulva. After adequate |

| | |time for the acetic acid effect, the colposcope is then directed at the vulva under appropriate magnification. |

| | |As no suspicious lesions are found, the patient is reassessed and biopsies are not performed. |

|[pic] |

|56821 |  |Clinical Example (56821) |

| | |A 55-year-old woman with a history of vulvar intraepithelial neoplasia complains of vulvar itching. Physical |

| | |examination does not reveal an obvious lesion. She is advised to undergo vulvar colposcopy with biopsies of |

| | |colposcopically abnormal areas of the vulva. |

| | |Description of Procedure (56821) |

| | |The vulva is cleansed several times with 5% acetic acid. Colposcopic examination is done at 7-15 magnification.|

| | |Abnormal area suspicious for cancer is identified. The area is cleansed and locally infiltrated with lidocaine.|

| | |A 3-mm punch biopsy instrument is used to obtain a biopsy. The biopsy site is treated with silver nitrate or |

| | |Monsel's solution. |

|[pic] |

|57022 |  |Clinical Example (57022) |

| | |A 25-year-old womam who recently delivered vaginally has begun complaining of vaginal pain. An examination |

| | |reveals a large hematoma in the vaginal canal. The patient is taken to the operating room and the vaginal wall |

| | |is incised and the hematoma evacuated under anesthesia. |

|[pic] |

|57023 |  |Clinical Example (57023) |

| | |A 28-year-old woman is brought to the emergency room complaining of severe pain following an alleged sexual |

| | |assault. An examination reveals a large hematoma in the vaginal canal. The patient is taken to the operating |

| | |room and the vaginal wall is incised and the hematoma evacuated under anesthesia. |

|[pic] |

|57155 |  |Clinical Example (57155) |

| | |A 49-year-old patient with stage 2 B cervical cancer has completed her external beam radiation and is now |

| | |scheduled for placement of tandems and ovoids for brachytherapy for completion of her radiation therapy. |

| | |Description of Procedure (57155) |

| | |The patient is placed in the lithotomy position and prepped and draped. The cervix is dilated using Hegar |

| | |dilators and the uterus is sounded. A tandem (hollow cylinder) is inserted into the uterus, the other end of |

| | |which protrudes through the vaginal opening. Two ovoids then are placed in the upper part of the vagina, the |

| | |other end of which protrudes through the vaginal opening. The ovoids and tandem are packed carefully in place |

| | |to protect the bladder and rectum from radiation damage and to prevent any movement of the devices. Subsequent |

| | |loading of the radioelement(s) into the cylinders at a later time will deliver a high dose of potentially |

| | |curative radiation to the cervix from an intracavitary location. |

|[pic] |

|57267 |  |Clinical Example (57267) |

| | |A 65-year-old, gravida 4 para 4, female patient presents complaining of vaginal pressure, discomfort, and |

| | |bulging exacerbated by lifting and straining. She has had a previous attempt at repair of rectocele and has no |

| | |history of urinary incontinence. Her past medical history is negative. Her pertinent physical examination |

| | |reveals a significant loss of support of the rectum to 2 cm beyond the hymen. Vaginal apical support is |

| | |adequate but the intervening native, endopelvic, fascial, supportive tissues are very poor. The surgeon |

| | |considers them inadequate to provide future support alone. He/she performs rectocele repair. Because of the |

| | |lack of reasonable tissue strength, the surgeon inserts a prosthetic graft over the native tissues to buttress |

| | |the weak endopelvic fascia between the vagina and rectum. |

| | |Description of Procedure (57267) |

| | |The physician examines the vaginal defect. He/she prepares the surgical graft material and cuts the graft |

| | |material to the correct size. Next, dissection deep in the pelvis is done to identify ischial spines and |

| | |surrounding ligamentous tissues for attachment. The sutures are placed deep into the pelvis beyond the vaginal |

| | |apex for initial attachment. The graft is attached to the stay sutures and tied to suspend deep in the pelvis. |

| | |Several subsequent sutures are placed in the graft in the levator muscles and the lateral vagina and attached |

| | |to the graft along the full length of the vagina bilaterally. Additional sutures are placed through the distal,|

| | |perineal muscles and the graft to attach to the distal vagina. The excess vaginal epithelium is resected and |

| | |irrigated copiously. The remaining vaginal epithelium is closed with running suture. Finally, the vagina is |

| | |packed with gauze. |

|[pic] |

|57282 |  |Clinical Example (57282) |

| | |A 62-year-old, gravida 3, para 3, female patient presents complaining of vaginal pressure, discomfort, and |

| | |heaviness, as well as vaginal bulging exacerbated by lifting and prolonged standing. There is no history of |

| | |incontinence, but she has some bladder pressure and urinary frequency. Her past medical history is negative. |

| | |Her pertinent physical examination reveals significant prolapse of the vaginal apex to 3 cm beyond the hymen. |

| | |There is also moderate loss of support of the bladder (cystocele), rectum (rectocele), and an enterocele is |

| | |present. The physician is trained in pelvic reconstructive surgery and performs suspension of the vaginal apex |

| | |to the sacrospinous or iliococcygeus ligaments. Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, |

| | |iliococcygeus), as well as repair of cystocele, rectocele and enterocele. |

| | |Description of Procedure (57282) |

| | |Pre-service activities consist of hospital admission, history and physical examination, record review, chart |

| | |preparation, review of laboratory tests, pre-operative discussion and evaluation, waiting time, scrub time, |

| | |positioning of the patient, checking equipment, and waiting time during anesthesia induction. |

| | |A vaginal colpopexy is a procedure developed to correct the defect in the support of the vaginal apex. This can|

| | |occur in association with uterine prolapse or after hysterectomy. Available ligamentous structures in the |

| | |pelvis which are accessible via the extra-peritoneal approach through the vagina include the sacrospinous |

| | |ligament(s) and the iliococcygeus ligament(s). Access to these structures is via dissection into the |

| | |para-rectal space posteriorly or the para-vesical space anteriorly; both of these are via an extra-peritoneal |

| | |route. To complete the vaginal colpopexy, permanent sutures are placed through these pelvic ligaments and then |

| | |through the apex of the vagina inclusive of the anterior and/or posterior endopelvic fascia and tied to suspend|

| | |the vagina deep into the pelvis to a more normal position and reduce and repair the apical prolapse. The |

| | |operator must be completely knowledgeable of the anatomy of the entire pelvic region to avoid hemorrhage and |

| | |potential damage to vital structures, blood vessels and nerves within the operative field. |

| | |The physician writes orders for post-operative care, accompanies the patient to the recovery room, and speaks |

| | |with the patient's family members. The patient is visited in the hospital until discharged. She returns for |

| | |office visits during the global period. |

|[pic] |

|57283 |  |Clinical Example (57283) |

| | |A 71-year-old, gravida 3, para 3, female patient presents complaining of vaginal pressure, discomfort, and |

| | |heaviness as well as vaginal bulging exacerbated by lifting and prolonged standing. There is no history of |

| | |incontinence but she has some bladder pressure and urinary frequency. Her past medical history is negative. Her|

| | |pertinent physical examination reveals significant inversion of the vaginal apex 2 cm beyond the level of the |

| | |hymen. In addition, an enterocele is demonstrated at the vault of the apex. The physician is trained in pelvic,|

| | |reconstructive surgery and performs transvaginal colpopexy with entrance into the peritoneal cavity through the|

| | |enterocele sac and bilateral attachment of the vaginal apex (anterior and posterior, endopelvic fascia) to the |

| | |uterosacral ligaments or levator musculature with enterocele repair. |

| | |Description of Procedure (57283) |

| | |The physician first examines the vaginal defect. He/she then opens the vaginal mucosa at the apex of the |

| | |vagina. Next the anterior and posterior endopelvic fascia is dissected away from the mucosa exposing the |

| | |enterocele. The peritoneum is identified and entered sharply under direct visualization. The bowel is retracted|

| | |away and packed with a laparotomy towel. Then the ureters are identified and palpated bilaterally. The |

| | |uterosacral ligaments are identified on each side. The uterosacral ligaments high in the pelvis are grasped |

| | |with clamps and placed on traction. Next, a series of interrupted sutures is placed through the uterosacral |

| | |ligaments on both sides. A culdeplasty is performed to obliterate the culdesac. The physician brings the |

| | |sutures through the exposed anterior (pubocervical) and posterior (rectovaginal) endopelvic fascia. Then the |

| | |sutures are tied to suspend the vagina deep in the pelvis. The vaginal vault is closed with interrupted |

| | |sutures. A catheter is placed and left in for bladder drainage. Finally, the vagina is packed with gauze. |

|[pic] |

|57287 |  |Clinical Example (57287) |

| | |A 58-year-old woman with stress urinary incontinence had undergone a transvaginal sling procedure utilizing |

| | |synthetic material. One year postoperatively, she develops urinary retention and sling removal is recommended. |

| | |Description of Procedure (57287) |

| | |A left vaginal incision is performed in the anterior vaginal vault lateral to the urethra and carried down to |

| | |the graft material. The graft material is mobilized from the surrounding tissue to the level of the endopelvic |

| | |fascia. The same dissection is carried out on the contralateral side. The graft material is then mobilized |

| | |underneath the urethra and the graft removed. The wounds are closed with absorbable sutures and the patient is |

| | |placed on post-operative antibiotics. |

|[pic] |

|57295 |  |Clinical Example |

| | |A 65-year-old Gravida 4 Para 4 female patient complains of vaginal discharge, discomfort, and painful |

| | |intercourse. She underwent abdominal sacral colpopexy using mesh about 1 year ago, which was uncomplicated. Her|

| | |past medical history is negative. Her pertinent physical examination reveals mesh eroding through the apex of |

| | |the vagina. Vaginal apical support is adequate. The surgeon decides that excision is necessary and performs |

| | |this via the vaginal route. |

| | |Description of Procedure |

| | |Access to the vaginal apex is achieved using deep vaginal retractors. Dissection around the eroding mesh is |

| | |performed sharply. Care is taken not to dissect too deeply to avoid entering the bladder or rectum. The vaginal|

| | |epithelium is dissected sharply around the eroding mesh, creating a plane between the vaginal epithelium and |

| | |the endopelvic fascia. This dissection is taken circumferentially about 2 cm. The eroding mesh is grasped |

| | |placing tension outward. All of the eroding material is excised sharply, being careful to avoid the rectum, |

| | |bladder, and small bowel. Once the excision is complete, the remaining edges of the endopelvic fascia are |

| | |re-approximated with delayed absorbable sutures and the vaginal epithelium is also closed in layers. Irrigation|

| | |is carried out and a urinary catheter and vaginal packing is placed to complete the procedure. |

|[pic] |

|57296 |  |Clinical Example (57296) |

| | |A 65-year-old Gravida 4 Para 4 female presents with complaints of vaginal discharge, discomfort, and painful |

| | |intercourse. She had an abdominal sacral colpopexy using mesh approximately 1 year ago. Physical examination |

| | |reveals mesh eroding through the apex of the vagina. The surgeon decides that excision is necessary and |

| | |performs this procedure via the abdominal route. |

| | |Description of Procedure (57296) |

| | |Access to the pelvis is achieved via laparotomy. Dissection into the pelvis is achieved sharply. The vaginal |

| | |tissue may be elevated by the surgeon's free hand introduced vaginally, or by an instrument placed within the |

| | |vaginal cavity. The graft is identified and the peritoneum is opened over it. Sharp dissection at the area of |

| | |graft attachment to the vagina is performed. Care is taken during dissection to avoid entering the bladder or |

| | |rectum. The vaginal epithelium is dissected sharply around the eroding mesh, creating a plane between the |

| | |vaginal epithelium and the endopelvic fascia. This dissection is taken circumferentially about 2 cm and the |

| | |graft with attached tissue is removed. All of the eroding material is excised sharply, taking care to avoid the|

| | |rectum, bladder, and small bowel. Once the excision is complete, the remaining edges of the endopelvic fascia |

| | |are reapproximated with delayed absorbable suture, and the vaginal epithelium is closed in layers. The portion |

| | |of the graft that is attached to the presacral ligament is then identified. Again, sharp dissection is |

| | |completed with care to avoid the presacral and perisacral vasculature. The graft is removed, as are the |

| | |permanent sutures that were used to attach it. Skin wounds and vaginal mucosa are reapproximated. Irrigation is|

| | |carried out and a urinary catheter is placed. To complete the procedure, the abdominal incision is closed in |

| | |layers in the usual manner prior to the approximation of the skin edges. |

|[pic] |

|57420 |  |Clinical Example (57420) |

| | |A 42-year-old female has a Pap smear test result showing atypical cells of undetermined significance. The |

| | |physician cannot rule out dysplasia. Three years ago she was treated with a radical hysterectomy and adjuvant |

| | |radiation therapy for Stage IB squamous carcinoma of the cervix. She now presents for colposcopic evaluation of|

| | |the entire vagina. |

| | |Description of Procedure (57420) |

| | |Acetic acid is applied to the entire vagina. After adequate time for acetic acid effect, all vaginal surfaces |

| | |are evaluated with a colposcope at several magnifications. Colposcopic evaluation shows no evidence of |

| | |neoplastic or pre-neoplastic changes, and the abnormal cytologic changes are interpreted as being due to |

| | |radiation effect. Accordingly, biopsies are not performed. |

|[pic] |

|57421 |  |Clinical Example |

| | |A 42-year-old female has a Pap smear showing a high-grade squamous intraepithelial lesion. Three years ago, she|

| | |had a radical hysterectomy for stage IB squamous cell carcinoma of the cervix. Acetic acid is applied to the |

| | |vagina. Colposcopic examination of the entire vagina is performed. An area of aceto white changes is |

| | |identified. The area is infiltrated with 1% lidocaine and a biopsy is obtained under colposcopic guidance. |

| | |Hemostasis is obtained with silver nitrate or monsol solution. |

| | |Description of Procedure |

| | |Acetic acid is applied to the entire vagina. After adequate time for acetic acid effect, surfaces of the vagina|

| | |are evaluated with the colposcope at several magnifications. Colposcopic evaluation reveals a suspicious lesion|

| | |at the vaginal cuff and a second area in the mid-vagina. Both areas are injected with local anesthetic, |

| | |biopsies are taken, and bleeding is controlled with Monsel’s solution or silver nitrate. |

|[pic] |

|57425 |  |Clinical Example (57425) |

| | |A 63-year-old sexually active Gravida 5, Para 5 (G5P5) underwent abdominal hysterectomy 20 years ago for |

| | |leiomyomata. She developed a symptomatic cystocele and rectocele and was treated with anterior and posterior |

| | |repair 3 years ago. Now she is being evaluated for pelvic and vaginal pressure-like discomfort and tissue |

| | |prolapsing through the introitus. Examination documents prolapse of the vaginal vault through the introitus and|

| | |good anterior and posterior support. A colpopexy is required. The physician is trained in operative laparoscopy|

| | |and a laparoscopic approach is planned. |

| | |Description of Procedure (57425) |

| | |The "Y" Graft is prepared by suturing two pieces of mesh. A standard laparoscopic entry is made into the |

| | |peritoneal cavity. The abdominal cavity is inspected and explored. A vaginal probe is placed for manipulation |

| | |of the vault. Adhesiolysis is carried out to gain access to the vaginal apex. The peritoneum is incised over |

| | |the vaginal apex. The vesicovaginal space is developed and the bladder is mobilized inferiorly, exposing the |

| | |pubocervical fascia anteriorly. The rectovaginal space is developed and the rectum is mobilized inferiorly, |

| | |exposing the rectovaginal fascia posteriorly. A culdeplasty (Halban or McCall) is performed to obliterate the |

| | |cul de sac, preventing future bowel entrapment. The graft is secured anteriorly and posteriorly to the |

| | |pubocervical and rectovaginal fascia respectively. The peritoneum overlying the sacral promontory is opened and|

| | |extended down to the superior margin of the culdeplasty. Presacral dissection is carried out to expose the |

| | |anterior longitudinal ligament of the sacrum. The presacral vessels are carefully ligated. The graft is sized |

| | |and secured to the anterior longitudinal ligament of the sacrum. The peritoneum is closed over the entire graft|

| | |to prevent internal hernia and mesh adhesion to the bowel. The trocar sites are closed at the fascia. The skin |

| | |incisions are closed. |

|[pic] |

|57452 |  |Clinical Example (57452) |

| | |A 30-year-old woman with a mildly abnormal Pap smear result is advised to undergo colposcopic visualization of |

| | |the cervix. She is advised that a biopsy will be obtained if a lesion is identified. |

| | |Description of Procedure (57452) |

| | |The cervix including the upper/adjacent vagina is cleaned several times with 3% acetic acid. After adequate |

| | |time for acetic acid effect, the cervix and vaginal fornices are examined with a colposcope at several |

| | |magnifications. The transformation zone (area at risk for cervical cancer) is seen completely and no |

| | |colposcopically abnormal areas are identified. Accordingly, no biopsy procedure is performed. |

|[pic] |

|57454 |  |Clinical Example (57454) |

| | |A 30-year-old female with an abnormal Pap smear is advised to undergo colposcopic visualization of the cervix. |

| | |She is advised that a biopsy will be obtained if a lesion is identified. |

| | |Description of Procedure (57454) |

| | |The cervix including the upper/adjacent vagina is cleaned several times with 3% acetic acid. After adequate |

| | |time for acetic acid effect, the cervix and vaginal fornices are examined with a colposcope at several |

| | |magnifications. The transformation zone (area at risk for cervical cancer) is seen completely and abnormal |

| | |acetowhite areas are noted at 12 o'clock extending into the endocervical canal. An endocervical curettage and a|

| | |cervical biopsy at 12 o'clock are performed. The biopsy site is treated with Monsel's solution or silver |

| | |nitrate for hemostasis. |

|[pic] |

|57455 |  |Clinical Example (57455) |

| | |A 27-year-old female has a Pap smear test result of epithelial cell abnormality. The descriptive report |

| | |includes any of the following: atypical squamous cells of undetermined significance (ASCUS), possible HPV, |

| | |dysplasia; low-grade squamous intraepithelial lesion encompassing HPV, mild dysplasia, CIN I; any reference to |

| | |moderate or high-grade dysplasia, CIN III, or invasive carcinoma. |

| | |Description of Procedure (57455) |

| | |The cervix including the upper/adjacent vagina is cleaned several times with 3% acetic acid. After adequate |

| | |time for acetic acid effect, the cervix and vaginal fornices are examined with a colposcope at several |

| | |magnifications. An adequate exam views the entire transformation zone (area at risk for cervical cancer). An |

| | |abnormality consisting of leukoplakia, mosaicism, punctation, or atypical vessels is noted during exam. |

| | |Abnormal acetowhite areas are noted at 12 o'clock not extending into the endocervical canal. A cervical biopsy |

| | |at 12 o'clock is done. The biopsy site is treated with Monsel's solution or silver nitrate for hemostasis. |

|[pic] |

|57456 |  |Clinical Example (57456) |

| | |A 27-year-old female has a Pap smear test result of epithelial cell abnormality. The descriptive report |

| | |includes any of the following: ASCUS, possible HPV, dysplasia; low-grade squamous intraepithelial lesion |

| | |encompassing HPV, mild dysplasia, CIN I; any reference to moderate or high-grade dysplasia, CIN III, or |

| | |invasive carcinoma. |

| | |Description of Procedure (57456) |

| | |The cervix including the upper/adjacent vagina is cleaned several times with 3% acetic acid. After adequate |

| | |time for acetic acid effect, the cervix and vaginal fornices are examined with a colposcope at several |

| | |magnifications. A suspicious lesion is noted in the endocervical canal. The exocervix is completely normal. An |

| | |endocervical curettage is done under direct colposcopic visualization. |

|[pic] |

|57460 |  |Clinical Example (57460) |

| | |A 25-year-old woman with an abnormal Pap smear is advised to undergo colposcopic visualization of the cervix. |

| | |She is advised that a biopsy will be obtained if a lesion is visualized. |

| | |Description of Procedure (57460) |

| | |The cervix including upper/adjacent vagina is cleaned several times with 3% acetic acid. After adequate time |

| | |for acetic acid effect, the cervix and vaginal fornices are examined with a colposcope at several |

| | |magnifications. A suspicious lesion is noted in the endocervical canal. The exocervix is completely normal. An |

| | |endocervical curettage is done under direct colposcopic visualization. |

|[pic] |

|57461 |  |Clinical Example (57461) |

| | |A 31-year-old female patient previously underwent a colposcopic evaluation following a Class IV Pap smear. She |

| | |was found to have CIN III, extending into the endocervix. |

| | |Description of Procedure (57461) |

| | |The cervix is cleansed several times with 3% acetic acid. After adequate time for acetic acid effect, the |

| | |cervix and vaginal fornices are examined with a colposcope at several magnifications. The size of the lesion is|

| | |determined. A grounding pad is placed. A Teflon-coated speculum is hooked up to suction. The cervix is |

| | |infiltrated from 1-12 o'clock with lidocaine. An appropriate-sized loop electrode is then used to ensure |

| | |excision of the lesion on the ectocervix with adequate margins. A second loop is then utilized to remove the |

| | |involved portion of the endocervix. At the conclusion of the excision, a curette is used to sample the upper |

| | |boundary of the excision to assure complete removal of the dysplasia. Homeostasis is achieved with |

| | |electrocautery and topical Monsel's solution. |

|[pic] |

|58110 |  |Clinical Example |

| | |A 48-year-old female presents for evaluation of an abnormal cervical cytology result that shows “atypical |

| | |glandular cells.” An interval history and physical examination, including a pelvic exam, is performed. |

| | |Colposcopy of the cervix is performed, and the exocervix appears normal. In order to evaluate the patient for a|

| | |lesion in either the endocervix or endometrium, both an endocervical curettage and an endometrial biopsy are |

| | |performed to determine the source of the atypical glandular cells in the lower genital tract. |

| | |Note: Survey results for 58100 were used to develop this recommendation. |

| | |Description of Procedure |

| | |Since the speculum has already been properly positioned, the physician work for this add-on begins by prepping |

| | |the cervix with an antiseptic solution. The anterior lip of the cervix is grasped with a tenaculum and the |

| | |uterus is sounded with a uterine sound to gauge the depth of the endometrial cavity. The endometrial curette is|

| | |passed through the cervix to the fundus of the uterus. The endometrial biopsy is performed in four quadrants by|

| | |applying suction with a syringe attached to the hollow curette. Three passes with the suction curette are |

| | |typically performed. The curette is withdrawn and the tissue is placed in formalin. The tenaculum is removed. |

| | |Pressure is applied to the cervix to control any postoperative bleeding. The speculum is removed and the |

| | |patient is taken down from the lithotomy position. |

|[pic] |

|58140 |  |Clinical Example (58140) |

| | |A 37-year-old, gravida 1 para 0 woman is referred for abnormal uterine bleeding causing anemia. The patient has|

| | |been treated pharmacologically and has received a dilatation and curettage during the past year without |

| | |success. The patient has also experienced heavier and longer menses and dysmenorrhea over the past 6 months. |

| | |Multiple scattered intramural and subserosal myomata ranging in size from 1 cm to 8 cm were documented by |

| | |ultrasonography. The patient is given treatment alternatives and still desires childbearing. A myomectomy is |

| | |indicated and the abdominal approach is recommended because of the location of the fibroids. |

| | |Description of Procedure (58140) |

| | |Under general anesthesia the abdomen is entered through a midline incision. An exploratory laparotomy is |

| | |performed. The fibroid is identified. An incision is made in the overlying serosa and myometrium down to the |

| | |level of the fibroid. The fibroid is dissected free. The myometrial defect is closed in multiple layers. The |

| | |serosa is closed with fine suture to try to decrease the rise of post operative adhesion formation. The |

| | |abdominal wall is closed in a routine fashion. |

|[pic] |

|58146 |  |Clinical Example (58146) |

| | |A 35-year-old, nulligravid patient is evaluated for menorrhagia with anemia. She is recently married and is |

| | |anxious to have children. On examination she is found to have a 16-week-size fibroid uterus. Ultrasound |

| | |confirms a 15-cm uterus with multiple fibroids distorting the endometrium. Management options are discussed |

| | |with her. The patient expresses a desire to keep fertility options open to her and keep her uterus. The patient|

| | |elects a myomectomy. An abdominal myomectomy is performed. |

| | |Description of Procedure (58146) |

| | |Exam under anesthesia is performed. The patient is prepped and draped in a sterile fashion. A catheter is |

| | |inserted into the bladder. A low transverse abdominal incision is made. This incision provides good exposure |

| | |and allows good assistance and careful isolation of the tumors. A multi-arm self-retaining retractor is |

| | |inserted. A rubber tourniquet is applied to the entire uterine mass. As the uterus is approached, the location |

| | |and direction of the blood supply are assessed. The uterus is also assessed as to how to make as few incisions |

| | |as possible. Vasopressin is injected into the myometrium overlying the fibroids. An incision is made on the |

| | |uterus parallel with the course of the vascular bed. |

| | |Once the first myoma is exposed, it is grasped with a tenaculum. The myoma is dissected free from the |

| | |surrounding myometrium using a combination of sharp and principally blunt dissections. The dissection is |

| | |carried down to the pedicle that contains the main blood supply to the myoma. The pedicle is isolated and |

| | |clamped before the myoma is removed. The patient is found to have eight myomas ranging from 4-cm to 6-cm in |

| | |size. Multiple uterine incisions are utilized to remove all of the intramural fibroids. The physician then |

| | |repairs the multiple uterine incisions that were made during the procedure. Each uterine incision is closed in |

| | |layers to obtain hemostasis and preserve the anatomic relationship. The tourniquet is removed. The uterus is |

| | |observed during reperfusion and additional sutures are placed in each incision to assure complete hemostasis. |

| | |The physician then closes the layers of the abdominal incision. |

|[pic] |

|58260 |  |Clinical Example (58260) |

| | |A 44-year-old patient, gravida 1 para 1, presents with menorrhagia and dysmenorrhea unresponsive to medical |

| | |management. She has failed both oral contraceptives and non-steroidal anti-inflammatory drugs (NSAIDs). On |

| | |examination her uterus is 6-8 weeks' size and boggy. It is somewhat tender to palpation and has limited |

| | |descensus. The patient feels strongly about maintaining her ovarian function but requests hysterectomy since |

| | |her quality of life is significantly impaired by her symptoms. She is therefore scheduled for vaginal |

| | |hysterectomy without removal of the ad nexae. |

| | |Description of Procedure (58260) |

| | |The speculum is inserted into the vaginal canal. The cervix is visualized and the tenaculum is applied. |

| | |Following administration of fluid (saline, local anesthesia, vasoconstrictive agents), the uterus and cervix |

| | |are excised. Following hemostasis, closure and suturing of the vaginal cuff are completed. |

|[pic] |

|58290 |  |Clinical Example (58290) |

| | |A 45-year-old gravida 1 para 1 patient is evaluated for profound menorrhagia with anemia. Her hematocrit is 25%|

| | |despite daily iron therapy and treatment with oral contraceptives. On physical examination she has an |

| | |irregular, mobile 14-week-size fibroid uterus. Ultrasound confirms multiple uterine fibroids, several of which |

| | |impinge on the endometrium. After management options are discussed with her, the patient elects hysterectomy. A|

| | |vaginal hysterectomy is performed. |

| | |Description of Procedure (58290) |

| | |As soon as the patient is under anesthesia, a careful bimanual pelvic examination is conducted. Through this |

| | |examination it is determined that the uterus is clearly mobile; there is surgical accessibility to the lower |

| | |uterine segment; and the size and configuration of the uterine fibroids are determined. |

| | |All of these factors indicate that although it is an enlarged uterus, the conditions are favorable for it to be|

| | |removed transvaginally. |

| | |Since the uterine size greatly limits the surgeon, the surgeon focuses on reducing the uterine size |

| | |intra-operatively to facilitate the vaginal hysterectomy. Once the pelvic examination is complete, the cervix |

| | |is grasped by tenaculums bilaterally. A circumferential incision is made at the junction of the vagina and |

| | |cervix so that the vagina could be reflected upward, thereby freeing the attachments of the bladder to the |

| | |uterus. The anterior and posterior cul-de-sacs are entered. The uterosacral, cardinal, and broad ligaments are |

| | |bilaterally clamped, cut and ligated. The uterus is bisected in an antero-posterior direction with a knife with|

| | |progressive reposition of tenaculums until the fundus is reached. The pedicles are clamped. Bisection assists |

| | |in reducing the tension on the infundibulopelvic ligament. This allows the descent of the uterus and it also |

| | |helps in removal of myomas during the course, thus reducing the bulk of the uterus. Once the uterine fundus can|

| | |be delivered into the vagina, it is removed in multiple separate pieces. |

| | |All procedures are now complete. All pedicles are carefully inspected to assure hemostasis. The peritoneum and |

| | |vaginal cuff are closed. |

|[pic] |

|58291 |  |Clinical Example (58291) |

| | |A 45-year-old gravida 1 para 1 female is evaluated for profound menorrhagia with anemia. Her hematocrit is 25% |

| | |despite daily iron therapy and treatment of oral contraceptives. On physical examination she has an irregular, |

| | |mobile fibroid uterus. Ultrasound confirms multiple uterine fibroids, several of which impinge on the |

| | |endometrium. After management options are discussed with her, the patient elects hysterectomy. The patient has |

| | |a strong history of ovarian cancer in her family and does not desire any more children, so she elects to have |

| | |her tube(s) and ovary(s) removed. An attempt at a vaginal approach is made since the uterus is mobile. |

| | |Description of Procedure (58291) |

| | |As soon as the patient is under anesthesia, a careful bimanual pelvic examination is conducted. Through this |

| | |examination the uterus is found to be clearly mobile; surgical accessibility to the lower uterine segment is |

| | |confirmed; and the size and configuration of the uterine fundus with multiple and discrete predominately |

| | |posterior fundal myomas are determined. |

| | |All of these factors indicate that although it is an enlarged uterus, the conditions are favorable for it to be|

| | |removed transvaginally. |

| | |Since the uterine size greatly limits the surgeon, the surgeon focuses on reducing the uterine size |

| | |intra-operatively to facilitate the vaginal hysterectomy. Once the pelvic examination is complete, the cervix |

| | |is grasped by tenaculums bilaterally. A circumferential incision is made at the junction of the vagina and |

| | |cervix so that the vagina can be reflected upward, thereby freeing the attachments of the bladder to the |

| | |uterus. The uterus is bisected in an antero-posterior direction with a knife with progressive reposition of |

| | |tenaculums until the fundus is reached. The pedicles are clamped. Bisection assists in reducing the tension on |

| | |the infundibulopelvic ligament. This allows the descent of the uterus. It also helps in removal of small myomas|

| | |during the course, thus reducing the bulk of the uterus. These debulking techniques, which are only necessary |

| | |with an enlarged uterus, require an experienced surgeon with good manual dexterity. Once the uterine fundus is |

| | |able to be delivered into the vagina, it is removed in multiple separate pieces. |

| | |Once the uterus is removed, it is noted that the tube(s) and ovary(s) are visible and accessible. This |

| | |indicates favorable conditions to continue with the procedure. The fimbriated end of the fallopian tube is |

| | |incorporated into the utero-ovarian ligament pedicle. The infundibulopelvic ligament is then double-clamped and|

| | |tied and the fallopian tube and ovary are then resected. Both procedures are now complete. A peritoneal |

| | |purse-string suture is done just prior to the vaginal cuff closure. |

|[pic] |

|58292 |  |Clinical Example (58292) |

| | |A 45-year-old gravida 1 para 1 patient is evaluated for profound menorrhagia with anemia. Her hematocrit is 25%|

| | |despite daily iron therapy and treatment with oral contraceptives. On physical examination she has an |

| | |irregular, mobile fibroid uterus. Ultrasound confirms multiple uterine fibroids, several of which impinge on |

| | |the endometrium. After management options are discussed with her, the patient elects hysterectomy. The patient |

| | |has a strong history of ovarian cancer in her family and does not desire any more children, so she elects to |

| | |have her tube(s) and ovary(s) removed. An attempt at a vaginal approach is made since the uterus is mobile. |

| | |Description of Procedure (58292) |

| | |As soon as the patient is under anesthesia, a careful bimanual pelvic examination is conducted. Through this |

| | |examination it is determined that the uterus is clearly mobile; there is surgical accessibility to the lower |

| | |uterine segment; and the size and configuration of the uterine fundus are multiple with discrete predominately |

| | |posterior fundal myomas. All of these factors indicate that although it is an enlarged uterus, the conditions |

| | |are favorable for it to be removed transvaginally. |

| | |Since the uterine size greatly limits the surgeon, the surgeon focuses on reducing the uterine size |

| | |intra-operatively to facilitate the vaginal hysterectomy. Once the pelvic examination is complete, the cervix |

| | |is grasped by tenaculums bilaterally. A circumferential incision is made at the junction of the vagina and |

| | |cervix so that the vagina can be reflected upward, thereby freeing the attachments of the bladder to the |

| | |uterus. The uterus is bisected in an antero-posterior direction with a knife with progressive reposition of |

| | |tenaculums until the fundus is reached. The pedicles are clamped. Bisection assists in reducing the tension on |

| | |the infundibulopelvic ligament allowing the descent of the uterus. It also helps in removal of small myomas |

| | |during the course, thus reducing the bulk of the uterus. These debulking techniques, which are only necessary |

| | |with an enlarged uterus, require an experienced surgeon with good manual dexterity. Once the uterine fundus can|

| | |be delivered into the vagina, it is removed in multiple separate pieces. |

| | |Once the uterus is removed, it is noted that the tube(s) and ovary(s) are visible and accessible. This |

| | |indicates favorable conditions to continue with the procedure. The fimbriated end of the fallopian tube is |

| | |incorporated into the utero-ovarian ligament pedicle. The infundibulopelvic ligament is then double-clamped and|

| | |tied and the fallopian tube and ovary are then resected. |

| | |During the procedure a vaginal enterocele is identified. The enterocele is protruding through the posterior |

| | |vaginal wall. The physician attempts to repair it. The hernia sac is excised and ligated, and the surrounding |

| | |tissues are strengthened and sutured. |

| | |All procedures are now complete. A peritoneal purse-string suture is done just prior to the vaginal cuff |

| | |closure. |

| | |The bladder is suspended by using the Marshall, Marchetti and Krantz (MMK) technique. First, the retropubic |

| | |space is assessed via an abdominal incision. The retropubic space is dissected, cleared and sutures are placed |

| | |through the fibromuscular wall of the paravaginal tissue, lateral to the urethra. The abdomen is closed in |

| | |layers and dressings are applied. All procedures are now complete. A peritoneal purse-string suture is done |

| | |just prior to the vaginal cuff closure. |

|[pic] |

|58293 |  |Clinical Example (58293) |

| | |A 45-year-old gravida 1 para 1 female is evaluated for profound menorrhagia with anemia. Her hematocrit is 25% |

| | |despite daily iron therapy and treatment with oral contraceptives. She also complains of urinary incontinence. |

| | |On physical examination she has an irregular, mobile fibroid uterus. Ultrasound confirms multiple uterine |

| | |fibroids, several of which impinge on the endometrium. After management options are discussed with her, the |

| | |patient elects hysterectomy. An attempt at a vaginal approach with bladder suspension is made since the uterus |

| | |is mobile. |

| | |Description of Procedure (58293) |

| | |As soon as the female is under anesthesia, a careful bimanual pelvic examination is conducted. Through this |

| | |examination it is determined that the uterus is clearly mobile; there is surgical accessibility to the lower |

| | |uterine segment; and the size and configuration of the uterine fundus are multiple with discrete predominately |

| | |posterior fundal myomas. |

| | |All of these factors indicate that although it is an enlarged uterus, the conditions are favorable for it to be|

| | |removed transvaginally. |

| | |Through an incision in the vagina around the cervix, the physician removes the uterus including the cervix. |

| | |Since the uterine size greatly limits the surgeon, the surgeon will focus on reducing the uterine size |

| | |intra-operatively to facilitate the vaginal hysterectomy. Once the pelvic examination is complete, the cervix |

| | |is grasped by tenaculums bilaterally. A circumferential incision is made at the junction of the vagina and |

| | |cervix so that the vagina can be reflected upward, thereby freeing the attachments of the bladder to the |

| | |uterus. The uterus is bisected in an antero-posterior direction with a knife with progressive reposition of |

| | |tenaculums until the fundus is reached. The pedicles are clamped. Bisection assists in reducing the tension on |

| | |the infundibulopelvic ligament. This allows the descent of the uterus. It also helps in removal of small myomas|

| | |during the course thus reducing the bulk of the uterus. These debulking techniques, which are only necessary |

| | |with an enlarged uterus, require an experienced surgeon with good manual dexterity. Once the uterine fundus can|

| | |be delivered into the vagina, it is removed in multiple separate pieces. |

|[pic] |

|58294 |  |Clinical Example (58294) |

| | |A 45-year-old gravida 1 para 1 female is evaluated for profound menorrhagia with anemia. Her hematocrit is 25% |

| | |despite daily iron therapy and treatment with oral contraceptives. On physical examination she has an |

| | |irregular, mobile fibroid uterus. Ultrasound confirms multiple uterine fibroids, several of which impinge on |

| | |the endometrium. After management options are discussed with her, the patient elects hysterectomy. An attempt |

| | |at a vaginal approach is made since the uterus is mobile. |

| | |Description of Procedure (58294) |

| | |As soon as the patient is under anesthesia, a careful bimanual pelvic examination is conducted. Through this |

| | |examination it is determined that the uterus is clearly mobile; there is surgical accessibility to the lower |

| | |uterine segment; and the size and configuration of the uterine fundus are multiple with discrete predominately |

| | |posterior fundal myomas. All of these factors indicate that although it is an enlarged uterus, the conditions |

| | |are favorable for it to be removed transvaginally. |

| | |Since the uterine size greatly limits the surgeon, the surgeon focuses on reducing the uterine size |

| | |intra-operatively to facilitate the vaginal hysterectomy. Once the pelvic examination is complete, the cervix |

| | |is grasped by tenaculums bilaterally. A circumferential incision is made at the junction of the vagina and |

| | |cervix so that the vagina can be reflected upward, thereby freeing the attachments of the bladder to the |

| | |uterus. The uterus is bisected in an antero-posterior direction with a knife with progressive reposition of |

| | |tenaculums until the fundus is reached. The pedicles are clamped. Bisection assists in reducing the tension on |

| | |the infundibulopelvic ligament. This allows the descent of the uterus and it also helps in removal of small |

| | |myomas during the course, thus reducing the bulk of the uterus. These debulking techniques, which are only |

| | |necessary with an enlarged uterus, require an experienced surgeon with good manual dexterity. Once the uterine |

| | |fundus can be delivered into the vagina, it is removed in multiple separate pieces. |

| | |During the procedure a vaginal enterocele is identified. The enterocele is protruding through the posterior |

| | |vaginal wall. The physician repairs it. The hernia sac is excised and ligated, and the surrounding tissues are |

| | |strengthened and sutured. |

| | |All procedures are now complete. A peritoneal purse-string suture is done just prior to the vaginal cuff |

| | |closure. |

|[pic] |

|58346 |  |Clinical Example (58346) |

| | |A 75-year-old patient with severe cardiac disease is diagnosed with uterine cancer. She is found not to be a |

| | |candidate for surgery and the decision is made to treat her cancer with radiation therapy including clinical |

| | |brachytherapy. The patient is scheduled for insertion of Heyman capsules. |

| | |Description of Procedure (58346) |

| | |The patient is placed in the lithotomy position and prepped and draped. The cervix is dilated using Hegar |

| | |dilators and the uterus is sounded. The Heyman (afterloading) capsules are then inserted into the uterine |

| | |cavity. The number of capsules will vary from patient to patient and depends solely on the size of the uterine |

| | |cavity. As few as 4-5 or as many as 12-15 capsules may be inserted. Long tubes connect with capsules to the |

| | |outside of vaginal outlet. The radiation oncologist will apply the radioactive element through these tubes into|

| | |the capsules at the same session or a later session. Subsequent loading of the radio- element(s) into the |

| | |capsules through the connecting tubes at a later time will deliver a high dose of potentially curative |

| | |radiation to the uterine corpus from an intracavitary location. |

|[pic] |

|58353 |  |Clinical Example (58353) |

| | |A 42-year-old premenopausal woman who has completed childbearing was diagnosed with menorrhagia. Pap smear and |

| | |endometrial biopsy were normal. Standard sonography and hysteroscopy indicated that anatomy of the uterine |

| | |cavity was normal (depth, 8 cm), and ruled out submucous fibroids, large polyps, and congenital abnormalities. |

| | |Drug therapy was the initial course of action, but multiple courses of hormone replacement therapy proved |

| | |inadequate. The patient was advised to undergo thermal endometrial ablation. |

| | |Description of Procedure (58353) |

| | |A non-steroidal anti-inflammatory drug (NSAID) is given one hour prior to treatment and continued |

| | |post-operatively as necessary to reduce intra-operative and post-operative uterine cramping. Patient is |

| | |positioned and anesthetized appropriately. System is visually inspected for defects and signs of wear. Balloon |

| | |is pre-filled with 5-10cc of D5W. |

| | |Suction curettage is performed for 3 minutes. Fluid and air are evacuated from the balloon to a negative |

| | |pressure of -150 to -200 mmHg. Negative pressure is maintained for 10 seconds. The cervix is dilated to 5 mm, |

| | |if necessary. Depth of uterus is measured. Balloon catheter is inserted ensuring that the depth indicated is |

| | |consistent with the previous sound measurement. Balloon catheter is filled to pressure of 160-180 mm Hg and |

| | |held at stable pressure for a minimum of 30 seconds. The controller is activated to achieve treatment |

| | |temperature. This cycle may require as much as 4 minutes. The therapy cycle is 8 min. following achievement of |

| | |87°C. At completion of the treatment cycle, the fluid is allowed to cool for 30 seconds. Fluid is removed from |

| | |balloon and balloon is removed from uterus. |

| | |In the operating room, postoperative services include completing the operative record. In the recovery setting,|

| | |the patient is typically monitored for approximately one to two hours and given discharge instructions about |

| | |follow-up care. |

|[pic] |

|58356 |  |Clinical Example (58356) |

| | |The typical patient is a premenopausal woman who presents with menorrhagia due to benign causes and for whom |

| | |childbearing is complete. Appropriately selected patients include women with heavy menstrual bleeding where |

| | |conservative therapy (hormonal therapy and/or dilation and curretage) has failed and hysterectomy is the next |

| | |treatment option considered by her physician. |

| | |Uterine cryoablation therapy is contraindicated in patients with known or suspected endometrial carcinoma or |

| | |premalignant changes in the endometrium, or any anatomic or pathologic condition in which weakness of the |

| | |myometrium could exist. Active genital infection, active pelvic inflammatory disease, active urinary tract |

| | |infection (UTI), or intrauterine device (IUD) currently in place is ruled out. |

| | |Before scheduling a patient for uterine cryoablation therapy, the physician first attempts to determine the |

| | |cause of the woman's abnormal uterine bleeding. The patient's diagnostic work-up includes blood tests to rule |

| | |out any bleeding disorders, thyroid disease, and pregnancy. In addition, the physician obtains visualization of|

| | |the endometrium by vaginal ultrasound, sonohysterogram or diagnostic hysteroscopy. An endometrial biopsy is |

| | |performed, as well as a Pap smear. |

| | |Description of Procedure (58356) |

| | |It is recommended that the lining of the uterine cavity be thinned prior to the cryoablation procedure by |

| | |administering a gonadotropin releasing hormone (GnRH) agonist (Lupron) 21 to 28 days prior to the procedure. If|

| | |a GnRH agonist is not used, cryoablation may be performed any time during the menstrual cycle, but a suction |

| | |curettage may be performed immediately prior to cryoablation to thin the lining. |

| | |The site of service is decided by the physician in consultation with the patient, and can include a hospital |

| | |outpatient, ambulatory surgery center, or physician's office. |

| | |In the hospital, the patient is placed into dorsal lithotomy position. In the office, the patient reclines, |

| | |with her legs placed in stirrups. The patient is prepped and draped in a sterile manner. |

| | |When the procedure is performed in a hospital setting, the patient is typically given intravenous (IV) sedation|

| | |or general anesthesia. In addition, some physicians will perform a paracervical block on the patient. When the |

| | |procedure is performed in an office setting, physicians typically recommend their patients take oral |

| | |medications (eg, non-steroidal anti-inflammatory drugs, diazepam, etc) one hour before the treatment. A topical|

| | |anesthetic spray is sometimes applied to the cervix and cervical canal. A paracervical block is administered. |

| | |The sterile, disposable cryoablation control unit is locked onto the cryoablation console and the sterile drape|

| | |is deployed. The cryoablation console needs to be pre-cooled before starting the procedure. Particularly in the|

| | |office setting, it is important to allow the paracervical block to set in for five to ten minutes before |

| | |starting the procedure. |

| | |A full bladder is required to provide a good backdrop to enhance the ultrasound image of the uterus. For |

| | |patients treated in the hospital, a Foley catheter is typically placed and the bladder is filled. For patients |

| | |in the office setting, many physicians will encourage the patient not to void prior to the procedure to ensure |

| | |an appropriately filled bladder. |

| | |If necessary, a single tooth tenaculum is placed on the anterior cervical lip and the physician applies gentle |

| | |traction to straighten out the uterus. The uterus is sounded; first in the center and then in both cornu to |

| | |determine the symmetrical nature of the cavity. The physician also checks the cervical canal diameter to |

| | |determine passage of the 5.5 mm cryoprobe. At this point, the physician will dilate the cervix to 6.0 mm, if |

| | |dilation is necessary. |

| | |When performed in the hospital, hysteroscopy may be performed. Suction curettage is recommended to thin the |

| | |endometrial lining if pre-treatment with a GnRH agonist was not utilized. |

| | |Probe Placement with Ultrasound Guidance |

| | |The ultrasound probe is placed on the lower abdomen to locate the uterus. The ultrasound is lined up so that |

| | |the longitudinal axis of the uterus is displayed. The physician then applies gentle traction on the tenaculum |

| | |and carefully inserts the cryoprobe into the uterus, through the cervix, observing its path on the ultrasound. |

| | |With the probe gently touching the fundus, the physician notes the appearance of the cryoprobe on the |

| | |ultrasound, ensuring that the probe has not created a false passage or perforated the uterus. The physician |

| | |compares the depth of the cryoprobe to the depth noted when the uterus was sounded, in order to confirm that a |

| | |uterine perforation has not occurred. The procedure is terminated if the uterus is perforated. |

| | |The physician then redirects the tip of the cryoprobe towards one cornu. The ultrasound is repositioned so the |

| | |uterus is viewed in a horizontal axis. The cryoprobe is slowly moved in and out for a distance of about a |

| | |centimeter and its position in the cornu confirmed with the ultrasound. |

| | |The probe placement under ultrasound guidance has similarities to the probe placement that is performed with |

| | |prostate cryoablation procedures. The primary difference is that with prostate cancer, the probe placement is |

| | |performed with multiple probes each placed once, while with cryoablation of the uterus, placement is performed |

| | |multiple times with a single probe. |

| | |First Freeze Monitored with Ultrasound Guidance |

| | |Approximately 5 cc of sterile saline is injected through the bottom injection port of the cryoprobe. The |

| | |injection of saline removes air from the uterus and provides better visualization of the uterine cavity and |

| | |probe placement. |

| | |In order to begin the initial freeze, the physician depresses the "minus" button on the cryoprobe handle. The |

| | |physician maintains the cryoprobe and tenaculum pressure until the cryoprobe tip temperature reaches minus |

| | |60°C. The tension on the cryoprobe and tenaculum are relaxed and gradual expansion of the cryozone is observed |

| | |on the ultrasound. The cryoprobe tip temperature is monitored and shown on the cryoablation console. The tip |

| | |temperature should reach negative 80°C within three minutes of starting the procedure. |

| | |A black area corresponding to the formation of ice along and extending out from the cryoprobe appears. The |

| | |first treatment session lasts for four minutes, or the physician stops the procedure if the cryozone gets |

| | |within 2 mm of the serosa of the uterus. Clinical safety and effectiveness data in the Federal Drug |

| | |Administration (FDA) premarket approval was derived from a four-minute freeze followed by a six-minute freeze; |

| | |however, some physicians may choose to freeze longer, using ultrasound guidance, in order to get more complete |

| | |coverage of the uterus. It is important that the cryozone not extend beyond the serosa of the surface as this |

| | |could cause serious complications associated with freezing adjacent organs and structures. |

| | |Once adequate freezing is achieved, the physician depresses the plus button to stop freezing and to start |

| | |heating the probe. The skills associated with monitoring the extent of the cryozone and deciding on the |

| | |appropriate time to stop treatment are similar to the skills required during a cryoablation of the prostate. |

| | |Remove Cryoprobe and Reposition to Contralateral Cornu |

| | |Once the tip temperature of the cryoprobe reaches positive 20°C, the probe can be removed from the cryozone. |

| | |The physician gently rotates the cryoprobe back and forth and slowly withdraws the cryoprobe from the first |

| | |cryozone. It is not necessary to remove the cryoprobe from the uterus, but it must be withdrawn out to or near |

| | |the internal cervical os. |

| | |The cryoprobe is then repositioned into the contralateral cornu. The cryoprobe is swung 90° (toward the |

| | |patient's opposite leg) to be sure that the cryoprobe is being placed into the contralateral cornu. The |

| | |physician applies gentle traction on the tenaculum and gently slides the cryoprobe next to the initial cryozone|

| | |into the untreated cornu. In repositioning the cryoprobe tip, the initial cryozone is often encountered. If |

| | |resistance is encountered, the cryoprobe is placed on the cryozone, angled toward the targeted cornu, and the |

| | |heater on the cryoprobe is used to melt a pathway for the cryoprobe to be placed into the second cornu. The |

| | |injection of warm saline may also be used to facilitate the passage of the cryoprobe. |

| | |Probe Placement Confirmation |

| | |The physician confirms by ultrasound that the cryoprobe is at the fundus and in the untreated cornu. The |

| | |physician will also use ultrasound to confirm that a perforation has not occurred. The temperature on the |

| | |console should register greater than positive 10°C. If the tip reading is below 10°C, the physician rechecks |

| | |the probe placement to be sure that the cryoprobe has not been placed in the original cryozone. |

| | |Second Freeze Monitored with Ultrasound Guidance |

| | |Approximately 5 cc of sterile saline is injected through the bottom injection port of the cryoprobe. The |

| | |physician maintains counter traction on the tenaculum and depresses the minus button to start the second freeze|

| | |cycle. Once the cryoprobe tip reaches minus 60°C, tension may be relaxed. The physician monitors the developing|

| | |cryozone as previously outlined. Observation of cryozone growth is best viewed through the horizontal plane. |

| | |The physician continues freezing for six minutes or stops if the advancing edge of the cryozone reaches within |

| | |2 mm of the serosa. Again, it is important that the physician monitor the cryozone to ensure it does not extend|

| | |beyond the uterus. The second cryozone should completely merge with the first cryozone, creating one single |

| | |large ice ball. |

| | |Once adequate freezing is achieved, the physician depresses the "plus" button to stop freezing and to start |

| | |heating the probe. At 20°C, the physician rotates the cryoprobe and removes it. |

| | |Alternate Freeze Pattern Third Freeze |

| | |Some physicians may choose to perform a third freeze in the lower uterine segment, particularly for patients |

| | |with a uterus that sounds to larger than 9 cm. |

| | |Procedure Completion and Recovery |

| | |Once all freezes are complete, the cryoprobe is removed. The tenaculum is then removed from the cervix. |

| | |Hemostasis of the cervix is achieved, as necessary. If a Foley catheter has been used, the patient's bladder is|

| | |emptied and the catheter removed. The speculum is removed. The patient is typically sent to a recovery room or |

| | |an appropriate waiting area for observation and recovery from the anesthesia. |

|[pic] |

|58541 |  |Clinical Example (58541) |

| | |A 35-year-old G3P3 female with chronic, anovulatory bleeding is evaluated for profound menorrhagia with anemia.|

| | |Her hematocrit is 25% despite daily iron therapy and treatment with oral contraceptives. On physical |

| | |examination she has a mobile, normal-sized uterus. After management options are discussed with her, the patient|

| | |elects a hysterectomy. She denies any recent history of abnormal pap smears. The patient wishes to preserve her|

| | |cervix; therefore, a laparoscopic supracervical hysterectomy (LSH) is performed without removal of the adnexae.|

| | |Description of Procedure (58541) |

| | |A pelvic examination is performed with the patient under anesthesia to confirm the positioning of the uterus. A|

| | |surgical prep of the vagina and abdomen is performed and a catheter is placed transurethrally. The physician |

| | |then places a speculum into the vagina and inserts an instrument through the vagina to grasp the cervix and |

| | |manipulate the uterus during surgery. Next, the surgeon makes a small incision just below the umbilicus through|

| | |which a needle is inserted and the abdomen insufflated. A trocar is placed and the laparoscope is inserted. |

| | |Second, third, and sometimes fourth incisions are made in the lower parts of the abdomen and additional |

| | |instruments are placed through these incisions. The bladder peritoneum is opened and the bladder is dissected |

| | |off of the lower uterine segment. The attachments of the uterus are sequentially coagulated or ligated and |

| | |transected. If necessary, myomectomies of individual fibroids may be undertaken in order to debulk the size of |

| | |the uterus in order to safely continue to dissect the uterine attachments. These fibroids are suture-tagged for|

| | |later removal via morcellation. The uterine arteries are skeletonized and control of this vasculature is |

| | |obtained. At this point, the uterine body is separated from the cervix. The endocervical canal is coagulated. |

| | |Hemostasis of the cervical stump is obtained. A morcellator is inserted through one of the incisions and |

| | |morcellation of the uterine body is undertaken. Once the specimen has been completely removed, the abdominal |

| | |cavity is deflated, and the instruments and trocars are removed. The trocar sites are closed with sutures at |

| | |the level of both the fascia and the skin. |

|[pic] |

|58542 |  |Clinical Example (58542) |

| | |A 45-year-old G3P3 female with chronic, anovulatory bleeding is evaluated for profound menorrhagia with anemia.|

| | |Her hematocrit is 25% despite daily iron therapy and treatment with oral contraceptives. On physical |

| | |examination she has a mobile, normal-sized uterus. After management options are discussed with her, the patient|

| | |elects a hysterectomy. She denies any recent history of abnormal pap smears. The patient has a strong family |

| | |history for malignancy and elects to have her ovaries removed. The patient wishes to preserve her cervix; |

| | |therefore, a laparoscopic supracervical hysterectomy (LSH) with bilateral salpingo-oophorectomy is performed. |

| | |Description of Procedure (58542) |

| | |A pelvic examination is performed with the patient under anesthesia to confirm the positioning of the uterus. A|

| | |surgical prep of the vagina and abdomen is performed and a catheter is placed transurethrally. The physician |

| | |then places a speculum into the vagina and inserts an instrument through the vagina to grasp the cervix and |

| | |manipulate the uterus during surgery. Next, the surgeon makes a small incision just below the umbilicus through|

| | |which a needle is inserted and the abdomen insufflated. A trocar is placed and the laparoscope is inserted. |

| | |Second, third, and sometimes fourth incisions are made in the lower parts of the abdomen and additional |

| | |instruments are placed through these incisions. The bladder peritoneum is opened and the bladder is dissected |

| | |off of the lower uterine segment. The location and course of the ureters are identified and the leaves of the |

| | |broad ligament opened. The vasculature of the infundibulopelvic ligament is isolated, secured, and transected. |

| | |The attachments of the uterus are sequentially coagulated or ligated and transected. If necessary, myomectomies|

| | |of individual fibroids may be undertaken in order to debulk the size of the uterus in order to safely continue |

| | |to dissect the uterine attachments. These fibroids are suture-tagged for later removal via morcellation. The |

| | |uterine arteries are skeletonized and control of this vasculature is obtained. At this point, the uterine body |

| | |is separated from the cervix. The endocervical canal is coagulated. Hemostasis of the cervical stump is |

| | |obtained. A morcellator is inserted through one of the incisions and morcellation of the uterine body is |

| | |undertaken. Once the specimen has been completely removed, the abdominal cavity is deflated, and the |

| | |instruments and trocars are removed. The trocar sites are closed with sutures at the level of both the fascia |

| | |and the skin. |

|[pic] |

|58543 |  |Clinical Example (58543) |

| | |A 32-year-old G3P2 female is evaluated for profound menorrhagia with anemia. Her hematocrit is 25% despite |

| | |daily iron therapy and treatment with oral contraceptives. On physical examination, she has an irregular, |

| | |mobile, 14-week sized, enlarged uterus. After management options are discussed with her, the patient elects a |

| | |hysterectomy and wishes to preserve her cervix. She denies any recent history of abnormal pap smears. Due to |

| | |her previous surgeries that make the vaginal route more risky, a laparoscopic supracervical hysterectomy (LSH) |

| | |is performed without removal of the adnexae. |

| | |Description of Procedure (58543) |

| | |A pelvic examination is performed with the patient under anesthesia to confirm the positioning of the uterus. A|

| | |surgical prep of the vagina and abdomen is performed and a catheter is placed transurethrally. The physician |

| | |then places a speculum into the vagina and inserts an instrument through the vagina to grasp the cervix and |

| | |manipulate the uterus during surgery. Next, the surgeon makes a small incision just below the umbilicus through|

| | |which a needle is inserted and the abdomen is insufflated. A trocar is placed and the laparoscope is inserted. |

| | |Second, third, and sometimes fourth incisions are made in the lower parts of the abdomen and additional |

| | |instruments are placed through these incisions. The bladder peritoneum is opened and the bladder is dissected |

| | |off of the lower uterine segment. The attachments of the uterus are sequentially coagulated or ligated and |

| | |transected. If necessary, myomectomies of individual fibroids may be undertaken in order to debulk the size of |

| | |the uterus in order to safely continue to dissect the uterine attachments. These fibroids are suture-tagged for|

| | |later removal via morcellation. The uterine arteries are skeletonized and control of this vasculature is |

| | |obtained. At this point, the uterine body is separated from the cervix. The endocervical canal is coagulated. |

| | |Hemostasis of the cervical stump is obtained. A morcellator is inserted through one of the incisions and |

| | |morcellation of the uterine body is undertaken. Once the specimen has been completely removed, the abdominal |

| | |cavity is deflated, and the instruments and trocars are removed. The trocar sites are closed with sutures at |

| | |the level of both the fascia and the skin. |

|[pic] |

|58544 |  |Clinical Example (58544) |

| | |A 46-year-old G3P2 female is evaluated for profound menorrhagia with anemia. She is anemic despite daily iron |

| | |therapy and a history of a prior deep vein thrombosis precludes treatment with oral contraceptives. On physical|

| | |examination, she has an irregular, mobile, 14-week sized, enlarged uterus. After management options are |

| | |discussed with her, the patient elects a hysterectomy. After discussing the risks and benefits, she desires |

| | |preservation of her cervix and wishes to have her ovaries removed. She denies any recent history of abnormal |

| | |pap smears. Due to her previous surgeries that make the vaginal route more risky, a laparoscopic supracervical |

| | |hysterectomy (LSH) with bilateral salpingo-oophorectomy is performed. |

| | |Description of Procedure (58544) |

| | |A pelvic examination is performed with the patient under anesthesia to confirm the positioning of the uterus. A|

| | |surgical prep of the vagina and abdomen is performed and a catheter is placed transurethrally. The physician |

| | |places a speculum into the vagina and inserts an instrument through the vagina to grasp the cervix and |

| | |manipulate the uterus during surgery. Next, the surgeon makes a small incision just below the umbilicus through|

| | |which a needle is inserted and the abdomen is insufflated. A trocar is placed and the laparoscope is inserted. |

| | |Second, third, and sometimes fourth incisions are made in the lower parts of the abdomen and additional |

| | |instruments are placed through these incisions. The bladder peritoneum is opened and the bladder is dissected |

| | |off of the lower uterine segment. The location and course of the ureters are identified and the leaves of the |

| | |broad ligament opened. The vasculature of the infundibulopelvic ligament is isolated, secured, and transected. |

| | |The attachments of the uterus are sequentially coagulated or ligated and transected. If necessary, myomectomies|

| | |of individual fibroids may be undertaken in order to debulk the size of the uterus in order to safely continue |

| | |to dissect the uterine attachments. These fibroids are suture-tagged for later removal via morcellation. The |

| | |uterine arteries are skeletonized and control of this vasculature is obtained. At this point, the uterine body |

| | |is separated from the cervix. The endocervical canal is coagulated. Hemostasis of the cervical stump is |

| | |obtained. A morcellator is inserted through one of the incisions and morcellation of the uterine body is |

| | |undertaken. Once the specimen has been completely removed, the abdominal cavity is deflated, and the |

| | |instruments and trocars are removed. The trocar sites are closed with sutures at the level of both the fascia |

| | |and the skin. |

|[pic] |

|58545 |  |Clinical Example (58545) |

| | |A 35-year-old nulligravid patient is evaluated for menorrhagia with anemia. She is recently married and anxious|

| | |to have children. On examination she is found to have a 16-week-size fibroid uterus. Ultrasound confirms a |

| | |15-cm uterus with multiple fibroids distorting the endometrium. Management options are discussed with her. The |

| | |patient expresses a desire to keep her fertility options open and keep her uterus. The patient elects a |

| | |myomectomy. An attempt at a laparoscopic myomectomy is made since her physician is trained and experienced in |

| | |this procedure and the patient wishes to take advantage of the benefits of the laparoscopic approach. |

| | |Description of Procedure (58545) |

| | |The physician places an instrument transvaginally that will facilitate manipulating the uterus in the |

| | |forth-coming procedure. A small incision is then made just below the umbilicus and a laparoscope is inserted. |

| | |Additional incisions are made in the lower quadrants of the abdomen depending on the location of the myomas. |

| | |Additional instruments are inserted as needed. The physician manipulates the uterine manipulator as well as the|

| | |laparoscopic instruments so the pelvic organs can be comprehensively inspected. The patient is found to have |

| | |several myomas ranging from 4 to 6 cm in size. Hemostatic techniques are employed such as the use of a harmonic|

| | |scalpel or injection of vasopressin to minimize blood loss during the forth-coming myomectomy. |

| | |The myomas must then be surgically excised from the body of the uterus. Each of them is tagged to facilitate |

| | |retrieval. Next, the surgical site from which the myomas have been excised must be repaired. Depending on the |

| | |depth of the myoma, this may require a multi-layer or single-layer closure. This is performed using a |

| | |laparoscopic suturing technique. After repair of the uterine sites of myoma excision, the myomas themselves |

| | |must then be removed from the abdominal cavity. Several techniques can be employed from morcellation to piece |

| | |meal extraction or vaginal colpotomy and removal. Once the operation is complete, the abdomen is deflated, the |

| | |trocars are removed, and the abdominal incisions are closed with sutures. |

|[pic] |

|58548 |  |Clinical Example (58548) |

| | |A 52-year-old female presents with postcoital bleeding and an abnormal Pap smear. On speculum examination, the |

| | |patient is found to have a 2-cm exophytic cervical lesion, which on cervical biopsy is confirmed to be invasive|

| | |squamous cell cancer. On bimanual examination, the cervical cancer appears confined to the cervix without |

| | |parametrial extension. Computed tomography scans of the chest, abdomen, and pelvis show no evidence of |

| | |extrapelvic metastases. A laparoscopic radical hysterectomy with laparoscopic pelvic lymphadenectomy and |

| | |para-aortic node sampling is performed. |

| | |Description of Procedure (58548) |

| | |A subumbilical skin incision is made. A needle is placed transabdominally and confirmed to be intraperitoneally|

| | |in the standard fashion. Carbon dioxide is insufflated into the abdomen. The needle is removed and a |

| | |laparoscopic trocar sheath is inserted. A laparoscope is placed through the sheath and the abdomen is |

| | |visualized for location and to identify any injuries. Three accessory ports are placed into the abdominal wall |

| | |under direct vision, including the right and left lateral ports and one suprapubic port. |

| | |The patient is placed in Trendelenburg position and the small bowel is mobilized out of the pelvis into the |

| | |upper abdomen. The round ligaments are serially grasped and divided with cautery. The peritoneum lateral to the|

| | |ovarian vessels is opened from the external iliac to the common iliac vessels. The perirectal and perivesical |

| | |spaces are developed bilaterally. A total pelvic lymphadenectomy is then performed using laparoscopic scissors,|

| | |cautery, and vascular clips, and separate specimens of right and left external iliac nodes, obturator nodes, |

| | |internal iliac nodes, and common iliac nodes are obtained. During dissection of the obturator space, the |

| | |obturator nerve is mobilized to prevent injury. All nodal specimens are sent for permanent pathology. |

| | |The ovarian vessels are isolated separate of the ureters, and then divided with the stapling device. The |

| | |uterine arteries are identified at their origin on the internal iliac arteries, and then divided between |

| | |vascular clips. The parametria are developed between the perirectal and perivesical spaces, and divided using |

| | |the stapling device. The vesicouterine fold of peritoneum is opened and the bladder flap is developed over the |

| | |lower uterine segment and upper vagina. The ureters are mobilized off of the medial leaves of the broad |

| | |ligament bilaterally. The rectovaginal septum is opened and the rectum is dissected off the posterior vagina. |

| | |The uterosacral ligaments are divided with the stapling device. The ureters are further mobilized off the broad|

| | |ligament. The uterine vessels are elevated off the ureters, and then divided with vascular clips. The ureters |

| | |are deflected laterally. The parametria are dissected off the periureteral tissues using cautery. The |

| | |paracolpos are divided. The vagina is then opened circumferentially with a 2-cm margin of upper vagina around |

| | |the cervix. The uterus, cervix, parametria, tubes, and ovaries are delivered vaginally. |

| | |The vagina is closed with interrupted sutures. The pelvis is irrigated and hemostasis is obtained with vascular|

| | |clips and cautery. The course and function of the ureters are evaluated. Carbon dioxide is allowed to escape. |

| | |The laparoscopic trocars are removed, and the fascial defects are closed. The skin incisions are closed with |

| | |subcuticular sutures. Dressings are placed. |

|[pic] |

|58550 |  |Clinical Example (58550) |

| | |A 45-year-old, gravida 1 para 1 female is evaluated for profound menorrhagia with anemia. Her hematocrit is 25%|

| | |despite daily iron therapy and treatment with oral contraceptives. On physical examination she has an |

| | |irregular, mobile 12- to 14-week size fibroid uterus. Ultrasound confirms multiple uterine fibroids, several of|

| | |which impinge on the endometrium. After management options are discussed with her, the patient elects a |

| | |hysterectomy. Due to previous surgeries that make the vaginal route more risky, an attempt at a |

| | |laparoscopic-assisted vaginal hysterectomy (LAVH) is made. |

| | |Description of Procedure (58550) |

| | |The physician first inserts an instrument through the vagina to grasp the cervix and manipulate the uterus |

| | |during surgery. Next, the surgeon makes a small incision just below the umbilicus through which the fiberoptic |

| | |laparoscope is inserted. A second incision is made on the left side of the abdomen and additional instruments |

| | |are placed through this incision. Gas is gently pumped into the abdomen and pelvis to cause it to tent and |

| | |create a cavity in which the surgeon can operate by viewing through the camera. The myomas are assessed in |

| | |terms of their size and location to plan sequential removal that would enable a size reduction of the uterus to|

| | |proceed with the laparoscopic hysterectomy. To protect from intra operative hemorrhage, additional techniques |

| | |and instrumentation are employed to minimize blood loss that would require increased operative time. As the |

| | |large myomas are removed, they are either morcellated using special instrumentation or suture tagged for |

| | |subsequent removal so they are not lost within the abdominal cavity. The uterus itself can either be bisected |

| | |or sequentially morcellated to reduce its size to the point where it can eventually fit through the colpotomy |

| | |incision at the level of the vaginal cuff. The various debulking techniques, which are only necessary with such|

| | |an enlarged uterus, are technically challenging and even with experienced surgeons, operating time is |

| | |significantly prolonged. Once the uterine fundus can be delivered through the vagina, it too may be removed in |

| | |multiple or separate pieces. A vaginal incision is sutured closed either through a transvaginal or laparoscopic|

| | |approach. The abdominal cavity is then deflated and instruments and trocars are removed, with suture closure of|

| | |the trocar sites both at the level of the fascia and skin. |

|[pic] |

|58551 |  |A 42-year-old multigravida woman has been evaluated for an enlarging symptomatic pelvic mass. The uterus has |

| | |increased from 6 to 12 weeks' size over 8 months and is causing urinary frequency, nocturia, and dyspareunia. |

| | |Ultrasound documented a leiomyomatous uterus with two separate myomas, 4x5 and 3x4 cm. The patient does not |

| | |want a hysterectomy. |

|[pic] |

|58555 |  |A 55-year-old postmenopausal woman presented with abnormal bleeding on combined continuous hormone replacement |

| | |therapy. An endometrial biopsy was attempted, but yielded inadequate tissue for diagnosis. An endovaginal |

| | |ultrasound revealed an endometrial thickness of greater than 1 cm with the suggestion of an intrauterine |

| | |filling defect. |

|[pic] |

|58558 |  |A 55-year-old postmenopausal woman presented with abnormal bleeding on combined continuous hormone replacement |

| | |therapy. An endometrial biopsy was attempted, but yielded inadequate tissue for diagnosis. An endovaginal |

| | |ultrasound revealed an endometrial thickness of greater than 1 cm with the suggestion of an intrauterine |

| | |filling defect. |

|[pic] |

|58559 |  |A 32-year-old G3P0030 woman has had three first trimester spontaneous abortions, all of which required a D&C. |

| | |Hysterosalpingography revealed multiple thick irregular filling defects within the endometrial cavity |

| | |suggestive of intrauterine adhesions. |

|[pic] |

|58560 |  |A 32-year-old G3P0 woman with three spontaneous pregnancy losses presented for evaluation. |

| | |Hysterosalpingography revealed a thick uterine septum. Ultrasound documented a septate uterus with normal |

| | |serosal uterine contour. The patient now undergoes hysteroscopy. |

|[pic] |

|58561 |  |A 35-year-old nulligravid woman presented with profound menorrhagia, anemia, and primary infertility. |

| | |Laboratory analysis documented ovulation. Ultrasound demonstrated several intrauterine filling defects. The |

| | |anemia was corrected with iron supplementation and hormonal suppression of menses. The patient is now taken to |

| | |the operating room. |

|[pic] |

|58562 |  |A 34-year-old woman was referred by another physician for removal of an impacted IUD. The patient had the |

| | |intrauterine device placed approximately 10 years earlier following her last pregnancy. She has remarried and |

| | |desires another pregnancy. The referring physician attempted removal of the IUD unsuccessfully and broke the |

| | |string above the cervical os. Attempts at retrieval in the office with an IUD hook have been unrewarding. |

| | |Ultrasound demonstrated the intrauterine position of the device. |

|[pic] |

|58563 |  |A 44-year-old massively obese women was referred by another physician for management of menorrhagia to the |

| | |point of significant anemia. Attempts to control her bleeding with cyclic progestins and antiprostaglandins |

| | |have been unsuccessful. She is a heavy smoker and therefore not a candidate for oral contraceptives. An |

| | |endometrial biopsy revealed no abnormality. |

|[pic] |

|58565 |  |Clinical Example (58565) |

| | |A 37-year-old, multiparous female desires permanent sterilization. She is a poor candidate for laparoscopy in |

| | |that she is obese and has had several, previous, abdominal, surgical procedures. She has been counseled |

| | |regarding the various options available to her and her partner including vasectomy, minilaparotomy, open |

| | |laparoscopy as well as hysterscopic techniques and has opted for the hysterscopic approach. |

| | |Description of Procedure (58565) |

| | |Following induction of appropriate anesthesia, a pelvic exam is performed. A perineal/vaginal prep is |

| | |performed. Sterile drapes are placed. A speculum is inserted into the vagina and a single-toothed tenaculum is |

| | |placed on the anterior lip of the cervix. A paracervical block is performed. The cervix is serially dilated. |

| | |The operative hysterscope is introduced through the dilated cervix. A complete diagnostic survey of the uterine|

| | |cavity is performed. Access to both fallopian tube ostia is assessed for adequacy. Each tube is cannulated, |

| | |then microinserts are placed bilaterally. The hysteroscope is removed from the uterus. The tenaculum is removed|

| | |and bleeding from the site controlled, if necessary. The patient is transferred to a stretcher and escorted to |

| | |the recovery room. |

|[pic] |

|58660 |  |A 30-year-old woman presents with complaints of midcycle pain and dysmenorrhea, which have gotten progressively|

| | |worse. She had an appendectomy for a ruptured appendix at the age of 18. She has been trying to conceive for 18|

| | |months without success. A recent hysterosalpingography showed patent tubes. However, there was loculation of |

| | |contrast around both tubes, suggesting peritubal adhesions. |

|[pic] |

|58661 |  |A 52-year-old postmenopausal woman has been evaluated for an adnexal mass palpated on routine exam. She had a |

| | |vaginal hysterectomy 15 years ago for benign disease. Ultrasound documents a 5 cm simple cystic mass arising |

| | |from the left adnexa. Color Doppler flow analysis shows a normal resistive index and CA-125 is 5. |

|[pic] |

|58662 |  |A 34-year-old woman presented with progressively severe dysmenorrhea, pelvic pain, and dyspareunia. She had |

| | |previously taken oral contraceptives, which helped but did not completely relieve the pain. She stopped oral |

| | |contraceptives 9 months ago to begin trying to conceive. She misses 1 or 2 days of work with each menses. |

|[pic] |

|58670 |  |A 25-year-old G3P3 woman requests sterilization. |

|[pic] |

|58671 |  |A 25-year-old G3P3 woman requests sterilization. |

|[pic] |

|58672 |  |A 28-year-old woman who recently underwent a hysterosalpingogram, which showed that the distal tube was |

| | |dilated. |

|[pic] |

|58673 |  |A 28-year-old woman, who recently underwent a hystero-salpingogram that showed nonpatent hydrosalpinges now |

| | |undergoes laparoscopy. |

|[pic] |

|58950 |  |Clinical Example (58950) |

| | |A 48-year-old female who had undergone a prior vaginal hysterectomy for abnormal bleeding was found to have |

| | |bilateral pelvic masses. She was seen in consultation and was advised to undergo an exploratory laparotomy. She|

| | |was counseled about the possibility that ovarian cancer might be present. At the time of surgery, an |

| | |exploratory laparotomy was performed confirming the presence of bilateral ovarian masses. A bilateral |

| | |salpingo-oophorectomy was performed and a frozen section obtained intraoperatively confirmed the presence of a |

| | |well-differentiated mucinous carcinoma. Because of the high risk of occult metastatic disease to the omentum, |

| | |an omentectomy was also performed. |

| | |Description of Procedure (58950) |

| | |Local anesthesia is injected. An abdominal incision is performed followed by a thorough inspection and |

| | |evaluation of the pelvis and abdomen. Both of the ovaries, fallopian tubes, and the omentum are excised. |

| | |Hemostasis is obtained, and the wound is closed. |

|[pic] |

|58952 |  |Clinical Example (58952) |

| | |A 59-year-old woman presented with ascites and a pelvic mass. Evaluation has yielded a presumed diagnosis of |

| | |ovarian cancer. She now undergoes a resection of ovarian malignancy with radical dissection, which includes a |

| | |bilateral salpingo-oophorectomy, omentectomy and removal of pelvic tumor and abdominal tumor. |

| | |Description of Procedure (58952) |

| | |An incision is made and carefully carried by layers until the peritoneal cavity is entered. Cytologic washings |

| | |and subdiaphragmatic scrapings are taken. The abdomen and pelvis are explored and the extent of tumor assessed.|

| | |A bilateral salpingo-oophorectomy is performed by dissecting the pelvic sidewalls, ureters, and sigmoid from |

| | |the adnexal masses. The pelvic peritoneum may need to be removed as part of the radical resection. An |

| | |omentectomy is performed. An attempt is made to remove all tumor nodules larger than 1 cm in the abdomen and |

| | |pelvis. An omentectomy is performed. The abdomen is closed in layers and the dressing applied. |

|[pic] |

|58953 |  |Clinical Example (58953) |

| | |A 48-year-old woman presents with a distended abdomen from ascites with a pelvic mass and a palpable abdominal |

| | |mass. She is advised to undergo an exploratory laparotomy for a presumed advanced ovarian malignancy. |

| | |Description of Procedure (58953) |

| | |An abdominal incision is made, exploration of the abdomen is performed and, if appropriate, peritoneal fluid is|

| | |obtained for cytological investigation. Placement of an appropriate retractor, typically a Bookwalter |

| | |retractor, is done with packing of the abdominal contents out of the pelvis. The patient is found to have |

| | |bilateral ovarian cancers with extensive pelvic tumor nodularity in the cul-de-sac of the pelvis in addition to|

| | |extensive omental replacement with metastatic cancer. The patient undergoes a total abdominal hysterectomy with|

| | |bilateral salpingo-oophorectomy, excision of the pelvic peritoneum with removal of the metastatic implants |

| | |within the pelvis and an omentectomy. The hysterectomy, with removal of the uterus, ovaries, fallopian tubes, |

| | |and excision of the pelvic peritoneum, is completed. This step requires dissection of the ureters off their |

| | |peritoneal attachments along their courses in the pelvis. The entire omentum then is removed by initially |

| | |separating it from the tranverse colon and developing the anatomical space between the omentum and the |

| | |transverse mesocolon to the level of the lesser sac of the omentum. The gastroepiploic and short gastric |

| | |vessels are divided permitting complete removal of the omentum. At completion of the operative procedure more |

| | |than 98% of the cancer has been resected with only residual tumor studding in the region of the diaphragmatic |

| | |and liver surfaces. The abdomen is then closed in layers typically with the use of retention sutures. Where |

| | |required, suction drainage is employed. |

|[pic] |

|58954 |  |Clinical Example (58954) |

| | |A 48-year-old woman presents with a distended abdomen from ascites with a pelvic mass and a palpable abdominal |

| | |mass. She is advised to undergo an exploratory laparotomy for a presumed advanced ovarian malignancy. |

| | |Description of Procedure (58954) |

| | |An abdominal incision is made, exploration of the abdomen is performed, and, if appropriate, peritoneal fluid |

| | |is obtained for cytological investigation. The patient is found to have bilateral ovarian cancers with |

| | |extensive pelvic tumor nodularity in the cul-de-sac of the pelvis in addition to extensive omental replacement |

| | |with metastatic cancer. The patient undergoes a total abdominal hysterectomy with bilateral |

| | |salpingo-oophorectomy, excision of the pelvic peritoneum with removal of the metastatic implants within the |

| | |pelvis and an omentectomy. Placement of an appropriate retractor, typically a Bookwalter retractor, is done |

| | |with packing of the abdominal contents out of the pelvis. The hysterectomy, with removal of the uterus, |

| | |ovaries, fallopian tubes, and excision of the pelvic peritoneum, is completed. This step requires dissection of|

| | |the ureters off their peritoneal attachments along their courses in the pelvis. Because of a high risk of |

| | |pelvic or periaortic metastasis a limited para-aortic lymphadenectomy including external iliac, hypogastric and|

| | |obturator nodes is done and the lower periaortic lymph nodes (below the renal vessels) are biopsied or excised.|

| | |Complete removal of the bilateral pelvic lymph nodes including the external iliac, obturator, hypogastric and |

| | |common iliac lymph nodes in addition to sampling of the lymph nodes over the lower inferior vena cava and |

| | |abdominal aorta is performed. The entire omentum is then removed by initially separating it from the transverse|

| | |colon and developing the anatomical space between the omentum and the transverse mesocolon to the level of the |

| | |lesser sac of the omentum. The gastroepiploic and short gastric vessels are divided permitting complete removal|

| | |of the omentum. At completion of the operative procedure all of the visible cancer has been resected. The |

| | |abdomen is then closed in layers typically with the use of retention sutures. Where required, suction drainage |

| | |is employed. |

|[pic] |

|58956 |  |Clinical Example (58956) |

| | |A 67-year-old female presents with postmenopausal bleeding for 18 months duration. A biopsy reveals a FIGO, |

| | |grade 3, endometrial carcinoma. The patient is taken for exploratory laparotomy. At the time of surgery, there |

| | |are several 2 cm implants found in the omentum. There is no adenopathy and no peritoneal implants. The patient |

| | |undergoes TAH BSO and a complete omentectomy to remove all gross disease. The patient receives the usual |

| | |follow-up care in the hospital and office during the 90-day global period. |

| | |Description of Procedure (58956) |

| | |The patient is positioned on the table and an exam under anesthesia is performed. The patient is prepared and |

| | |draped and an abdominal incision is made. A thorough exam of the abdomen and pelvis is done which reveals |

| | |multiple omental metastases that involve the greater and lesser omentum. There does not appear to be other |

| | |intraperitoneal disease and there is no retroperitoneal lymphadenopathy. A retractor is placed and a complete |

| | |TAH BSO is performed. The lymph nodes and retroperitoneal spaces are carefully inspected. After completion of |

| | |the TAH BSO a complete omentectomy is perfomed. The omentum is freed from the transverse colon and the omentum |

| | |is taken off the greater curvature of the stomach up to the splenic hilum. All of the metastatic disease is |

| | |resected with the omentectomy. Hemostasis is ensured and the abdomen is irrigated, and closed. |

|[pic] |

|58957 |  |Clinical Example (58957) |

| | |A 73-year-old female with a previous history of suboptimally debulked stage IIIC epithelial ovarian cancer |

| | |(based on the intraoperative finding of extrapelvic metastases to the upper abdomen including the omentum, |

| | |stomach, and right hemidiaphragm, which could not be debulked to minimal volume) 2 years ago, underwent primary|

| | |surgery including a total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and suboptimal debulking |

| | |of extrapelvic disease. She subsequently received postoperative adjuvant chemotherapy with a complete clinical |

| | |response, including normalization of the CA 125, normal physical examination, and no evidence of persistent |

| | |malignancy on a computed tomography (CT) scan of the abdomen and pelvis. In the recent few months prior to her |

| | |current presentation, the patient has a rising CA 125 and a CT scan of the abdomen and pelvis that suggests |

| | |recurrent tumors involving multiple sites in the abdomen and pelvis. Resection of the recurrent ovarian |

| | |malignancy is performed. |

| | |Description of Procedure (58957) |

| | |The laparotomy is accomplished through a midline vertical incision. A general exploration of the abdomen, |

| | |pelvis, and viscera is performed, with a careful assessment of the location, size, and number of recurrent |

| | |tumors. Recurrent malignancy is found to involve the right paracolic gutter, gastrosplenic ligament, |

| | |small-bowel mesentery, and pelvis. The small bowel is mobilized from the ileocecal valve to the ligament of |

| | |Treitz. Adhesions of bowel loops from the abdomen and pelvis are lysed. The right paracolic mass is mobilized |

| | |by making a peritoneal incision around the mass and developing the retroperitoneal space and ascending colon. |

| | |It is resected off the colon with minimal serosal injury and is repaired with imbricating sutures. A |

| | |gastrosplenic tumor adjacent to the greater curvature of the stomach is excised by developing the lesser sac |

| | |and serially dividing and ligating the short gastric vessels. Multiple tumor masses involving the bowel |

| | |mesentery are excised and fulgurated. The pelvic sidewall mass is also approached by opening the |

| | |retroperitoneum and developing the perirectal and perivesical spaces. The right ureter is deflected laterally |

| | |off the peritoneum and tumor. The pelvic mass is then resected with peritoneal margins. Hemostasis is obtained |

| | |with suturing and fulguration using cautery. At the end of the procedure, all gross disease has been resected. |

| | |The patient requires a blood transfusion to replace intraoperative bleeding. The abdominal wall is closed in |

| | |layers and a pressure dressing is placed. |

|[pic] |

|58958 |  |Clinical Example (58958) |

| | |A 63-year-old female with a previous history of optimally debulked stage IIIC epithelial ovarian cancer (based |

| | |on the intraoperative finding of a right ovarian mass and extrapelvic metastases in the pelvis and the omentum)|

| | |3 years ago, underwent primary surgery including a total hysterectomy, bilateral salpingo-oophorectomy, |

| | |omentectomy, and resection of pelvic metastases. She subsequently received postoperative adjuvant chemotherapy |

| | |with a complete clinical response, including normalization of the CA 125, normal physical examination, and no |

| | |evidence of persistent malignancy on a computed tomography (CT) scan of the abdomen and pelvis. In the recent |

| | |few months prior to her current presentation, the patient has a rising CA 125 and a CT scan of the abdomen and |

| | |pelvis that suggests recurrent tumors involving the pelvis, right paracolic gutter, and right pelvic and |

| | |para-aortic nodes. Resection of the recurrent ovarian malignancy, including lymphadenectomy of pelvic and |

| | |aortic nodal metastases, is performed. |

| | |Description of Procedure (58958) |

| | |The laparotomy is accomplished through a midline vertical incision. A general exploration of the abdomen, |

| | |pelvis, and viscera is performed, with a careful assessment of the location, size, and number of recurrent |

| | |tumors. Recurrent malignancy is found to involve the right pelvic sidewall, small-bowel mesentery, and right |

| | |pelvic and para-aortic lymph nodes. The small bowel is mobilized from the ileocecal valve to the ligament of |

| | |Treitz. Adhesions of bowel loops from the abdomen and pelvis are lysed. The pelvic sidewall mass is approached |

| | |by opening the retroperitoneum and developing the perirectal and perivesical spaces. The right ureter is |

| | |deflected laterally off the peritoneum and tumor. The pelvic mass is then resected with peritoneal margins. |

| | |Hemostasis is obtained with suturing and fulguration using cautery. Multiple tumor masses involving the bowel |

| | |mesentery are excised and fulgurated. Metastatic pelvic lymph nodes over the external iliac vessels and |

| | |obturator space are resected. The obturator nerve is mobilized to avoid injury. The cecum and right colon are |

| | |mobilized and reflected superiorly. The third part of the duodenum is mobilized cephalad and the lower aorta |

| | |and inferior vena cava from the aortic bifurcation to the renal vessels are exposed. The enlarged para-aortic |

| | |lymph nodes over the inferior vena cava and right para-aortic region are then resected up to the renal vessels.|

| | |Hemostasis is obtained with use of cautery and vascular clips. At the end of the procedure, all gross disease |

| | |has been resected. The patient requires a blood transfusion to replace intraoperative bleeding. The abdominal |

| | |wall is closed in layers and a pressure dressing is placed. |

|[pic] |

|58960 |  |Clinical Example (58960) |

| | |A 59-year-old woman completed six cycles of platinum-based chemotherapy following cytoreductive surgery for |

| | |ovarian cancer. She now undergoes end-staging laparotomy. Multiple specimens of cytology washings of abdominal |

| | |quadrants, pelvic and subdiaphragm, as well as multiple biopsies are taken. |

| | |Description of Procedure (58960) |

| | |An incision is made. On opening the peritoneal cavity, care is taken to avoid injury to adherent loops of bowel|

| | |from previous surgery. Peritoneal washings are taken and subdiaphragmatic scrapings are obtained for cytologic |

| | |evaluation. Multiple biopsies are taken from the abdominal and pelvic peritoneum. A selected bilateral pelvic |

| | |and paraaortic lymphadenectomy is performed. An omentectomy is done, if not done at the initial surgery. The |

| | |abdomen is closed in layers. A dressing is applied. |

|[pic] |

|59001 |  |Clinical Example (59001) |

| | |The patient is seen at 22-weeks gestation with a rapidly increasing uterine size. Limited ultrasound scanning |

| | |reveals the presence of a twin gestation. One twin is small for gestational age and has oligohydramnios. The |

| | |other twin is appropriate for gestational age and has severe polyhydramnios. The diagnosis of a twin-twin |

| | |transfusion syndrome is made and the patient is counseled as to the available therapies and elects amniotic |

| | |fluid reduction. |

| | |Description of Procedure (59001) |

| | |The risks and benefits of the procedure are explained to the patient. Real-time ultrasound scanning is |

| | |performed to identify the sac with increased amniotic fluid. The area is draped and prepped and a needle |

| | |insertion site is identified. Under real-time ultrasound guidance, a 22 gauge needle is inserted into the |

| | |amniotic sac. The needle is then attached to tubing by an assistant while the operator holds the needle in |

| | |place. The assistant then attaches the needle to a drainage system. Utilizing continuous ultrasound guidance, |

| | |fluid is removed until a normal amount of fluid is seen on ultrasound. The physician remains in constant |

| | |communication with the ultrasound operator regarding the status of both fetuses and the fluid level; this |

| | |continual monitoring of the needle location is required to avoid injury to the fetus or placenta since the |

| | |uterine shape is altered by the removal of fluid. Once a normal fluid level is obtained, the needle is removed.|

|[pic] |

|59070 |  |Clinical Example (59070) |

| | |Patient referred at 23 weeks of pregnancy for decreased amniotic fluid seen on ultrasound. Fetal renal |

| | |anomalies are suspected and the fetal anatomy cannot be seen because of the decreased fluid. An amnioinfusion |

| | |is performed. |

| | |Description of Procedure (59070) |

| | |Previous scans and records are reviewed. The patient is counseled about the risks and benefits of the |

| | |procedure. Informed consent is obtained. Under continuous ultrasound guidance, an amniocentesis is performed by|

| | |guiding the needle between the fetal extremities. Sterile saline is instilled under continuous ultrasound until|

| | |adequate visualization of the fetal anatomy is possible. The needle is removed. A detailed ultrasound of the |

| | |fetus is performed. The patient is monitored for 30-60 minutes. The results of the procedure are discussed with|

| | |the patient and questions answered. Discharge and follow-up instructions are given. A report and letters to |

| | |referring physicians are dictated, read and signed. |

|[pic] |

|59072 |  |Clinical Example (59072) |

| | |The patient is 19 weeks pregnant and has a confirmed monochorionic diamniotic pregnancy. One fetus has spina |

| | |bifida and the other fetus is structurally normal. Patient requests umbilical cord occlusion to terminate the |

| | |affected fetus and to allow safe maintenance of the coexisting normal fetus. |

| | |Description of Procedure (59072) |

| | |Previous records, ultrasounds and laboratory results are reviewed. The patient is counseled extensively about |

| | |the risks and benefits of the procedure. Informed consent is obtained. Ultrasound is performed to identify a |

| | |placental free area with access to the umbilical cord. Under direct ultrasound guidance, small coagulation |

| | |forceps are inserted into the uterus, the umbilical cord of the affected fetus identified and grasped, and |

| | |using either laser, suture, or bipolar coagulation, is occluded. Ultrasound, including color Doppler, is used |

| | |to confirm complete absence of flow through the occluded cord. The scope is removed. The patient is monitored |

| | |for a minimum of 1 hour. Discharge instructions are given. A report and letters to referring physicians are |

| | |dictated, read and signed. |

|[pic] |

|59074 |  |Clinical Example (59074) |

| | |Patient is a 22-year-old primagravida. Ultrasound at 26 weeks reveals reduced amniotic fluid, an enlarged fetal|

| | |bladder with "keyhole appearance" and bilateral hydronephrosis. A fetal bladder aspiration is performed to |

| | |analyze urinary electrolytes, to determine fetal renal function, and to determine subsequent therapy. |

| | |Description of Procedure (59074) |

| | |Previous record and ultrasound scans are reviewed. The patient is counseled about the risks and benefits of the|

| | |procedure. Informed consent is obtained. Using continuous ultrasound guidance, a 20-22 gauge needle is directed|

| | |into the fetal bladder and fetal urine is aspirated. The needle is removed and the patient monitored. Imaging |

| | |is repeated in 30-60 minutes to check for refilling of the bladder. Urine is sent to the laboratory for |

| | |analysis. Patient is given discharge instructions. Urinary electrolyte results are reviewed. A report and |

| | |letters to referring physicians are dictated, read and signed. |

|[pic] |

|59076 |  |Clinical Example (59076) |

| | |A 22-year-old woman undergoes an obstetrical ultrasound for dating at 18 weeks gestation. Unexpectedly there is|

| | |noted to be a lack of amniotic fluid, evidence of an enlarged fetal bladder and bilateral hydronephrosis. A |

| | |fetal bladder tap is performed and later reveals a normal male karyotype and minimally abnormal urinary |

| | |electrolytes (sodium, chloride, osmolality). A repeat ultrasound, 48 hours later, reveals a reaccumulation of |

| | |urine in the fetal bladder. A second bladder tap reveals normalization of the fetal urinary electrolytes. After|

| | |extensive counseling, the patient elects to continue the pregnancy with fetal bladder shunt placement. |

| | |Description of Procedure (59076) |

| | |Records of previous ultrasounds and urinary studies are reviewed. The patient is extensively counseled and the |

| | |risks and benefits of the procedure explained. Informed consent is obtained. The double pigtailed shunt is |

| | |sterilized along with the insertion instruments. The instruments are evaluated to make certain that all |

| | |components are present and compatible. The abdominal wall and the fascia of the mother are anesthetized to |

| | |allow the percutaneous placement of a double pigtailed catheter. The catheter is straightened and placed into a|

| | |trocar. Under continuous ultrasound guidance, the trocar is guided through the maternal abdominal wall and |

| | |uterus and into the fetal bladder (if a pleural effusion is the indication, the shunt is placed into the |

| | |thorax). The proximal portion of the catheter is advanced into the fetal bladder. Once the proximal coil is in |

| | |the bladder, the tip of the trocar is retracted so that the distal portion can be advanced into the amniotic |

| | |cavity. This allows for a conduit of fluid into the amniotic space. Scanning is continued to confirm |

| | |appropriate placement. The patient and fetus are then monitored for 1 hour or longer. A repeat scan is |

| | |performed to evaluate bladder drainage and reaccumulation of amniotic fluid. Post procedure instructions are |

| | |given. A report and letters to referring physicians are dictated, read and signed. |

|[pic] |

|60650 |  |A 45-year-old man has poorly controlled hypertension despite multi-drug therapy. Biochemical and imaging |

| | |evaluations reveal a 3.5 cm pheochromocytoma of the right adrenal gland, and he is referred for consideration |

| | |of adrenalectomy. Work-up has also disclosed mild hypertensive cardiomyopathy. |

|[pic] |

|61210 |  |Clinical Example (61210) |

| | |A 45-year-old male has a severe closed-head injury with a Glasgow Coma Scale score of 6 and no focal or |

| | |lateralizing signs. The admitting computed tomography scan shows no hematomas or shift but obliteration of the |

| | |basal cisterns. Intracranial pressure monitoring with capability for drainage of ventricular fluid is desired. |

| | |A frontal ventriculostomy catheter is implanted and attached to an external monitoring and collection system. |

| | |Description of Procedure (61210) |

| | |A frontal scalp is made under local anesthesia. A twist drill hole is made, and a ventriculostomy catheter is |

| | |introduced into the anterior horn of the lateral ventricle. The catheter is tunneled beneath the scalp for |

| | |about 1-2 cm and then brought to the surface via a small stab wound. The catheter is connected to a pressure |

| | |transducer and drainage tubing system. The system is calibrated to assure patency of the catheter. The scalp is|

| | |then closed and dressings are applied. |

|[pic] |

|61316 |  |Clinical Example (61316) |

| | |A 25-year-old male was taken to the operating room for emergency supratentorial craniotomy and decompressive |

| | |lobectomy. |

| | |Description of Procedure (61316) |

| | |While in the operating room, at the time of a primary surgical procedure for the treatment of intracranial |

| | |hypertension (eg, decompressive craniotomy, lobectomy or evacuation of intracranial hematoma) where immediate |

| | |replacement of the cranial bone flap may aggravate intracranial hypertension from brain swelling, a suitable |

| | |area of the abdominal wall is prepped and draped in a sterile manner. An incision is made, and a subcutaneous |

| | |pocket is created. Hemostasis is achieved. The cranial bone flap is placed into the subcutaneous space. Closure|

| | |of the subcutaneous tissues and skin is completed. A sterile dressing is applied. Orders appropriate for the |

| | |primary procedure are written and specific description of the bone graft transplantation is incorporated into |

| | |the operative report. Postoperative exams of this wound site are made, as necessary, until such time that the |

| | |graft is used for reconstruction. |

|[pic] |

|61322 |  |Clinical Example (61322) |

| | |A 36-year-old male, involved in a motor vehicle accident, has suffered a severe traumatic brain injury and has |

| | |been in the Surgical Intensive Care Unit for approximately 24 hours. An intracranial pressure monitor was |

| | |placed for recording of continuous intracranial pressure (ICP). The patient develops intracranial hypertension |

| | |uncontrolled by medical therapy. A CT scan revealed multiple non-hemorrhagic supratentorial contusions |

| | |producing obliteration of the basal cisterns. At operation, a supratentorial decompressive craniotomy/ |

| | |craniectomy with duraplasty is performed. |

| | |Description of Procedure (61322) |

| | |Under general anesthesia, the head is positioned and fixed in a pin headholder, using care to protect the |

| | |intracranial pressure device. A bicoronal incision is made with elevation of a large bifrontal cranial bone |

| | |flap. Meticulous hemostasis is observed. The frontal sinus opened during the craniotomy is stripped of its |

| | |mucosa and obliterated with absorbable gelatin sponge. The dura is noted to be extremely tense. The dura is |

| | |then opened, beginning over the polar areas of the frontal lobes. The dural opening is made very low near the |

| | |frontal skull base, the sagittal sinus is ligated at its rostral extremity, the falx cerebri is divided, and |

| | |the dural opening is carried across midline for approximately 10 cm length opening from one temporal to the |

| | |opposite temporal fossa, allowing the frontal lobes to expand through the dural opening. Hemostasis is ensured |

| | |and the dura is closed with a cadaveric dural graft in a watertight manner to allow for anterior expansion of |

| | |the swollen brain. The bifrontal bone flap is not replaced. An epidural drain is left in place to prevent |

| | |epidural hematoma formation. A two-layer closure of the scalp is then completed. (Placement of the bone flap in|

| | |the abdominal area through a separate incision for subsequent cranioplasty, if elected, is reported |

| | |separately.) |

|[pic] |

|61323 |  |Clinical Example (61323) |

| | |A 25-year-old male has suffered a severe traumatic brain injury and has been in the Surgical Intensive Care |

| | |Unit for several days. An intracranial pressure monitor was placed for recording of continuous intracranial |

| | |pressure (ICP). The patient develops intracranial hypertension uncontrolled by medical therapy. CT scan reveals|

| | |a non-hemorrhagic supratentorial, temporal lobe contusion with significant edema and uncal herniation. At |

| | |operation, a decompressive supratentorial craniectomy and lobectomy and duraplasty are performed. |

| | |Description of Procedure (61323) |

| | |Under general anesthesia, the head is positioned and fixed in a pin headholder, using care to protect the |

| | |intracranial pressure device. The neurosurgeon performs a cranial incision and turns a large unilateral bone |

| | |flap overlying the frontal and temporal lobes. Care is taken to preserve the pericranium, which may be used for|

| | |a dural expansion graft. Prior to the opening of the dura, close coordination with anesthesia is carried out to|

| | |maximize medical control of the swollen brain. The dura over the temporal lobe is then opened. The brain is |

| | |swollen and surgical landmarks are extremely difficult to identify. The anterior 5 cm of the temporal lobe are |

| | |removed including the mesial structures in order to clearly identify the incisura. The vessels in the sylvian |

| | |fissure are distorted by the underlying edema and are avoided to prevent disruption of major vascular channels.|

| | |Adequate mesial temporal lobe resection allows the visualization of the third nerve, posterior cerebral artery |

| | |and lateral portion of the brain stem. Following adequate decompression and thorough hemostasis, the dura is |

| | |closed with a pericranial graft to allow for expansion. The bone flap is replaced, if ICP and brain swelling |

| | |permit (if brain swelling precludes safe replacement of the cranial flap, it can be placed in a subcutaneous |

| | |pocket in the abdominal area; separately reportable). A layered closure is completed. |

|[pic] |

|61517 |  |Clinical Example (61517) |

| | |A 50-year-old male is diagnosed with a recurrent frontal-parietal brain tumor. The tumor is a glioblastoma |

| | |multiforme. He undergoes surgery to resect the tumor followed by implantation of brain |

| | |interstitial/intracavitary chemotherapy wafers. |

| | |Description of Procedure (61517) |

| | |As part of the base service, the tumor is resected using standard techniques. When the tumor is resected, a |

| | |sample of the tumor is evaluated by a neuropathologist who determines that the tumor is in fact a glioblastoma |

| | |multiforme and not radiation necrosis. The neurosurgeon determines that it is appropriate to implant BCNU |

| | |wafers in the resected tumor bed, which is prepared by inspection for bleeding and any communication with a |

| | |ventricle. |

| | |The neurosurgeon puts on an extra pair of gloves and receives the wafers from the scrub nurse. The number of |

| | |wafers implanted is dependent on the size and location of the tumor cavity. The wafers are placed against the |

| | |wall of the tumor cavity by forceps, close together with only slight overlapping. Great care is taken to ensure|

| | |that the wafers cover the greatest area of the walls of the tumor cavity and yet avoid the ventricles and large|

| | |vascular structures. Once full coverage of the surgical cavity is achieved, the neurosurgeon applies a topical |

| | |absorbable haemostatic agent to the area to secure the wafers in place. |

|[pic] |

|61537 |  |Clinical Example (61537) |

| | |A 24-year-old woman presents with chronic, intractable complex partial seizures. She previously had undergone |

| | |an extensive evaluation with long-term video EEG analysis of her seizures that had clearly identified the |

| | |seizure focus in the right temporal lobe. At operation, her right temporal lobe, including the amygdala and |

| | |anterior hippocampus, are removed (without intraoperative electrocorticography). Postoperative hospital care |

| | |and office visits are conducted as necessary through the 90-day global. |

| | |Description of Procedure (61537) |

| | |An incision is made and hemostasis achieved with retraction and electrocautery. Burr holes are made at the |

| | |periphery of the exposure and connected using the craniotome. The bone flap is elevated and the dura is |

| | |exposed. The dura is opened with sharp dissection and the dural edges are retracted. The neurosurgeon measures |

| | |the temporal lobe from its anterior extent and determines where the cortical incisions will be made. After |

| | |cortical incisions are made, a dissection is made deep to the cortex with the ultrasonic aspirator. This |

| | |dissection is made in the coronal plane approximately 4 cm from the anterior tip of the temporal lobe until the|

| | |temporal horn of the lateral ventricle and the hippocampus are identified. The dissection then spares these |

| | |medial structures for the time being. When the pia of the medial cortex is encountered, a subpial dissection is|

| | |made. The pia is then coagulated with bipolar coagulation and opened with sharp dissection. The anterior and |

| | |lateral portion of the temporal lobe is then removed, leaving the mesial temporal structures. A very careful |

| | |and delicate dissection is then made of the hippocampus, amygdala and uncus. Great care is taken to identify, |

| | |coagulate and divide perforating arteries from the posterior cerebral artery to the hippocampus without |

| | |damaging the posterior cerebral artery. Great care is also taken to preserve the anterior choroidal artery and |

| | |the pia-arachnoid overlying the ambient cistern which contains the internal carotid artery, the posterior |

| | |cerebral artery, the third, fourth, fifth and sixth cranial nerves, the basilar vein of Rosenthal, the optic |

| | |tract, the lateral geniculate, and the brainstem. Hemostasis is achieved. The dura is sutured so that it is |

| | |watertight. The bone flap is replaced and secured to the surrounding bone with titanium plates and screws. The |

| | |temporalis muscle is sutured together and then the galea and skin are closed. |

|[pic] |

|61538 |  |Clinical Example (61538) |

| | |A 42-year-old woman with intractable temporal lobe seizures has had extensive EEG monitoring with |

| | |identification of a seizure focus in the medial temporal lobe. Supplementary single photon emission computed |

| | |tomograpy (SPECT) scanning shows metabolic abnormalities in the same suspect area. A craniotomy with resection |

| | |of the mesial temporal lobe structures is performed. |

| | |Description of Procedure (61538) |

| | |After the decision to operate is made, the neurosurgeon plans a surgical approach, which will allow him to |

| | |enter the skull, record the electrical activity of the brain, and carefully remove the portion of temporal |

| | |lobe, hippocampus and amygdala that is responsible for the patient's seizures. The neurosurgeon then discusses |

| | |the proposed surgery with the patient and her family, discussing the nature of the problem, the surgical plan, |

| | |the alternatives to surgery, the benefits of surgery, the risks of surgery and the risks of not doing surgery, |

| | |and obtains consent. The neurosurgeon then calls the operating room and schedules the procedure, specifying the|

| | |need for the electrocorticography electrodes and apparatus. The neurosurgeon also orders the appropriate |

| | |pre-operative laboratory testing. The neurosurgeon dictates a letter to the referring physician and then calls |

| | |the referring physician to discuss the proposed surgery. |

| | |The next morning, the neurosurgeon locates the pre-operative MRI of the brain and brings the films to the |

| | |operating room. The neurosurgeon greets the patient in the pre-operation holding area and answers any final |

| | |questions from the patient and her family. The neurosurgeon reviews the results of the pre-operative testing |

| | |and determines that it is appropriate to continue with surgery. The neurosurgeon accompanies the patient to the|

| | |surgical suite and helps to position the patient on the operating table. The neurosurgeon places the |

| | |appropriate MRI films on the view box for later reference during the procedure. After general anesthesia is |

| | |induced, the neurosurgeon shaves the patient's scalp at the site of the incision. The Mayfield pin-head holder |

| | |is applied to the patient's head and the patient positioned with the right shoulder elevated and the patient's |

| | |head turned to the left. The neurosurgeon positions the patient carefully on the operating table to ensure that|

| | |there is not any unusual pressure on neuro-vascular structures. The neurosurgeon carefully prepares the skin |

| | |with iodine soap and then iodine solution. The neurosurgeon then scrubs and is gowned by the scrub nurse. The |

| | |neurosurgeon then marks the incisions and drapes the patient. |

| | |An incision is made and hemostasis achieved with retraction and electrocautery. Burr holes are made at the |

| | |periphery of the exposure and connected using the craniotome. The bone flap is elevated and the dura is |

| | |exposed. The dura is opened with sharp dissection and the dural edges are retracted. The neurosurgeon selects |

| | |the electrodes and prepares the electrode contacts so that they will not harm the cortex of the brain. The |

| | |neurosurgeon then places the electrodes on the brain in a pattern that the neurosurgeon in consultation with |

| | |the epileptologist (neurologist) has determined will derive the best information about the electrical activity |

| | |of the brain. The neurosurgeon makes several careful measurements of the position of the electrodes in |

| | |reference to the cortical anatomy. The neurosurgeon then takes a sterile pen and draws the position of each |

| | |electrode on a line drawing of the right cerebral hemisphere. The neurosurgeon then hands the sterile |

| | |electrical cable from the electrode holder to the EEG technician. While the electrical activity of the brain is|

| | |being recorded, the neurosurgeon gently irrigates the cortex and electrode contacts. The neurologist tells the |

| | |neurosurgeon that one electrode is not making good contact with the brain. The neurosurgeon repositions the |

| | |electrode and the neurologist tells the neurosurgeon that the problem has been solved. The neurosurgeon waits |

| | |while the neurologist collects sufficient recordings. He keeps the exposed cortex wet and weights down the |

| | |recording grid to make better electrical contact with the cortex. The recording strips and grids are moved |

| | |several times to check various sites. The neurosurgeon then confers with the neurologist about the results and |

| | |their implications for tailoring the resection. After the electrocorticography has been completed, the |

| | |neurologist and neurosurgeon confer and decide that 4.5 cm of the temporal lobe will need to be resected to |

| | |ensure that the seizure focus has been eliminated. Each electrode is then carefully removed from the brain and |

| | |replaced with a small numbered sterile "ticket." The neurosurgeon measures the temporal lobe from its anterior |

| | |extent and determines where he will make the cortical incisions in relation to the position of the tickets. |

| | |Cortical incisions are then made. A dissection is made deep to the cortex with the ultrasonic aspirator. This |

| | |dissection is made in the coronal plane approximately 4.5 cm from the anterior tip of the temporal lobe until |

| | |the temporal horn of the lateral ventricle and the hippocampus are identified. The dissection then spares these|

| | |medial structures for the time being. When the pia of the medial cortex is encountered, a subpial dissection is|

| | |made. The pia is then coagulated with bipolar coagulation and opened with sharp dissection. The anterior and |

| | |lateral portion of the temporal lobe is then removed, leaving the mesial temporal structures. The neurosurgeon |

| | |selects the electrodes and prepares the electrode contacts so that they will not harm the cortex of the brain. |

| | |The neurosurgeon then places the electrodes on the brain in a pattern that the neurosurgeon in consultation |

| | |with the epileptologist (neurologist) has determined will derive the best information about the electrical |

| | |activity of the brain, including the hippocampus. The neurosurgeon makes several careful measurements of the |

| | |position of the electrodes in reference to the cortical anatomy. The neurosurgeon then takes a sterile pen and |

| | |draws the position of each electrode on a line drawing of the right cerebral hemisphere. The neurosurgeon then |

| | |hands the sterile electrical cable from the electrode holder to the EEG technician. While the electrical |

| | |activity of the brain is being recorded, the neurosurgeon gently irrigates the cortex and electrode contacts. |

| | |It is determined that there is still a considerable amount of abnormal electrical activity from the anterior 3 |

| | |cm of hippocampus. The electrodes are then removed again. A very careful and delicate dissection is then made |

| | |of the hippocampus, amygdala and uncus. Great care is taken to identify, coagulate and divide perforating |

| | |arteries from the posterior cerebral artery to the hippocampus without damaging the posterior cerebral artery. |

| | |Great care is also taken to preserve the anterior choroidal artery and the pia-arachnoid overlying the ambient |

| | |cistern which contains the internal carotid artery, the posterior cerebral artery, the third, fourth, fifth and|

| | |sixth cranial nerves, the basilar vein of Rosenthal, the optic tract, the lateral geniculate, and the |

| | |brainstem. Hemostasis is achieved. The dura is sutured so that it is watertight. The bone flap is replaced and |

| | |secured to the surrounding bone with titanium plates and screws. The temporalis muscle is sutured together and |

| | |then the galea and skin are closed. |

| | |The patient's head is removed from three-point fixation and sterile dressings are applied. The patient is |

| | |observed by the neurosurgeon during emergence from anesthesia to ensure that no new abnormal neurological |

| | |findings are present. The neurosurgeon then writes the post-operative orders and meets with the patient's |

| | |family to discuss the surgery. The neurosurgeon dictates an operative report and calls the referring physician |

| | |to discuss the surgery. In the post-operative period, the neurosurgeon supervises the post-operative care and |

| | |recovery. The neurosurgeon obtains a post-operative CT of the head and reviews the report and the films to |

| | |ensure that there is no post-operative hemorrhage and that there are no new, unexpected findings. The |

| | |neurosurgeon reviews the results of post-operative blood and serum analysis and adjusts the patient's |

| | |anti-seizure medication to the appropriate dosage. The patient is transferred to the Intensive Care Unit (ICU) |

| | |where the neurosurgeon consults with the Epilepsy Team. The following day, the neurosurgeon sees the patient in|

| | |the ICU and determines that the patient is doing well and can be transferred to the acute care floor. The |

| | |neurosurgeon writes a note in the patient's chart and also writes transfer orders. The neurosurgeon sees the |

| | |patient in the hospital every day for the entire hospital stay and examines the patient to make sure that the |

| | |wounds are healing properly, that there is no evidence of infection, that the patient has reasonable pain |

| | |control and that there are no new medical or neurological problems. After each visit the neurosurgeon writes a |

| | |note in the patient's hospital chart. The neurosurgeon discharges the patient with all prescriptions and |

| | |post-operative instructions. Over the next week the neurosurgeon responds to telephone calls from the patient's|

| | |family to answer questions about persistent headache. The patient is examined by the neurosurgeon in the office|

| | |at appropriate intervals to remove the sutures and to be certain the headache is resolving and there are no |

| | |signs of new neurological difficulties or infection. After each visit, the neurosurgeon dictates a report to |

| | |the patient's referring physician and epileptologist. |

|[pic] |

|61540 |  |Clinical Example (61540) |

| | |A 30-year-old woman presents with chronic, intractable complex partial seizures. A preoperative MRI |

| | |demonstrated a glial scar in the frontal lobe. Prolonged video monitoring confirmed that the seizures arise |

| | |from that lobe. At operation, her right frontal lobe is removed (without intraoperative electrocorticography). |

| | |Postoperative hospital care and office visits are conducted as necessary through the 90-day global. |

| | |Description of Procedure (61540) |

| | |The neurosurgeon then makes an incision and achieves hemostasis with retraction and electrocautery. Burr holes |

| | |are made at the periphery of the exposure and connected using the craniotome. The bone flap is elevated and the|

| | |dura is exposed. The dura is opened with sharp dissection and the dural edges are retracted. The neurosurgeon |

| | |measures the frontal lobe from its anterior extent and determines where he will make the cortical incisions. |

| | |Cortical incisions are then made. A dissection is made deep to the cortex with the ultrasonic aspirator. This |

| | |dissection is made in the coronal plane approximately 3 cm from the anterior tip of the frontal lobe. When the |

| | |pia of the medial cortex is encountered, a subpial dissection is made. The pia is then coagulated with bipolar |

| | |coagulation and opened with sharp dissection. The anterior cerebral arteries are identified and protected |

| | |during the dissection. The anterior portion of the frontal lobe is then removed. Hemostasis is achieved. The |

| | |dura is sutured so that it is watertight. The bone flap is replaced and secured to the surrounding bone with |

| | |titanium plates and screws. The galea and skin are closed. |

|[pic] |

|61566 |  |Clinical Example (61566) |

| | |A 30-year-old woman presents with chronic, intractable complex partial seizures. She previously had undergone |

| | |an extensive evaluation with long-term video EEG analysis of her seizures that had clearly identified the |

| | |seizure focus in the right mesial temporal structures including the amygdala and hippocampus. A preoperative |

| | |MRI demonstrated hippocampal volume loss consistent with mesial temporal sclerosis. At operation, she undergoes|

| | |surgery for removal of her right amygdala and anterior hippocampus. Postoperative hospital care and office |

| | |visits are conducted as necessary through the 90-day global. |

| | |Description of Procedure (61566) |

| | |The neurosurgeon makes an incision and achieves hemostasis with retraction and electrocautery. Burr holes are |

| | |made at the periphery of the exposure and connected using the craniotome. The bone flap is elevated and the |

| | |dura is exposed. The dura is opened with sharp dissection and the dural edges are retracted. The neurosurgeon |

| | |measures the temporal lobe from its anterior extent and determines where he will make the cortical incisions. |

| | |Cortical incisions are then made. A dissection is made deep to the cortex with the ultrasonic aspirator. This |

| | |dissection is made until the temporal horn of the lateral ventricle and the hippocampus are identified. A very |

| | |careful and delicate dissection is then made of the hippocampus and amygdala. Great care is taken to identify, |

| | |coagulate and divide perforating arteries from the posterior cerebral artery to the hippocampus without |

| | |damaging the posterior cerebral artery. Great care is also taken to preserve the anterior choroidal artery and |

| | |the pia-arachnoid overlying the ambient cistern which contains the internal carotid artery, the posterior |

| | |cerebral artery, the third, fourth, fifth and sixth cranial nerves, the basilar vein of Rosenthal, the optic |

| | |tract, the lateral geniculate, and the brainstem. Hemostasis is achieved. The dura is sutured so that it is |

| | |watertight. The bone flap is replaced and secured to the surrounding bone with titanium plates and screws. The |

| | |temporalis muscle is sutured together and then the galea and skin are closed. |

|[pic] |

|61567 |  |Clinical Example (61567) |

| | |A 12-year-old boy presents with chronic, intractable complex partial seizures. He previously has undergone an |

| | |extensive evaluation with long-term video EEG analysis of his seizures. The seizure focus is suspected to be in|

| | |the right frontal-central region including the motor cortex but further characterization of the seizure focus |

| | |is indicated. At operation, he undergoes surgery for exposure of his right frontal-central cortex. |

| | |Intra-operative electrocorticography is performed and a seizure focus is clearly identified. The patient |

| | |undergoes multiple subpial transections of his motor cortex. Postoperative hospital care and office visits are |

| | |conducted as necessary through the 90-day global. |

| | |Description of Procedure (61567) |

| | |The neurosurgeon makes an incision and achieves hemostasis with retraction and electrocautery. Burr holes are |

| | |made at the periphery of the exposure and connected using the craniotome. The bone flap is elevated and the |

| | |dura is exposed. The dura is opened with sharp dissection and the dural edges are retracted. The neurosurgeon |

| | |selects the electrodes and prepares the electrode contacts so that they will not harm the cortex of the brain. |

| | |The neurosurgeon then places the electrodes on the brain in a pattern that the neurosurgeon in consultation |

| | |with the epileptologist (neurologist) has determined will derive the best information about the electrical |

| | |activity of the brain. The neurosurgeon makes several careful measurements of the position of the electrodes in|

| | |reference to the cortical anatomy. The neurosurgeon then takes a sterile pen and draws the position of each |

| | |electrode on a line drawing of the right cerebral hemisphere. The neurosurgeon then hands the sterile |

| | |electrical cable from the electrode holder to the EEG technician. While the electrical activity of the brain is|

| | |being recorded, the neurosurgeon gently irrigates the cortex and electrode contacts. The neurologist tells the |

| | |neurosurgeon that one electrode is not making good contact with the brain. The neurosurgeon repositions the |

| | |electrode and the neurologist tells the neurosurgeon that the problem has been solved. The neurosurgeon waits |

| | |while the neurologist collects sufficient recordings. He keeps the exposed cortex wet and weights down the |

| | |recording grid to make better electrical contact with the cortex. The recording strips and grids are moved |

| | |several times to check various sites. The neurosurgeon then confers with the neurologist about the results and |

| | |their implications for tailoring the resection. After the electrocorticography has been completed, the |

| | |neurologist and neurosurgeon confer and decide that multiple pial transections in a limited area of the motor |

| | |cortex will be required to ensure that the seizure focus has been isolated from the rest of the brain. Each |

| | |electrode is then carefully removed from the brain and replaced with a small numbered sterile "ticket." The |

| | |neurosurgeon pierces the cortex with a curved probe at a sulcus adjacent to the gyrus identified as the seizure|

| | |focus, and then in a linear motion disconnects the grey matter under the pia of the gyrus. The probe is removed|

| | |and the procedure is repeated at 1-cm intervals along the gyrus for the extent of the seizure focus. Hemostasis|

| | |is achieved. The dura is sutured so that it is watertight. The bone flap is replaced and secured to the |

| | |surrounding bone with titanium plates and screws. The temporalis muscle is sutured together and then the galea |

| | |and skin are closed. |

|[pic] |

|61623 |  |Clinical Example (61623) |

| | |A 70-year-old male presents with right retro-orbital pain, headache, and diplopia, progressively worsening over|

| | |three months. The patient is evaluated by his physician, who finds a right sixth nerve paresis and the |

| | |physician recommends a brain CT. This excludes a hemorrhage, but suggests a parasellar mass lesion. He is |

| | |referred to a neurosurgeon who orders an MRI and a cerebral angiogram. These imaging tests demonstrate a |

| | |wide-necked right cavernous sinus segment internal carotid artery aneurysm measuring 2.5 cm in diameter. The |

| | |right anterior cerebral artery A1 segment is noted to be hypoplastic and a small right posterior communicating |

| | |artery is identified. Endovascular trapping with resultant sacrifice of the cavernous right internal carotid |

| | |artery aneurysm is recommended. Prior to treatment of this aneurysm by endovascular therapy, it is mandatory to|

| | |ascertain whether occlusion of the internal carotid artery will result in a stroke. |

| | |Description of Procedure (61623) |

| | |Access to the vascular tree is made via the right common femoral artery. A micropuncture set is used to access |

| | |the common femoral artery by puncturing with a 22-gauge needle followed by a 0.021-in guidewire. This is then |

| | |exchanged for the micropuncture introducer sheath that is then used to introduce the 0.035-in guidewire. A 7 Fr|

| | |femoral sheath is placed and its tip deployed in the thoracic aorta. Through this, a JB-1 angled diagnostic |

| | |neuroangiography catheter is used to select the target vessel (in this case, the carotid artery) and confirm |

| | |the hemodynamic status. Fluoroscopic monitoring is performed for this process. |

| | |After catheter placement, diagnostic images are obtained to evaluate possible vessel damage or cerebral |

| | |embolization. The diagnostic angiogram confirms the suspected aneurysm and is used to evaluate baseline |

| | |hemodynamics of brain perfusion. If a recent pre-operative diagnostic angiogram of sufficient quality has been |

| | |performed and is available at the time of this endovascular surgical procedure, and there is no change in the |

| | |patient's clinical status, a repeat diagnostic angiogram would not be performed or coded at this time. If such |

| | |a recent high-quality angiogram were not available, a diagnostic angiogram would be performed at this time and |

| | |the diagnostic angiogram RS&I would be reported separately. |

| | |After placement of the diagnostic catheter, baseline arterial blood sampling is obtained for ACT. Intravenous |

| | |heparin is administered to reach an ACT of approximately 300. A temporary occlusion balloon catheter is |

| | |carefully prepared in sterile fashion with half-strength contrast to remove all bubbles from the system and |

| | |balloon. The diagnostic catheter is positioned in the internal carotid artery and a 300-cm neuro-exchange wire |

| | |is advanced through the catheter and its tip placed within the petrous portion of the internal carotid artery. |

| | |The diagnostic catheter is removed and replaced with the temporary balloon occlusion catheter over the |

| | |neuro-exchange wire utilizing fluoroscopic monitoring. The balloon is advanced into the high cervical internal |

| | |carotid artery and the wire removed. The catheter is double flushed with heparinized saline. The balloon |

| | |occlusion catheter is attached to a three-way stopcock and the system is then attached to an airless |

| | |heparinized flush system previously prepared. A baseline neurological examination is performed, consisting of |

| | |motor function, cognition, sensory function including visual fields, speech, and short- and long-term memory. |

| | |The system is attached to a separate flush system for baseline measurement of intra-arterial distal occlusion |

| | |pressure. The temporary balloon occlusion catheter is carefully inflated and the carotid artery is thus |

| | |occluded under radiographically confirmed roadmap technique utilizing contrast injections and filming to |

| | |confirm stasis. |

| | |A small amount of contrast is gently injected to document stasis distal to the balloon. Occlusion |

| | |intra-arterial "stump" pressure is then measured. Immediately, neurologic examination is performed for |

| | |confirmation of neurological stability. This is repetitively performed at three-minute intervals. After 15 |

| | |minutes of evaluation with no change in neurological status, systemic hypotension is induced by slow |

| | |administration of pharmaceutical agent (eg, sodium nitroprusside) to a level 30% lower than baseline mean |

| | |arterial pressure. The patient remains neurologically intact for an additional 30 minutes with confirmation of |

| | |neurological stability by repeated exams including tests of motor strength, speech, and cognition. Continued |

| | |monitoring of "stump" pressure is performed. After completion of the process of neurological testing, the |

| | |occlusion balloon is slowly deflated and withdrawn into the common carotid artery and the nitroprusside is |

| | |stopped. Contrast is injected through the catheter and images are obtained to verify the absence of trauma to |

| | |the internal carotid artery at the location of the balloon and to verify that there is no change in the filling|

| | |of the distal territory of the internal carotid artery as well as the vessels within the brain. No hemodynamic |

| | |change or embolus is identified and the patient remains neurologically intact. An arterial blood sample is |

| | |obtained to measure ACT. The heparin is reversed by means of a slow infusion of protamine over 10 minutes |

| | |intravenously. The catheter is removed from the groin and hemostasis is obtained utilizing an endovascular |

| | |suture device. |

|[pic] |

|61630 |  |Clinical Example |

| | |A 66-year-old male presents with a history of left hemisphere transient ischemic attacks that persist on |

| | |medical therapy. A carotid duplex exam demonstrated no significant stenosis of the left carotid bifurcation. |

| | |Magnetic resonance angiography of the head is suspicious for significant stenosis of the M1 segment of the left|

| | |middle cerebral artery. The patient is referred for possible intracranial angioplasty. |

| | |Note: The proposed new code includes all selective vascular catheterization of the target vascular family, all |

| | |diagnostic imaging for arteriography of the target vascular family, and all related radiological supervision |

| | |and interpretation. Additionally, when the diagnostic arteriogram (including imaging and selective |

| | |catheterization) confirms the need for angioplasty or stent placement, 61630 is inclusive of these services. If|

| | |angioplasty or stenting are not indicated, then the appropriate codes for selective catheterization and imaging|

| | |should be reported in lieu of code 61635. |

| | |Description of Procedure |

| | |The common femoral artery is accessed and a sheath is placed under sterile conditions. A bolus dose of |

| | |intravenous heparin is administered. The activated coagulation time (ACT) is checked. Additional heparin is |

| | |given as necessary throughout the procedure, and the ACTs are monitored at appropriate intervals. Pressurized, |

| | |continuous heparin-saline flush systems are prepared. Meticulous examination of these systems is performed by |

| | |the physician to exclude the possibility of residual air bubbles. The left common carotid artery is selectively|

| | |catheterized with a 5 Fr catheter. Biplane anteroposterior (AP) and lateral angiograms of the cervical common |

| | |carotid artery are obtained. If necessary, oblique views are obtained to profile the carotid bifurcation. |

| | |Biplane AP and lateral (and possibly oblique) angiograms of the intracranial vessels are also obtained to |

| | |determine that no interval change has occurred since the original diagnostic angiogram. The catheter is |

| | |advanced into the external carotid artery over a steerable guidewire. Utilizing an exchange wire placed into |

| | |the external carotid artery, a neuroguide catheter is placed into the common carotid artery. |

| | |A common carotid artery angiogram is obtained to confirm the appropriate positioning of the guide catheter |

| | |below the carotid bifurcation and to exclude the possibility of arterial spasm, dissection, or thromboembolus |

| | |during the guide catheter placement. The guide catheter is advanced into the internal carotid artery over a |

| | |steerable guidewire. A cervical internal carotid artery angiogram is obtained to confirm the appropriate |

| | |positioning of the guide catheter and to exclude the possibility of arterial spasm, dissection, or |

| | |thromboembolus. The guide catheter is placed on a continuous heparin flush using a flow control Y-connector. |

| | |Biplane AP, lateral, and oblique angiograms of the cerebral vessels are obtained. High-magnification biplane |

| | |angiograms are obtained, centered upon the arterial stenosis. The target lesion must be carefully reassessed |

| | |for subtle changes that indicate the development of subacute intraluminal thrombus, which is a contraindication|

| | |to the performance of an angioplasty. Precise, quantitative measurements of the stenotic artery are obtained to|

| | |determine the proper diameter and length of the angioplasty balloon to be used. External reference markers may |

| | |be placed on the skin in order to calculate the precise dimensions. The physician prepares the appropriate size|

| | |angioplasty balloon. Meticulous preparation is done by the physician to eliminate the air within the balloon. A|

| | |steerable micro-guidewire and a low-profile microcatheter are advanced through the guide catheter into the |

| | |intracranial arteries using an angiographic roadmap. The micro-guidewire and microcatheter are advanced gently |

| | |across the arterial stenosis. The guidewire is removed and replaced with an exchange length wire, leaving the |

| | |wire tip beyond the stenotic area. The physician removes the microcatheter. The micro-angioplasty balloon is |

| | |advanced over the exchange wire and across the stenosis. Slowly the balloon is inflated to dilate the lesion |

| | |under fluoroscopic control while monitoring the balloon pressure. The physician deflates the balloon and |

| | |withdraws it into the internal carotid artery, leaving the guidewire across the stenosis. Post-angioplasty |

| | |angiograms are obtained by injecting contrast through the guide catheter to confirm satisfactory dilation of |

| | |vessel lumen and antegrade filling of distal blood vessels. Fifteen minutes pass before the angiogram is |

| | |repeated so as to exclude the possibility of hyperacute thrombotic occlusion or rebound stenosois. If evidence |

| | |of rebound stenosis arises, the balloon is placed again to re-dilate the lesion or exchanged for a larger |

| | |angioplasty balloon, if needed. Again, the physician waits 15 minutes and repeats the angiogram to exclude the |

| | |possibility of hyperacute thrombotic occlusion or rebound stenosois. After a 15-minute period of observation |

| | |with no further evidence of restenosis or acute arterial occlusion, the balloon and wire are removed and final |

| | |angiograms are obtained of the regional circulation to check for possible embolic complications. The physician |

| | |removes the guide catheter. All fluoroscopy, contrast injection, angiography, and image interpretation |

| | |associated with the arterial stenosis treated is included in the procedure up to this point |

|[pic] |

|61635 |  |Clinical Example |

| | |A 66-year-old male presents with a history of left hemisphere transient ischemic attacks that persist on |

| | |medical therapy. A carotid duplex exam demonstrated no significant stenosis of the left carotid bifurcation. |

| | |Magnetic resonance angiography of the head is suspicious for significant stenosis of the M1 segment of the left|

| | |middle cerebral artery. The patient is referred for possible intracranial stent. |

| | |Note: The proposed new code includes all selective vascular catheterization of the target vascular family, all |

| | |diagnostic imaging for arteriography of the target vascular family, and all related radiological supervision |

| | |and interpretation. Additionally, when the diagnostic arteriogram (including imaging and selective |

| | |catheterization) confirms the need for angioplasty or stent placement, 61635 is inclusive of these services. If|

| | |angioplasty or stenting are not indicated, then the appropriate codes for selective catheterization and imaging|

| | |should be reported in lieu of code 61635. |

| | |Description of Procedure |

| | |The common femoral artery is accessed and a 5 Fr sheath is placed under sterile conditions. A bolus dose of |

| | |intravenous heparin is administered. The right common carotid artery is selectively catheterized with a 5 Fr |

| | |catheter. The physician advances the catheter into the internal carotid artery over a guidewire. Using a neuro |

| | |exchange wire, a neuroguide catheter is placed into the internal carotid artery. Biplane anteroposterior (AP) |

| | |and lateral angiograms of the cerebral vessels are obtained. High-magnification biplane angiograms are obtained|

| | |centered upon the arterial stenosis. Precise, quantitative measurements of the stenotic artery are obtained to |

| | |determine the proper diameter and length of the angioplasty balloon to be used. External reference markers may |

| | |be placed on the skin to calculate the precise dimensions. Injection of a contrast in the AP and lateral images|

| | |and placement of an external marker help to measure the diameter and length of stenotic segment and assess |

| | |local flow dynamics. |

| | |The physician prepares the appropriate size of angioplasty balloon and stent systems. A hydrophilic guidewire |

| | |and a low profile microcatheter are advanced through the guide catheter using an angiographic roadmap into the |

| | |stenotic vessel. The microcatheter is passed across the middle cerebral artery stenosis. The physician removes |

| | |the guidewire and replaces it with an exchange wire, leaving the tip beyond the stenotic area. The |

| | |micro-angioplasty balloon is advanced over the exchange wire and across the stenosis. Slowly, the physician |

| | |inflates the balloon to pre-dilate the lesion under fluoroscopic control while monitoring the balloon’s |

| | |pressure. The balloon is deflated and withdrawn into the internal carotid artery, leaving the guidewire across |

| | |the stenosis. Postangioplasty angiograms are obtained by injecting contrast through the guide catheter to |

| | |confirm satisfactory pre-dilation of the vessel lumen such that a subsequent passage of the stent will be |

| | |possible. If pre-dilation appears to be insufficient to allow subsequent stent placement, then the balloon is |

| | |placed again to re-dilate the region or it is exchanged with a larger angioplasty balloon and the angioplasty |

| | |is repeated as necessary. The angioplasty balloon is removed, leaving the micro-exchange wire across the |

| | |lesion. |

| | |The physician advances the stent delivery system across the stenosis and deploys the stent. The stent delivery |

| | |catheter is withdrawn into the internal carotid artery, leaving the micro-guidewire across the stenosis. |

| | |Post-stent placement angiograms are obtained by injecting contrast through the guide catheter to confirm |

| | |satisfactory dilation of the vessel lumen and antegrade filling of the distal blood vessels. After a 15-minute |

| | |wait, the angiogram is repeated to exclude the possibility of hyperacute thrombotic occlusion. The guidewire is|

| | |removed. Final angiograms of the entire vascular circulation are obtained to check for possible embolic |

| | |complications. The guide catheter is removed. |

|[pic] |

|61640 |  |Clinical Example |

| | |A 42-year-old female with recent subarachnoid hemorrhage deteriorates clinically. She undergoes complete |

| | |cerebral angiography (separately reportable even if performed on the same day), which demonstrates significant |

| | |spasm of the supraclinoid segment of the right internal carotid artery. After receiving the report of this |

| | |finding, the attending neurosurgeon requests balloon dilatation of the spastic segment. |

| | |Note: The proposed new code includes all selective vascular catheterization of the target vessel, contrast |

| | |injection(s), vessel measurement, roadmapping, postdilatation angiography, and fluoroscopic guidance for |

| | |balloon dilatation. |

| | |Description of Procedure |

| | |The common femoral artery is accessed and a sheath is placed under sterile conditions. A bolus dose of |

| | |intravenous heparin is administered. The activated coagulation time (ACT) is checked. Additional heparin is |

| | |given as necessary throughout the procedure, and the ACTs are monitored at appropriate intervals. Pressurized, |

| | |continuous heparin-saline flush systems are prepared. Meticulous examination of these systems is performed by |

| | |the physician to exclude the possibility of residual air bubbles. The left common carotid artery is selectively|

| | |catheterized with a 5 Fr catheter. Biplane anteroposterior (AP) and lateral angiograms of the cervical common |

| | |carotid artery are obtained. If necessary, oblique views are obtained to profile the carotid bifurcation. |

| | |Biplane AP and lateral (and possibly oblique) angiograms of the intracranial vessels are also obtained to |

| | |determine that no interval change has occurred since the original diagnostic angiogram. The catheter is |

| | |advanced into the external carotid artery over a steerable guidewire. Using an exchange wire placed into the |

| | |external carotid artery, a neuroguide catheter is placed into the common carotid artery. |

| | |A common carotid artery angiogram is obtained to confirm the appropriate positioning of the guide catheter |

| | |below the carotid bifurcation and to exclude the possibility of arterial spasm, dissection, or thromboembolus |

| | |during guide catheter placement. The guide catheter is advanced into the internal carotid artery over a |

| | |steerable guidewire. A cervical internal carotid artery angiogram is obtained to confirm appropriate |

| | |positioning of the guide catheter and to exclude the possibility of arterial spasm, dissection, or |

| | |thromboembolus. The guide catheter is placed on a continuous heparin flush using a flow-control Y-connector. |

| | |Biplane AP, lateral, and oblique angiograms of the cerebral vessels are obtained. High-magnification biplane |

| | |angiograms are obtained, centered upon the arterial stenosis. The target lesion must be carefully reassessed |

| | |for subtle changes that indicate the development of subacute intraluminal thrombus, which is a contraindication|

| | |to performance of angioplasty. |

| | |Precise, quantitative measurements of the stenotic artery are obtained to determine the proper diameter and |

| | |length of the angioplasty balloon to be used. External reference markers may be placed on the skin in order to |

| | |calculate the precise dimensions. The appropriate size angioplasty balloon is prepared. Meticulous preparation |

| | |is done by the physician to eliminate the air within the balloon. A steerable micro-guidewire and a low-profile|

| | |microcatheter are advanced through the guide catheter into the intracranial arteries using an angiographic |

| | |roadmap. The micro-guidewire and microcatheter are advanced gently across the arterial stenosis. The guidewire |

| | |is removed and replaced with an exchange length wire, leaving the wire tip beyond the stenotic area. The |

| | |microcatheter is removed. The micro-angioplasty balloon is advanced over the exchange wire and across the |

| | |stenosis. Slowly the physician inflates the balloon to dilate the lesion under fluoroscopic control while |

| | |monitoring the balloon’s pressure. The balloon is deflated and withdrawn into the internal carotid artery, |

| | |leaving the guidewire across the stenosis. Post-angioplasty angiograms are obtained by injecting contrast |

| | |through the guide catheter to confirm satisfactory dilation of the vessel lumen and antegrade filling of the |

| | |distal blood vessels. After a 15-minute wait, the physician repeats the angiogram to exclude the possibility of|

| | |hyperacute thrombotic occlusion or rebound stenosois. If evidence of rebound stenosis arises, the balloon is |

| | |placed again to re-dilate the lesion or it is exchanged for a larger angioplasty balloon if needed. Again the |

| | |physician waits 15 minutes and repeats the angiogram to exclude the possibility of hyperacute thrombotic |

| | |occlusion or rebound stenosois. After a 15-minute period of observation with no further evidence of re-stenosis|

| | |or acute arterial occlusion, the balloon and wire are removed; final angiograms are obtained of the regional |

| | |circulation to check for possible embolic complications. The guide catheter is removed. All fluoroscopy, |

| | |contrast injection, angiography, and image interpretation associated with the arterial stenosis treated is |

| | |included in the procedure up to this point. |

|[pic] |

|61641 |  |Clinical Example |

| | |A 55-year-old male presents with a recent subarachnoid hemorrhage. Complete cerebral angiography (separately |

| | |reportable even if performed on the same day) demonstrated significant vasospasm in the supraclinoid left |

| | |internal carotid artery and the M1 segment of the left middle cerebral artery. After receiving the report of |

| | |this finding, the attending neurosurgeon requests balloon dilatation of the spastic segments. The internal |

| | |carotid spasm balloon dilatation is completed (separately reportable) and the M1 segment spasm is now to be |

| | |balloon dilated. |

| | |Note: Code 61641 is considered an add-on procedure code that should be reported in conjunction with 61640. |

| | |Additionally, the proposed new code includes all selective vascular catheterization of the target vessel, |

| | |contrast injection(s), vessel measurement, roadmapping, post-dilatation angiography, and fluoroscopic guidance |

| | |for balloon dilatation. |

| | |Description of Procedure |

| | |A second bolus dose of intravenous heparin may be administered. The activated coagulation time (ACT) is |

| | |checked. Additional heparin is given as necessary throughout the procedure, and the ACTs are monitored at |

| | |appropriate intervals. Biplane anteroposterior (AP), lateral, and oblique angiograms of the cerebral vessels |

| | |are obtained. High-magnification biplane angiograms are obtained, centered upon the arterial stenosis. The |

| | |target lesion must be carefully reassessed for subtle changes that indicate the development of subacute |

| | |intraluminal thrombus, which is a contraindication to the performance of an angioplasty. Precise, quantitative |

| | |measurements of the stenotic artery are obtained to determine the proper diameter and length of the angioplasty|

| | |balloon to be used. External reference markers may be placed on the skin in order to calculate the precise |

| | |dimensions. The physician prepares the appropriate size angioplasty balloon. Meticulous preparation is done by |

| | |the physician to eliminate the air within the balloon. A steerable micro-guidewire and a low-profile |

| | |microcatheter are advanced through the guide catheter into the second target intracranial artery(ies) |

| | |(additional vessel, same vascular family) using an angiographic roadmap. The micro-guidewire and microcatheter |

| | |are advanced gently across the arterial stenosis. The physician removes the guidewire and replaces it with an |

| | |exchange length wire, leaving the wire tip beyond the stenotic area. The microcatheter is removed. The |

| | |micro-angioplasty balloon is advanced over the exchange wire and across the stenosis. Slowly the physician |

| | |inflates the balloon to dilate the lesion under fluoroscopic control while monitoring the balloon’s pressure. |

| | |The balloon is deflated and withdrawn into the internal carotid artery, leaving the guidewire across the |

| | |stenosis. |

| | |Post-angioplasty angiograms are obtained by injecting contrast through the guide catheter to confirm |

| | |satisfactory dilation of the vessel lumen and antegrade filling of the distal blood vessels. After a 15-minute |

| | |wait, the physician repeats the angiogram to exclude the possibility of hyperacute thrombotic occlusion or |

| | |rebound stenosois. If evidence of rebound stenosis arises, the balloon is placed again to re-dilate the lesion |

| | |or it is exchanged for a larger angioplasty balloon if needed. Again 15 minutes is allowed to pass and the |

| | |angiogram is repeated to exclude the possibility of hyperacute thrombotic occlusion or rebound stenosois. After|

| | |a 15-minute period of observation with no further evidence of re-stenosis or acute arterial occlusion, the |

| | |balloon and wire are removed and final angiograms of the regional circulation are obtained to check for |

| | |possible embolic complications. The guide catheter is removed. All fluoroscopy, contrast injection, |

| | |angiography, and image interpretation associated with the arterial stenosis treated is included in the |

| | |procedure up to this point. |

|[pic] |

|61642 |  |Clinical Example |

| | |A 55-year-old male presents with a recent subarachnoid hemorrhage. A complete cerebral angiography (separately |

| | |reportable even if performed on the same day) demonstrated significant vasospasm in the supraclinoid left |

| | |internal carotid artery and the M1 segment of the right middle cerebral artery. After receiving the report of |

| | |this finding, the attending neurosurgeon requests balloon dilatation of the spastic segments. The left internal|

| | |carotid spasm balloon dilatation is completed (separately reportable) and the right M1 segment spasm is now to |

| | |be dilated. |

| | |Note: Code 61642 is considered an add-on procedure code that should be reported in conjunction with 61640. |

| | |Additionally, the proposed new code includes all selective vascular catheterization of the target vessel, |

| | |contrast injection(s), vessel measurement, roadmapping, post-dilatation angiography, and fluoroscopic guidance |

| | |for balloon dilatation. |

| | |Description of Procedure |

| | |A second bolus dose of intravenous heparin may be administered. The activated coagulation time (ACT) is |

| | |checked. Additional heparin is given as necessary throughout the procedure, and the ACTs are monitored at |

| | |appropriate intervals. Pressurized, continuous heparin-saline flush systems are prepared. Meticulous |

| | |examination of these systems is performed by the physician to exclude the possibility of residual air bubbles. |

| | |The left common carotid artery is selectively catheterized with a 5 Fr catheter. Biplane anteroposterior (AP) |

| | |and lateral angiograms of the cervical common carotid artery are obtained. If necessary, oblique views are |

| | |obtained to profile the carotid bifurcation. Biplane AP and lateral (and possibly oblique) angiograms of the |

| | |intracranial vessels are also obtained to determine that no interval change has occurred since the original |

| | |diagnostic angiogram. A catheter is advanced into the external carotid artery over a steerable guidewire. Using|

| | |an exchange wire placed into the external carotid artery, a neuroguide catheter is placed into the common |

| | |carotid artery. |

| | |A common carotid artery angiogram is obtained to confirm appropriate positioning of the guide catheter below |

| | |the carotid bifurcation and to exclude the possibility of arterial spasm, dissection, or thromboembolus during |

| | |guide catheter placement. The guide catheter is advanced into the internal carotid artery over a steerable |

| | |guidewire. A cervical internal carotid artery angiogram is obtained to confirm appropriate positioning of the |

| | |guide catheter and to exclude the possibility of arterial spasm, dissection, or thromboembolus. The guide |

| | |catheter is placed on continuous heparin flush using a flow-control Y-connector. Biplane AP, lateral, and |

| | |oblique angiograms of the cerebral vessels are obtained. High magnification biplane angiograms are obtained, |

| | |centered upon the arterial stenosis. The target lesion must be carefully reassessed for subtle changes that |

| | |indicate the development of subacute intraluminal thrombus, which is a contraindication to the performance of |

| | |an angioplasty. |

| | |Precise, quantitative measurements of the stenotic artery are obtained to determine the proper diameter and |

| | |length of the angioplasty balloon to be used. External reference markers may be placed on the skin in order to |

| | |calculate the precise dimensions. The physician prepares the appropriate size angioplasty balloon. Meticulous |

| | |preparation is done by the physician to eliminate the air within the balloon. A steerable micro-guidewire and a|

| | |low-profile microcatheter are advanced through the guide catheter into the additional vessel (in a vascular |

| | |family different from the vessel coded in 61640). The micro-guidewire and microcatheter are advanced gently |

| | |across the arterial stenosis. The physician removes the guidewire and replaces it with an exchange length wire,|

| | |leaving the wire tip beyond the stenotic area. The microcatheter is removed. The micro-angioplasty balloon is |

| | |advanced over the exchange wire and across the stenosis. Slowly the physician inflates the balloon to dilate |

| | |the lesion under fluoroscopic control while monitoring the balloon’s pressure. The balloon is deflated and |

| | |withdrawn into the internal carotid artery, leaving the guidewire across the stenosis. Post-angioplasty |

| | |angiograms are obtained by injecting contrast through the guide catheter to confirm satisfactory dilation of |

| | |the vessel lumen and antegrade filling of the distal blood vessels. After a 15-minute wait, the physician |

| | |repeats the angiogram to exclude the possibility of hyperacute thrombotic occlusion or rebound stenosois. If |

| | |evidence of rebound stenosis arises, the balloon is placed again to re-dilate the lesion or it is exchanged for|

| | |a larger angioplasty balloon if needed. Again, 15-minutes is allowed to pass and the angiogram is repeated to |

| | |exclude the possibility of hyperacute thrombotic occlusion or rebound stenosis. After a 15-minute period of |

| | |observation with no further evidence of re-stenosis or acute arterial occlusion, the balloon and wire are |

| | |removed and final angiograms of the regional circulation are obtained to check for possible embolic |

| | |complications. The guide catheter is removed. All fluoroscopy, contrast injection, angiography, and image |

| | |interpretation associated with the arterial stenosis treated is included in the procedure up to this point. |

|[pic] |

|61697 |  |Clinical Vignette (61697) |

| | |A 45-year-old woman presents with severe headache, nausea, vomiting and decreased level of consciousness. A |

| | |computed tomographic brain scan demonstrates diffuse subarachnoid hemorrhage and an angiogram discloses the |

| | |source of the hemorrhage as a 2.5 cm aneurysm arising from the right internal carotid artery apex with a wide |

| | |neck and intraluminal thrombus. The patient is a candidate for surgery for intracranial aneurysm. |

| | |Description of Procedure (61697) |

| | |The patient is placed under general anesthesia. The aneurysm(s) is approached as is done in 61702. After |

| | |dissection of the aneurysm is accomplished it is determined that because of the size and/or configuration of |

| | |the aneurysm or because of calcification of the aneurysm neck, simple clip ligation of the aneurysm is not |

| | |possible and other intraoperative measures will need to be executed to assure adequate treatment of the |

| | |aneurysm. Such measures include multiple clip application, temporary proximal vessel occclusion, temporary |

| | |trapping of the vascular segment containing the aneurysm, aneurysm puncture and/or endaneurymsorrhaphy or |

| | |profound hypothermia with cardiopulmonary bypass. Using these adjuncts the aneurysm is excluded from the |

| | |circulation and the cranial opening is closed in a similar manner to that described in 61702 after which |

| | |general anesthesia is terminated. |

|[pic] |

|61751 |  |A 45-year-old white man with recently onset of right arm weakness. Physical examination and radiologic brain |

| | |evaluation of the patient, as an outpatient, has revealed a 4 cm diameter, radiologic dye-enhancing mass in the|

| | |left posterior frontal lobe of the brain. Oncologic evaluation has revealed no evidence of any other mass in |

| | |the patient's body. The mass is deemed unresectable because of its location, and a stereotactic biopsy, using |

| | |MRI, is recommended to determine the nature of this mass. |

|[pic] |

|61770 |  |Clinical Vignette (61770) |

| | |The typical patient has metastatic brain cancer, from some other region of the body. |

| | |Description of Procedure (61770) |

| | |Prior to the procedure, a preliminary treatment plan is devised for each patient based on tumor size, location |

| | |and presumed histological type. Lesion dimensions are estimated from pre-treatment contrast-enhanced CT or MRI |

| | |and combined with isodose curves to determine the optimal radiation treatment plan. The probe tip position, |

| | |beam voltage and current are then used to calculate the duration of treatment required to administer the |

| | |prescribed dose (10 to 15 Gy) to the periphery of the tumor with a 2 mm margin. |

| | |A stereotactic frame is fixed to the patient. Stereotactic CT with contrast enhancement is performed. The |

| | |distance from the center of the lesion to the scalp surface bilaterally is also recorded to calculate the |

| | |expected surface dose for comparison to actual surface dose during treatment. Unless a biopsy was recently |

| | |performed, a stereotactic biopsy is performed through a burr hole, and specimens from the target are submitted |

| | |for pathological analysis. All procedures are performed under local anesthesia with IV sedation to minimize |

| | |patient discomfort. |

| | |The needle track for the biopsy is expanded to accommodate the 3 mm probe tip using a graduated series of |

| | |dilators. The housing of the PRS system is then mounted on the stereotactic frame. The probe tip is positioned |

| | |to the targeted coordinates. Treatment radiation monitors are then inserted into the side carrier rings of the |

| | |frame to confirm expected surface dose during treatment. Treatment is initiated by activation of the device at |

| | |the prescribed voltage and current parameters for the calculated time interval. On completion of treatment, the|

| | |probe is removed and the incision closed. |

|[pic] |

|61862 |  |A 45-year-old man presents with essential tremor that has become quite severe and is disabling. He has had the |

| | |disease for 8 years and has failed to obtain tremor relief with various oral medications and physical therapy. |

| | |He is not a candidate for direct brain resection or an ablative brain procedure because of the severity of his |

| | |tremor and the duration of symptoms. He undergoes a trial implantation of one stereotactically guided deep |

| | |brain stimulator elecrode array in the VIM nucleus of the thalamus. |

|[pic] |

|61863 |  |Clinical Example (61863) |

| | |A 66-year-old woman presents with a 10-year history of idiopathic Parkinson's disease that has caused |

| | |progressive disability. She continues to respond to antiParkinson medications; however, her symptoms are no |

| | |longer adequately controlled with medications and she is experiencing disability in many activities of daily |

| | |living. Medication adjustments and different medication regimens have failed to improve her level of |

| | |disability. She undergoes implantation of a stereotactically guided deep brain stimulator electrode array in |

| | |the subthalamic nucleus using macro-stimulation for targeting and confirmation of electrode placement. |

| | |Description of Procedure (61863) |

| | |Prior to surgery, a local anesthetic is administered and a stereotactic frame is attached using pins to anchor |

| | |the frame to the skull (inherent/bundled). Care is taken to align the frame with the inferior rim of the orbit |

| | |and the external auditory meatus and to keep the frame level with the head. The surgeon accompanies the patient|

| | |to the radiology department to obtain a CT or MRI scan (separately reportable with codes 70551 or 70450). The |

| | |surgeon aligns the patient in the scanner. After the scans are performed, the surgeon plans the stereotactic |

| | |surgery with computer assistance. This planning includes identifying MRI or CT marker points and the desired |

| | |target; determining the coordinates for the target; measuring the AC-PC line; and calculating angles. Using a |

| | |computer, various trajectories for the electrode placement to reach the target are examined before choosing one|

| | |specific trajectory and calculating the entry point through the skull based upon safety and target coverage |

| | |considerations using an anatomic atlas of the basal ganglia. After planning is complete, the patient returns to|

| | |the OR and the surgeon helps position the patient on the operating table. While the patient is prepped and |

| | |draped, the surgeon scrubs for the procedure. |

| | |Components of the frame are assembled, and the coordinates of the entry point are entered into the stereotactic|

| | |arc system. The entry point is localized with the stereotactic arc and the incision is marked. Under IV |

| | |sedation, the skin is infiltrated with local anesthetic. The previously marked incision is opened. The wound |

| | |edge is retracted and hemostasis is obtained with electrocautery. A cranial drill is used to make a single |

| | |twist drill or burr hole 25-35 mm from the midline at the level of the coronal suture. The dura is coagulated |

| | |and punctured. The entry point of the guide cannula is inspected and the brain surface is coagulated, taking |

| | |care to avoid major cortical vessels. Next, the electrode guide is attached to the stereotactic arc, and a |

| | |guide cannula inserted into the brain. The deep brain stimulation array is introduced to the selected target |

| | |point. Test stimulation is carried out, testing for tremor suppression, reduced rigidity, limb mobility and |

| | |coordination as well as possible side effects. The electrode array is repositioned and re-stimulated as many |

| | |times as necessary to obtain the best degree of tremor suppression and least side effects. Periodic examination|

| | |of relevant neurologic functions and the effect of trial stimulation is performed by either operating surgeon |

| | |or a neurologist/neurophysiologist. When optimal placement of the electrode is confirmed, the guide cannula is |

| | |removed from the brain, leaving the electrode array in place. This procedure is usually monitored |

| | |radiographically (fluoroscopic and/or x-ray, inherent/bundled) to assure that the electrode array has not |

| | |changed position. The electrode array is fastened in place using an anchoring device. Absolute hemostasis is |

| | |obtained. The lead is coiled in a subgaleal pocket. The galea is closed with sutures and the skin is closed |

| | |with sutures or staples. Sterile dressings are applied, and the stereotactic frame is removed. The four pin |

| | |sites are dressed. |

|[pic] |

|61864 |  |Clinical Example (61864) |

| | |A 66-year-old woman presents with a 10-year history of idiopathic Parkinson's disease that has caused |

| | |progressive disability. She continues to respond to antiParkinson medications; however, her symptoms are no |

| | |longer adequately controlled with medications and she is experiencing disability for many activities of daily |

| | |living. Medication adjustments and different medication regimens have failed to improve her level of |

| | |disability. She undergoes implantation of a second stereotactically guided deep brain stimulator electrode |

| | |array in the subthalamic nucleus using macro-stimulation for targeting and confirmation of electrode placement.|

| | |Description of Procedure (61864) |

| | |After the scans are performed and the first target plotted, the surgeon plans the stereotactic surgery for the |

| | |second target with computer assistance. This planning includes identifying MRI or CT marker points bilaterally |

| | |and the desired targets; determining the coordinates for the targets; measuring the AC-PC line; and calculating|

| | |angles. Using a computer, various trajectories for the electrode placement to reach the targets are examined |

| | |before choosing one specific trajectory and calculating the entry point through the skull based upon safety and|

| | |target coverage considerations using an anatomic atlas of the basal ganglia. After implantation of the first |

| | |electrode array, the scalp is re-prepped and draped for the second electrode implantation and the surgeon |

| | |scrubs. |

| | |The skin on the second side is infiltrated with local anesthetic. A linear incision is made just anterior to |

| | |the coronal suture. The wound edge is retracted and hemostasis is obtained with electrocautery. A cranial drill|

| | |is used to make a single twist drill or burr hole 25-35 mm from the midline at the level of the coronal suture.|

| | |The dura is coagulated and punctured. Next, components of the frame are assembled, coordinates set, and the |

| | |electrode guide is attached. The electrode array is marked for the appropriate depth of placement. The |

| | |electrode array is passed into the pre-determined site using stereotactic coordinates. To establish a baseline,|

| | |a neurologic examination is performed of relevant patient functions. The electrode array is inserted through |

| | |the stereotactic guide and stimulated to determine the degree of tremor suppression. Microelectrode recording |

| | |is not used during this phase of the procedure. The electrode array is repositioned and re-stimulated as many |

| | |times as necessary to obtain the best degree of tremor suppression, reduced rigidity, limb mobility and |

| | |coordination as well as possible side effects. When the position and clinical effect of stimulation appear |

| | |optimal, absolute hemostasis is obtained and the electrode array implanted, attaching the plastic ring and |

| | |grommet to the burr hole in the skull. This procedure is usually monitored radiographically (fluoroscopic |

| | |and/or x-ray, inherent/bundled) to assure that the electrode array has not changed position. The wounds are |

| | |irrigated with antibiotic solution. If this is to be a one-stage operation (ie, the stimulator generator is |

| | |placed at the same operative setting), then the lead is coiled in a subgaleal pocket. The subgaleal and |

| | |subcutaneous tissues are closed with interrupted 2-0 Vicryl suture. If this is to be a two-stage operation (ie,|

| | |the stimulator generator is placed at a later date), then the tail of the electrodes is subcutaneously tunneled|

| | |and left in the subgaleal space. Either way, the subcutaneous tissues and skin are closed with deep sutures and|

| | |staples. Sterile dressings are applied, and the stereotactic frame is removed. The four pin sites are dressed. |

|[pic] |

|61867 |  |Clinical Example (61867) |

| | |A 66-year-old woman presents with a 10-year history of idiopathic Parkinson's disease that has caused |

| | |progressive disability. She continues to respond to antiParkinson medications; however, her symptoms are no |

| | |longer adequately controlled with medications and she is experiencing disability in many activities of daily |

| | |living. Medication adjustments and different medication regimens have failed to improve her level of |

| | |disability. She undergoes implantation of a stereotactically guided deep brain stimulator electrode array in |

| | |the subthalamic nucleus using microelectrode recording and macro-stimulation for targeting and confirmation of |

| | |electrode placement. |

| | |Description of Procedure (61867) |

| | |Prior to surgery, a local anesthetic is administered and a stereotactic frame is attached using pins to anchor |

| | |the frame to the skull (inherent/bundled). Care is taken to align the frame with the inferior rim of the orbit |

| | |and the external auditory meatus and to keep the frame level with the head. The surgeon accompanies the patient|

| | |to the radiology department to obtain a CT or MRI scan (separately reportable with codes 70551 or 70450). The |

| | |surgeon aligns the patient in the scanner. After the scans are performed, the surgeon plans the stereotactic |

| | |surgery with computer assistance. This planning includes identifying MRI or CT marker points and the desired |

| | |target; determining the coordinates for the target; measuring the AC-PC line; and calculating angles. Using a |

| | |computer, various trajectories for the electrode placement to reach the target are examined before choosing one|

| | |specific trajectory and calculating the entry point through the skull based upon safety and target coverage |

| | |considerations using an anatomic atlas of the basal ganglia. After planning is complete, the patient returns to|

| | |the OR and the surgeon helps position the patient on the operating table. While the patient is prepped and |

| | |draped, the surgeon scrubs for the procedure. |

| | |Components of the frame are assembled, and the coordinates of the entry point are entered into the stereotactic|

| | |arc system. The entry point is localized with the stereotactic arc and the incision is marked. Under IV |

| | |sedation, the skin is infiltrated with local anesthetic. The previously marked incision is opened. The wound |

| | |edge is retracted and hemostasis is obtained with electrocautery. A cranial drill is used to make a single |

| | |twist drill or burr hole 25-35 mm from the midline at the level of the coronal suture. The dura is coagulated |

| | |and punctured. The entry point of the guide cannula is inspected and the brain surface is coagulated, taking |

| | |care to avoid major cortical vessels. Next, the electrode guide is attached to the stereotactic arc, and a |

| | |guide cannula inserted into the brain. The microelectrode is tested for appropriate electrical impedance, |

| | |placed into a second protective cannula, and attached to the microdrive. The microdrive/electrode assembly is |

| | |then attached to the stereotactic arc, placing the inner protective cannula into the outer guide cannula. The |

| | |microelectrode is then advanced using the microdrive, recording from individual neurons and pausing |

| | |periodically to test the response of these neurons to light touch, passive joint movement, and other peripheral|

| | |stimuli. The borders of the deep brain nuclei are mapped out and recorded in a linear format, referencing the |

| | |electrophysiological findings to a stereotactic atlas. Microstimulation may be periodically done during each |

| | |microelectrode track, and the patient asked to report any side effects from the stimulation. Periodic |

| | |examination of relevant neurologic functions and the effect of trial stimulation is performed by either the |

| | |operating surgeon or a neurologist/ neurophysiologist. Numerous microelectrode tracks may be required to |

| | |adequately define the target area. The average number of tracks is 2.4 for a unilateral procedure, which |

| | |requires an average of 91 separate advances of the electrode by the microdrive. |

| | |Once an optimal target has been defined by microelectrode recording and stimulation, the microelectrode is |

| | |removed from the outer cannula and the deep brain stimulation array is introduced. Test stimulation is carried |

| | |out, testing for tremor suppression, reduced rigidity, limb mobility and coordination as well as possible side |

| | |effects. The electrode array is repositioned and re-stimulated as many times as necessary to obtain the best |

| | |degree of tremor suppression and least side effects. When optimal placement of the electrode is confirmed, the |

| | |guide cannula is removed from the brain, leaving the electrode array in place. This procedure is usually |

| | |monitored radiographically (fluoroscopic and/or x-ray, inherent/bundled) to assure that the electrode array has|

| | |not changed position. The electrode array is fastened in place using an anchoring device. Absolute hemostasis |

| | |is obtained. The lead is coiled in a subgaleal pocket. The galea is closed with sutures and the skin is closed |

| | |with sutures or staples. Sterile dressings are applied, and the stereotactic frame is removed. The four pin |

| | |sites are dressed. |

|[pic] |

|61868 |  |Clinical Example (61868) |

| | |A 66-year-old woman presents with a 10-year history of idiopathic Parkinson's disease that has caused |

| | |progressive disability. She continues to respond to antiParkinson medications; however, her symptoms are no |

| | |longer adequately controlled with medications and she is experiencing disability in many activities of daily |

| | |living. Medication adjustments and different medication regimens have failed to improve her level of |

| | |disability. She undergoes implantation of a second stereotactically guided deep brain stimulator electrode |

| | |array in the subthalamic nucleus using microelectrode recording and macro-stimulation for targeting and |

| | |confirmation of electrode placement bilaterally. |

| | |Description of Procedure (61868) |

| | |After the scans are performed, the surgeon plans the stereotactic surgery with computer assistance. This |

| | |planning includes identifying MRI or CT marker points bilaterally and the desired targets on the second side; |

| | |determining the coordinates for the targets; measuring the AC-PC line; and calculating angles. Using a |

| | |computer, various trajectories for the electrode placement to reach the targets are examined before choosing |

| | |one specific trajectory and calculating the entry point through the skull based upon safety and target coverage|

| | |considerations using an anatomic atlas of the basal ganglia. After implantation of the first electrode array, |

| | |the scalp is re-prepped and draped for the second electrode implantation and the surgeon scrubs. |

| | |The coordinates of the entry point for the second side are entered into the stereotactic arc system. The entry |

| | |point for the second implant is localized with the stereotactic arc and the incision site is marked. Under IV |

| | |sedation, the skin is infiltrated with local anesthetic. The marked incision site is opened. The wound edge is |

| | |retracted and hemostasis is obtained with electrocautery. A cranial drill is used to make a single twist drill |

| | |or burr hole at the calculated entry site, which is usually 25-35 mm from the midline at the level of the |

| | |coronal suture. The dura is coagulated and punctured. The entry point of the guide cannula is inspected and the|

| | |brain surface is coagulated, taking care to avoid major cortical vessels. Next, the electrode guide is attached|

| | |to the stereotactic arc, and a guide cannula inserted into the brain. The microelectrode is tested for |

| | |appropriate electrical impedance, withdrawn into a second protective cannula, and attached to the microdrive. |

| | |The microdrive/electrode assembly is then attached to the stereotactic arc, placing the inner protective |

| | |cannula into the outer guide cannula. The microelectrode is then advanced using the microdrive, recording from |

| | |individual neurons and pausing periodically to test the response of these neurons to light touch, passive joint|

| | |movement, and other stimuli. The borders of the deep brain nuclei are mapped out and recorded in a linear |

| | |format, referencing the electrophysiological findings to a stereotactic atlas. Microstimulation may be |

| | |periodically carried out during each microelectrode track, and the patient is asked to report any side effects |

| | |from stimulation. Periodic examination of relevant neurologic functions and the effect of trial stimulation is |

| | |performed by either the operating surgeon or a neurologist/neurophysiologist. Numerous microelectrode tracks |

| | |may be required to adequately define the target area. The average number of tracks is 2.1 for the second |

| | |implantation, which requires an average of 92 separate advances of the electrode by the microdrive. |

| | |Once an optimal target has been defined by microelectrode recording and stimulation, the microelectrode is |

| | |removed from the outer cannula and the deep brain stimulation array is introduced. Test stimulation is carried |

| | |out, testing for tremor suppression, reduced rigidity, limb mobility and coordination as well as possible side |

| | |effects. The electrode array is repositioned and re-stimulated as many times as necessary to obtain the best |

| | |degree of tremor suppression and least side effects. The guide cannula is removed from the brain, leaving the |

| | |electrode array in place. This procedure is usually monitored radiographically (fluoroscopic and/or x-ray, |

| | |inherent/bundled) to assure that the electrode array has not changed position. The electrode array is fastened |

| | |in place using an anchoring device. Absolute hemostasis is obtained. The lead is coiled in a subgaleal pocket. |

| | |The galea is closed with sutures and the skin is closed with sutures or staples. Sterile dressings are applied,|

| | |and the stereotactic frame is removed. The four pin sites are dressed. |

|[pic] |

|61885 |  |Clinical Example (61885) |

| | |A 45-year-old male presents with essential tremor that has become quite severe and is disabling. He has had the|

| | |disease for 8 years and has failed to obtain tremor relief using various oral medications and physical therapy.|

| | |He is not a candidate for direct brain resection or an ablative brain procedure because of the severity of his |

| | |tremor and the length of symptoms. His history also includes implantation of a deep brain stimulator electrode |

| | |array, which upon stimulation, eliminated 80% of the patient's tremor. He undergoes internalization of the tail|

| | |of the electrode array and placement and connection of a subcutaneous stimulator generator for long-term brain |

| | |stimulation. |

| | |Description of Procedure (61885) |

| | |Under general anesthesia, the cranial lead is recovered from the subgaleal space. A linear incision is made |

| | |just below the clavicle over a distance of approximately 3 cm. A subcutaneous pocket is created under this |

| | |incision. The cephalic wound is re-opened where the electrode array had been placed. A small incision is made |

| | |at approximately the level of the mastoid and the electrode extension passer is passed from the cephalic wound |

| | |down a subgaleal tract and out the mastoid wound. Using this passer, the lead is pulled through the |

| | |subcutaneous tract. The same passer is passed from the mastoid wound down another subcutaneous tract and out |

| | |the clavicular wound, pulling the electrode tail and extension wire through this subcutaneous tract. A sleeve |

| | |is placed on the distal tail of the electrode array. The array tail is inserted into the proximal end of the |

| | |extension wire and tightened. The sleeve is placed over the connection and tied in place with 0-silk suture. |

| | |The boot and connector are placed in the subgaleal space while the proximal end of the extension wire is |

| | |secured to the skull. The distal end of the extension wire is inserted into the generator and tightened. Excess|

| | |extension wire is coiled behind the stimulator generator. The stimulator generator is sutured into place in the|

| | |subcutaneous tissue. The stimulator is tested, under sterile technique, to determine the impedance of the |

| | |connections and to rule out an electrical short. The skin and subcutaneous tissues of all wounds are closed |

| | |with deep sutures and skin staples. |

|[pic] |

|61886 |  |A 35-year-old man presents with bilateral essential tremor that has become quite severe and is disabling. He |

| | |has had the disease for 10 years and has failed to obtain tremor relief with various oral medications and |

| | |physical therapy. He is not a candidate for direct brain resection or an ablative brain procedure because of |

| | |the severity of his tremor and the duration of symptoms. His history also includes implantation of bilaterally |

| | |placed deep brain stimulator electrode arrays, which, upon stimulation, eliminated 90% of the patient's tremor.|

| | |Stimulation of either electrode alone, however, provides only about 80% relief on the one side and no relief on|

| | |the other side. He undergoes internalization of the tails both electrode arrays and placement and connection of|

| | |a single subcutaneous stimulator generator for long-term brain stimulation. |

|[pic] |

|62148 |  |Clinical Example (62148) |

| | |A 25-year-old male, who is status post-emergency craniotomy for decompression with intraoperative placement of |

| | |the bone graft into an abdominal subcutaneous pocket presents for elective cranioplasty repair of the skull |

| | |defect. While in the operating room for elective cranioplasty, the abdominal graft site incision is sterilely |

| | |prepped and draped. The previous incision is opened sharply, and the bone graft is identified. Using blunt |

| | |dissection and electrocautery, the graft is freed from the surrounding tissue and temporarily placed in |

| | |antibiotic solution on the back table, pending cranial implantation. The wound is irrigated, hemostasis is |

| | |ensured, and the skin is closed and dressed after completion of the cranial procedure. |

| | |Description of Procedure (62148) |

| | |While in the OR for elective cranioplasty, the abdominal graft site incision is sterilely prepped and draped. |

| | |The previous incision is opened sharply, and the bone graft is identified. Using blunt dissection and |

| | |electrocautery, the graft is freed from the surrounding tissue and temporarily placed in antibiotic solution on|

| | |the back table, pending cranial implantation. The wound is irrigated, hemostasis is ensured, and the skin is |

| | |closed and dressed after completion of the cranial procedure. |

|[pic] |

|62160 |  |Clinical Example (62160) |

| | |A 5-year-old boy with hydrocephalus secondary to intraventricular hemorrhage and prematurity develops shunt |

| | |malfunction. Examination of the shunt system shows very slow refilling and CT scan reveals enlarged ventricles |

| | |with the ventricular catheter positioned along the choroid plexus in the lateral ventricle. He is admitted for |

| | |replacement of his ventricular catheter using neuroendoscopy to facilitate removal of the obstructed catheter |

| | |and accurate placement of a new ventricular catheter. |

| | |Description of Procedure (62160) |

| | |At operation, the ventricular catheter is replaced (coded separately) using neuroendoscopy. The neuroendoscope |

| | |is placed through the burr hole into the lateral ventricle and advanced to allow identification of the |

| | |ventricular catheter, the foramen of Monro, and the choroid plexus. Under direct visualization, the |

| | |malfunctioning catheter is removed and a new ventricular catheter is placed in a location away from the choroid|

| | |plexus. |

|[pic] |

|62161 |  |Clinical Example (62161) |

| | |A 19-year-old male presents with a history of hydrocephalus complicated in the past by ventriculitis and |

| | |intraventricular pseudocyst formation, previously treated with two ventriculo-peritoneal shunts, now |

| | |complicated by infection of the peritoneal catheters. The shunts have been removed for treatment of the |

| | |infection and a new shunt must be placed with the terminus in the right atrium of the heart. He undergoes |

| | |neuroendoscopy where the pseudocyst walls are opened so that all the ventricles communicate and are drained by |

| | |a single ventriculo-atrial shunt catheter. |

| | |Description of Procedure (62161) |

| | |The skin is incised and hemostasis achieved with retraction and electrocautery. A power perforator is used to |

| | |make a burr hole and hemostasis is achieved with bone wax. The dura is coagulated with bipolar coagulation and |

| | |opened with sharp dissection. The cortex is inspected to make sure that there are no large cortical blood |

| | |vessels directly in the area where a cortical incision will be made. The cortex is coagulated with bipolar |

| | |coagulation and opened with sharp dissection. A 5-mm peel-away trocar is introduced through the brain into the |

| | |ventricle. The inner stylet of the trocar is removed and the flexible neuroendoscope is passed through the |

| | |trocar into the ventricle. The walls of the pseudocyst are identified. Using various micro-instruments through |

| | |the working channel of the neuroendoscope, the pseudocyst wall is perforated and the opening enlarged. The |

| | |neurosurgeon then advances the neuroendoscope into the pseudocyst and the back wall of the pseudocyst is opened|

| | |and enlarged with the micro-instruments. Bleeding is controlled with irrigation and bipolar electrocautery. The|

| | |neuroendoscope is advanced to inspect the rest of the ventricular system and ensure that there is good |

| | |communication of spinal fluid throughout the system. The neuroendoscope is carefully backed out until the tip |

| | |of the endoscope is straight and located in an area free of choroid plexus and loose pseudocyst wall. The |

| | |trocar sheath is then advanced to the tip of the neuroendoscope and the length of the neuroendoscope relative |

| | |to the trocar is noted. The neuroendoscope is removed and replaced with a ventricular catheter at exactly the |

| | |same length as the neuroendoscope. The neurosurgeon takes a small sample of cerebrospinal fluid and sends it to|

| | |pathology for analysis. The trocar is peeled away. The ventricular catheter is cut to the proper length and |

| | |secured to the proximal portion of a one-way flow-control valve. The distal shunt tubing is passed from the |

| | |scalp incision to a new incision in the neck using a shunt passer (coded separately). A branch of the external |

| | |jugular vein is isolated in the neck and the distal shunt is passed into the venous system toward the right |

| | |atrium. The location of the tip of the distal catheter is monitored by the neurosurgeon with intra-operative |

| | |fluoroscopy until it is in the right atrium. The neurosurgeon consults with the anesthesiologist to make sure |

| | |that there are no cardiac arrhythmias. The proximal portion of the catheter is cut to the proper length and |

| | |secured to the distal port of the flow-controlled valve. The ventricular catheter is secured to the periosteum.|

| | |The wounds are closed. |

|[pic] |

|62162 |  |Clinical Example (62162) |

| | |A 21-year-old male with acute hydrocephalus secondary to a third ventricular colloid cyst undergoes |

| | |neuroendoscopic excision of the colloid cyst. |

| | |Description of Procedure (62162) |

| | |The skin is incised and hemostasis achieved with retraction and electrocautery. A power perforator is used to |

| | |make a burr hole and hemostasis is achieved with bone wax. The dura is coagulated with bipolar coagulation and |

| | |opened with sharp dissection. The cortex is inspected to make sure that there are no large cortical blood |

| | |vessels directly in the area where a cortical incision will be made. The cortex is coagulated with bipolar |

| | |coagulation and opened with sharp dissection. A 5-mm peel-away trocar is introduced through the brain into the |

| | |ventricle. The inner stylet of the trocar is removed and the neuroendoscope is passed through the trocar into |

| | |the ventricle. The choroid plexus, the foramen of Monro, and the colloid cyst are identified. The |

| | |neuroendoscope is advanced toward the colloid cyst. A small cutting suction catheter is passed through the |

| | |working channel of the neuroendoscope until it touches the wall of the colloid cyst. While a small amount of |

| | |suction is applied, the neurosurgeon gently twists the catheter until an opening is made. The contents of the |

| | |colloid cyst are evacuated with the suction, shrinking the cyst. The cutting suction catheter is removed and |

| | |the attachment of the cyst is visualized by the neurosurgeon. An electrocautery probe is passed through the |

| | |working channel of the neuroendoscope. The wall of the cyst near its attachment is coagulated with the |

| | |electrocautery. The electrocautery probe is removed and a micro-scissor is passed through the working channel |

| | |of the neuroendoscope. The attachment is cut. The micro-scissor is removed and a micro-grasping forceps is |

| | |passed through the working channel of the neuroendoscope. The shrunken cyst wall is grasped and the colloid |

| | |cyst and neuroendoscope are removed together. After the colloid cyst and micro-grasping forceps are removed |

| | |from the neuroendoscope, the neuroendoscope is passed back into the ventricle and the site of the cyst removal |

| | |is observed. Bleeding at the site is irrigated and observed until clear. The foramen of Monro is inspected to |

| | |monitor for obstruction of the flow of spinal fluid from the lateral ventricles into the third ventricle. The |

| | |neuroendoscope is removed and a ventricular catheter is placed into the lateral ventricle. This catheter is |

| | |tunneled under the skin and pierces the skin remote from the incision. The neurosurgeon takes a small sample of|

| | |cerebrospinal fluid and sends it to pathology for analysis. The ventricular catheter is cut to the proper |

| | |length and secured to a closed extra-ventricular drainage system. The neurosurgeon looks to see that there is |

| | |spontaneous flow of blood-tinged cerebrospinal fluid throughout the system. The wounds are closed. |

|[pic] |

|62163 |  |Clinical Example (62163) |

| | |A 6-year-old male presents with a history of resolved hydrocephalus and a lost ventricular catheter from a |

| | |previous shunt attempt. The lost ventricular catheter is found and removed utilizing the neuroendoscope. |

| | |Description of Procedure (62163) |

| | |The skin is incised and hemostasis achieved with retraction and electrocautery. A power perforator is used to |

| | |make a burr hole and hemostasis is achieved with bone wax. The dura is coagulated with bipolar coagulation and |

| | |opened with sharp dissection. The cortex is inspected to make sure that there are no large cortical blood |

| | |vessels directly in the area where a cortical incision will be made. The cortex is coagulated with bipolar |

| | |coagulation and opened with sharp dissection. A 5-mm peel-away trocar is introduced through the brain into the |

| | |ventricle. The inner stylet of the trocar is removed and the flexible neuroendoscope is passed through the |

| | |trocar into the ventricle. The neurosurgeon orients herself to the intraventricular anatomy and finds the |

| | |choroid plexus, the foramen of Monro, and the third ventricle. The neuroendoscope is advanced into the |

| | |occipital horn of the lateral ventricle where the lost ventricular catheter is seen. The catheter is seen to be|

| | |adherent to the choroid plexus. Using various micro-instruments through the working channel of the |

| | |neuroendoscope, the catheter is freed from the surrounding scar tissue. Bleeding is controlled with irrigation |

| | |and bipolar electrocautery. The catheter is grasped with micro-grasping forceps and the neuroendoscope and |

| | |catheter together are removed from the brain. The neuroendoscope is replaced to inspect the rest of the |

| | |ventricular system and ensure that there is good communication of spinal fluid throughout the system. The |

| | |neuroendoscope is then removed. The wounds are closed. |

|[pic] |

|62164 |  |Clinical Example (62164) |

| | |A 56-year-old female with a lymphoma in her right caudate nucleus undergoes a neuroendoscopic partial excision |

| | |of the tumor. |

| | |Description of Procedure (62164) |

| | |The skin is incised and hemostasis achieved with retraction and electrocautery. A power perforator is used to |

| | |make a burr hole and hemostasis is achieved with bone wax. The dura is coagulated with bipolar coagulation and |

| | |opened with sharp dissection. The cortex is inspected to make sure that there are no large cortical blood |

| | |vessels directly in the area where a cortical incision will be made. The cortex is coagulated with bipolar |

| | |coagulation and opened with sharp dissection. A 5-mm peel-away trocar is introduced through the brain into the |

| | |ventricle. The inner stylet of the trocar is removed and the neuroendoscope is passed through the trocar into |

| | |the ventricle. The neurosurgeon orients herself to the intraventricular anatomy and finds the choroid plexus, |

| | |the foramen of Monro, and the third ventricle. The neurosurgeon advances the neuroendoscope into the frontal |

| | |horn of the right lateral ventricle and identifies a discoloration in the ependyma overlying the head of the |

| | |caudate nucleus, which represents the tumor. In a relatively avascular area, the micro-cup forceps is inserted |

| | |through the neuroendoscope and into the tumor. A portion of tumor tissue is excised and submitted for later |

| | |pathological examination. This procedure is repeated several times until approximately 1 cubic centimeter of |

| | |tumor tissue is removed. Hemostasis is achieved with a bipolar coagulation device introduced into the ventricle|

| | |through the working channel of the neuroendoscope. Bleeding from the excision site clears after a period of |

| | |gentle irrigation and observation. The neuroendoscope is removed. The wounds are closed. |

|[pic] |

|62165 |  |Clinical Example (62165) |

| | |A 62-year-old female presents with a six-month history of progressive headaches and blurred vision. Her primary|

| | |care physician had performed an MRI scan demonstrating a 1-cm pituitary tumor expanding the sella turcica. She |

| | |undergoes a neuroendoscopic excision of the tumor. |

| | |Description of Procedure (62165) |

| | |The nasal packs are removed and the endoscope is passed down the left nostril until the sphenoid ostium is |

| | |visualized. A rongeur is used to open the sphenoid ostium under endoscopic visualization. The sphenoid mucosa |

| | |is then stripped and electrocautery used for hemostasis. The sinus is irrigated with antibiotic solution. |

| | |Endoscopic visualization is used to guide a small osteotome into place where the bone of the floor of the sella|

| | |is removed, exposing the dura. The dura is coagulated by passing bipolar forceps down the right nostril. The |

| | |dura is opened in a cruciate fashion with a blade and the dural leaflets are coagulated. The tumor capsule is |

| | |visualized through the endoscope. Biopsy forceps are used to excise several pieces of the tumor which are sent |

| | |to pathology. The tumor is then removed using a combination of curettage and suction. Once the tumor is |

| | |removed, the endoscope is released from its clamp and passed through the hole in the dura, into the sella. |

| | |Using the 30 degree scope, the diaphragma sella is visualized. The endoscope is turned within the cavity to |

| | |identify any additional tumor remnants. A small dissector is passed through the endoscope and additional tumor |

| | |remnant(s) are removed with suction. Endoscopic bipolar forceps are used to assist with hemostasis within the |

| | |sella and endoscopic irrigation is applied. The endoscope is withdrawn into the nasal sinus and clamped there |

| | |to provide visualization during reconstruction of the sella floor. The dural defect is gently packed with |

| | |Gelfoam until all bleeding has stopped. The sphenoid sinus is packed with Vaseline-impregnated gauze. The |

| | |endoscope is withdrawn and the hypopharyngeal pack removed. The Mayfield headholder is removed and the patient |

| | |awakened and extubated for transport to recovery. |

|[pic] |

|62252 |  |Clinical Example #1 (62252) |

| | |A 75-year-old man presented with decreasing gait function, incontinence, and memory loss. Gait analysis, CT |

| | |scans, and neuro-psychometric testing were performed. He was admitted for possible normal pressure |

| | |hydrocephalus. External drainage of cerebrospinal fluid was performed via a lumbar tap over a 48-hour period |

| | |while the patient remained at rest. The patient was released. Two days later the patient returned with his son |

| | |and daughter-in-law, who handled his primary care. The gait was improved, bladder control had returned, and |

| | |some improvement was noted in dementia. The patient was scheduled for surgery to implant a programmable valve |

| | |and shunt system. The initial pressure was set at 200 mmH2O. The patient returned one month later with little |

| | |change in symptoms. The pressure was adjusted slowly (four times over the next three months to allow for |

| | |acclimation) down to 120 mmH2O. Each adjustment resulted in a marked improvement in gait, bladder control, and |

| | |memory. The setting remains at 120 mm H2O and the patient has returned to self care. |

| | |Description of Procedure #1 (62252) |

| | |The first stage in the shunt reprogramming process involves determination of whether reprogramming is needed. |

| | |The physician reviews the patient's chart and previous films, and takes the history of symptoms from either the|

| | |patient or patient's family. The physician evaluates this information for evidence of over- or under-drainage |

| | |of cerebrospinal fluid. |

| | |If the need for reprogramming is established, the process moves to the second stage, which is the valve |

| | |reprogramming. To accomplish this, the patient is placed in a sitting or standing position. The previously |

| | |implanted valve is palpated through the skin, usually in a position located posterior to the ear. The |

| | |transmitter head of the programmer unit is placed over the valve, the programming console is set to the desired|

| | |pressure, and the reprogramming is performed. The programmer uses an electromagnetic transmitter device that |

| | |sends a coded magnetic signal through the skin to the valve. This magnetic signal alters the pressure setting |

| | |of the valve. |

| | |Following the reprogramming, a radiograph must be taken to verify that the intended pressure setting has been |

| | |reached. It is often necessary for the physician to accompany the patient to the x-ray department to ensure the|

| | |x-ray is taken perpendicular to the valve as opposed to the standard AP or ML view. The physician must then |

| | |view the film to confirm that the valve has been set to the desired pressure setting. If the x-ray reveals |

| | |there is an inappropriate pressure setting, the procedure must be repeated. |

| | |The final stage in the process of reprogramming of a CSF shunt involves meeting with the patient and/or |

| | |patient's family to review care related to the programmable shunt. |

| | |Clinical Example #2 (62252) |

| | |A neonate (35 weeks gestation) born with myelomeningocele and hydrocephalus was managed successfully by |

| | |surgical closure of the spinal deformity followed by placement of an adjustable pressure valve and shunt |

| | |(programmable CSF shunt) for treatment of hydrocephalus. Intracranial pressure was measured intraoperatively |

| | |and the valve pressure was set at 50 mm H2O. Two months later the patient presented with irritability and |

| | |vomiting. CT scans indicated slit-like ventricles from overdrainage of cerebro-spinal fluid. |

| | |Description of Procedure #2 (62252) |

| | |The valve was reprogrammed as described above over two successive visits from 50 to 70 mm H2O and two weeks |

| | |later from 70 to 80 mmH2O. After one month the ventricles had returned to normal size and the clinical symptoms|

| | |had subsided. |

|[pic] |

|62263 |  |Clinical Example (62263) |

| | |A 35-year-old male has severe pain (rated 8/10) located in the right lower back and radiating down the outside |

| | |of the right leg to the top of the foot and the big toe after multiple back operations over a 10-year period. |

| | |Various systemic medications (oral narcotic and non-narcotic) and physical therapy have failed to provide |

| | |significant long-term pain relief. A catheter is placed percutaneously in the epidural space; an epidurogram is|

| | |performed to identify the areas of scar, nerve constriction, and possible nerve inflammation and degree of |

| | |fluid flow (or lack thereof) in the epidural space; and the epidural adhesions are lysed. |

| | |[Please note that the catheter is left in place for additional adhesiolysis sessions over the next one or more |

| | |days. This service encompasses 2 or more days and has a global period of 10 days.] |

| | |Description of Procedure (62263) |

| | |The skin is locally anesthetized. The introduction needle is directed into the epidural space at the proper |

| | |vertebral level or the caudal epidural space, under x-ray fluoroscopy. A flexible, directable catheter is |

| | |introduced through the needle into the epidural space. The catheter tip is carefully maneuvered in the epidural|

| | |space around bands of scar tissue until it is in the focal scar tissue at the target spinal nerve-nerve root. A|

| | |contrast injection is performed to confirm needle tip or catheter location and determine degree of free flow |

| | |liquid in the epidural space (eg, determine areas of scarring in the epidural space). This injection also is |

| | |used with temporary fluorogram monitor views to evaluate the nerve roots and spinal nerves in the area and any |

| | |focal constriction or swelling of the nerve. The free flow of dye through the epidural space adjacent to this |

| | |target spinal nerve-nerve root is also determined. A decision on the number, type, and quantity of |

| | |injections/infusions is made. For the typical patient described above, an injection is given at this point of |

| | |hyaluronidase, local anesthetic, and steroid, followed 30 minutes later by an injection of hypertonic (10%) |

| | |saline. The catheter exit site is dressed for sterility and secured and the patient is admitted to the hospital|

| | |for two days. At 12-24 hours and at 24-48 hours later, injections are repeated, using local anesthetic, |

| | |hyaluronidase, steroid, and hypertonic saline. Also, at each series of injections, a repeat epidural contrast |

| | |injection is performed with temporary fluorogram monitor views to verify correct catheter placement. Also |

| | |evaluated is the surrounding epidural space, including the gradual opening of constricted scar areas around the|

| | |target nerves-nerve roots. After the third series of injections, the catheter is removed and a sterile dressing|

| | |applied. |

|[pic] |

|62264 |  |Clinical Example (62264) |

| | |A 45-year-old white male has intermittent severe intractable low back pain with radiation into the right lower |

| | |extremity associated with numbness, tingling, and weakness for over 12 years that started following a |

| | |work-related injury. Subsequently, he underwent various modalities of treatments, initially conservative |

| | |management with medication, subsequently physical therapy followed by lumbar laminectomy followed by lumbar |

| | |fusion with hardware, with intermittent conservative management with physical therapy and continuous medication|

| | |management, but continued pain problems with significant deterioration of his physical and functional status |

| | |leading to disability. At this time, he is on significant amounts of narcotics, anxiolytics, as well as other |

| | |drugs with interrelated depression, generalized anxiety disorder, and significant functional limitations. |

| | |Following his presentation to a multidisciplinary pain management program, he was diagnosed to be negative for |

| | |facet joint-mediated pain. Subsequently, an epidurogram showed significant filling defects. His MRI also showed|

| | |significant scar tissue on the right side occupying L5 and S1 nerve roots. He failed to respond significantly |

| | |to transforaminal epidural steroid injections even though diagnosis was confirmed by blocking right L5 and S1 |

| | |nerve roots and also failed to respond to high-volume caudal epidural steroid injection. The patient is |

| | |scheduled for a one-day percutaneous lysis of epidural adhesions. |

| | |[Please note that this service is a 1-day procedure and has a global period of 10 days.] |

| | |Description of Procedure (62264) |

| | |After the appropriate preparation and consent, the patient is taken to the operating room or a sterile |

| | |procedure room where preparation is carried out with povidone-iodine prep. Draping is carried out to cover the |

| | |patient, extending into the midthoracic or cervical region, even if the procedure is performed in the |

| | |lumbosacral region. Appropriate monitoring is carried out, with monitoring of BP and pulse and pulse oximetry. |

| | |Sedation is slowly administered. The fluoroscope is adjusted over the lumbosacral region for AP and lateral |

| | |views. A physician, scrubbed and in sterile gown and gloves, infiltrates the area for needle insertion with |

| | |local anesthetic. Following this, an RK needle is introduced into the epidural space under fluoroscopic |

| | |utilization. Once the needle placement is confirmed to be in the epidural space, a lumbar epidurogram is |

| | |carried out utilizing approximately 2 to 5 mL of contrast. Finding the filling defects by examining the |

| | |contrast flow into the nerve roots is the purpose of the epidurogram. Intravascular or subarachnoid placement |

| | |of the needle or contrast is avoided; if such malpositioning occurs, the needle is repositioned. After |

| | |appropriate determination of epidurography, a Racz catheter, which is a spring-guided, reinforced catheter, is |

| | |slowly passed through the RK needle to the area of the filling defect or the site of pathology determined by |

| | |MRI, CT, or patient symptoms. Following the positioning of the catheter into the appropriate area, adhesiolysis|

| | |is carried out by mechanical means. After completion of the adhesiolysis, a repeat epidurogram is carried out |

| | |by additional injection of contrast. If appropriate adhesiolysis is completed, nerve root filling as well as |

| | |epidural filling will be noted. At this time, variable doses of local anesthetic and steroid are injected. Five|

| | |to 10 mL of 2% lidocaine hydrochloride or 5 to 10 mL of 0.25% bupivacaine are used for the local anesthetic. |

| | |Additionally, hyaluronidase may be injected at this time. A steroid is injected in the operating room or |

| | |recovery room. Following completion of the injection, the catheter is taped utilizing bio-occlusive dressing; |

| | |and the patient is turned to the supine position and transferred to the recovery room. |

|[pic] |

|62273 |  |A 39-year-old woman has recently undergone an intrathecal injection of some substance. Since the injection, the|

| | |patient has experienced severe headaches that are worse upon sitting or standing. The headaches have not |

| | |resolved after 1 week despite bedrest, oral hydration, and oral caffeine. There are no changes or fluid |

| | |accumulation at the injection site. |

|[pic] |

|62280 |  |A 45-year-old man with extensive rectal carcinoma involving the left lumbosacral plexus has intractable left |

| | |perirectal pain but has lost much of his control of both bladder and bowel function. Various systemic |

| | |medications (oral narcotic and nonnarcotic), physical therapy, radiation therapy, and chemotherapy have all |

| | |failed to provide significant long-term pain relief. There is no further operative resection possible for the |

| | |tumor. |

| | |This patient is a good candidate for a neurolytic injection because of the severity of the pain and the |

| | |diminished control of bladder and bowel function. A neurolytic injection to ablate the left S2-4 nerve roots is|

| | |recommended. |

|[pic] |

|62282 |  |A 45-year-old man with extensive rectal carcinoma involving the left lumbosacral plexus has intractable left |

| | |perirectal pain but has lost much of his control of both bladder and bowel function. Various systemic |

| | |medications (oral narcotic and nonnarcotic), physical therapy, radiation therapy, and chemotherapy have all |

| | |failed to provide significant long-term pain relief. There is no further operative resection possible for the |

| | |tumor. |

| | |This patient is a good candidate for a neurolytic injection because of the severity of the pain and the |

| | |diminished control of bladder and bowel function. A neurolytic injection to ablate the left S2-4 nerve roots is|

| | |recommended. |

|[pic] |

|62287 |  |A 25 year old male athlete has had 5 weeks of low back pain with sciatica, an absent ankle reflex, and weakness|

| | |of the posterior calf muscle. He has not responded to anti-inflammatory treatment and restricted activities. He|

| | |has a history of a previous similar episode that cleared in 3 weeks. An MRI exam shows a diffuse bulging |

| | |annulus and disk at L5-S1. |

|[pic] |

|62291 |  |A 33-year-old man with known scoliosis has severe right-sided pain. Correlation is made with a previous MR |

| | |imaging study of the thoracic spine. Preliminary AP and lateral radiograph scout views reveal 13 ribs with five|

| | |subjacent lumbar segments. There is scoliosis of the upper thoracic spine to the left with a moderate |

| | |rotational lower thoracic and upper lumbar curve to the right. There is moderate rotational midlumbar curvature|

| | |to the left. |

|[pic] |

|62310 |  |A 45-year-old man has severe pain (rated at 8/10) involving both arms and the neck after multiple neck |

| | |operations during a 10-year period. Various systematic medications (oral narcotic and nonnarcotic) and physical|

| | |therapy have failed to provide significant long-term pain relief. |

|[pic] |

|62311 |  |A 45-year-old man has severe pain (rated at 8/10) involving both legs and the lower back after multiple back |

| | |operations during a 10-year period. Various systemic medications (oral narcotic and non-narcotic) and physical |

| | |therapy have failed to provide significant long-term pain relief. |

|[pic] |

|62318 |  |A 45-year-old man has severe pain (rated at 8/10) involving both arms and the neck after multiple neck |

| | |operations during a 10-year period. Various systemic medications (oral narcotic and nonnarcotic) and physical |

| | |therapy have failed to provide significant long-term pain relief. |

|[pic] |

|62319 |  |A 45-year-old man has severe pain (rated at 8/10) involving both legs and the lower back after multiple neck |

| | |operations during a 10-year period. Various systemic medications (oral narcotic and nonnarcotic) and physical |

| | |therapy have failed to provide significant long-term pain relief. |

|[pic] |

|62350 |  |A 73-year-old man is referred for complaints of pain in the lumbar region and right lower extremity. The |

| | |patient has a history of lung carcinoma which was first diagnosed 2 years ago. He underwent a left lung |

| | |resection. One year later he was found to have a mass in the right chest or lung. X-ray therapy was performed |

| | |as his severe COPD precluded further lung resection. |

| | |He was doing well until 2 months ago, when he developed pain in the lumbar region. Work-up at that time |

| | |revealed metastasis at the L-5 vertebral body. Pain has persisted after radiation therapy. Oral narcotic |

| | |medications resulted in constipation or severe CNS side effects. His oncologist has requested a trial of spinal|

| | |narcotics and provides a 2-month life expectancy. |

|[pic] |

|63040 |  |Clinical Example (63040) |

| | |The patient is a 38-year-old man with a history of a fall three years previously. After that fall, there was |

| | |the sudden onset of pain in the top of the right foot with slight weakness and sensory changes in L5 |

| | |distribution. Radiographic evaluation revealed a right L4-5 herniated disc. The patient underwent a standard |

| | |right L4-5 discectomy with complete resolution of pain, sensory changes, and weakness. Three months ago, the |

| | |patient was involved in a car accident and had the onset two weeks later of right foot pain and weakness, again|

| | |in an L5 distribution. MRI evaluation revealed repeat disc herniation at right L4-5 with spondylitic narrowing |

| | |of the L5-S1 foramen. Conservative treatment with bed rest, various medications, and physical therapy provided |

| | |no relief. A decision for operation was made. |

| | |Description of Procedure (63040) |

| | |After induction of general anesthesia, the patient is placed in the prone position. The previous skin incision |

| | |is reopened and dissection performed to expose the right L4-5 previous laminotomy area. Scar tissue over the |

| | |laminae is removed and the laminotomy slightly enlarged. Sharp dissection is then used to remove scar tissue |

| | |from the spinal canal, just lateral to the dura. Much of this is performed with the aid of an operating |

| | |microscope. The right L5 nerve root is identified and a combination of new disc herniation and old scar tissue |

| | |is removed from the area, thus freeing the nerve root. The L4-5 disc space is likewise explored and disc |

| | |material curretted from the disc space, thus providing further decompression of the nerve root. |

| | |The L5 nerve root is explored and freed to its foramen. Rongeurs, currettes, and dissectors are then used to |

| | |remove bony spurs, scar tissue, and bony narrowing from the foramen to decompress the nerve root in the |

| | |foramen. All bleeding is coagulated, and the wound is irrigated and closed in multiple layers. |

|[pic] |

|63050 |  |Clinical Example (63050) |

| | |A 46-year-old male has a six-month history of progressive hand weakness, paresthesias, and gait difficulty. He |

| | |has hand intrinsic weakness and upper extremity sensory loss with lower extremity hyperreflexia and positive |

| | |Babinski signs. He undergoes a cervical laminoplasty from C3 to C7 for decompression of the spinal cord. Post |

| | |operative hospital care and office visits are conducted as necessary through the 90-day global period. |

| | |Description of Procedure (63050) |

| | |A midline, posterior, cervical incision is made and the paraspinous muscles are reflected out to the facet |

| | |joints, exposing the laminae, spinous processes and facet joints from C3 to C7. A high-speed drill is used to |

| | |create a multisegment osteotomy through the junction of the lamina and facet joints on the right side from C7 |

| | |up through and including C3. The underlying ligamentum flavum is sectioned with micro Kerrison rongeurs. On the|

| | |left side, the junction of the facet and lamina at each level is scored with the drill from C7 to C3 to create |

| | |a stress riser in the bone. A small Key elevator is then placed into the right side osteotomy, between the |

| | |lamina and facet joint, and the laminae are sequentially cracked back to expand the spinal canal. Hemostasis is|

| | |achieved and the incision is closed in layers. |

|[pic] |

|63051 |  |Clinical Example (63051) |

| | |A 32-year-old female has episodic paresthesias radiating into all limbs with cervical extension. She has upper |

| | |limb weakness and sensory loss with lower extremity hyperreflexia and positive Babinski signs. She undergoes a |

| | |cervical laminoplasty from C3 to C7 for decompression of the spinal cord and reconstruction of the posterior |

| | |spinal structures using an iliac crest allograft and non-segmental fixation. |

| | |Description of Procedure (63051) |

| | |A midline posterior cervical incision is made and the paraspinous muscles are reflected out to the facet |

| | |joints, exposing the laminae, spinous processes and facet joints from C3 to C7. A high-speed drill is used to |

| | |create a multisegment osteotomy through the junction of the lamina and facet joints on the right side from C7 |

| | |up through and including C3. The underlying ligamentum flavum is sectioned with micro rongeurs. On the left |

| | |side, the junction of the facet and lamina at each level is scored with the drill from C7 to C3 to create a |

| | |stress riser in the bone. An elevating device is then placed into the right side osteotomy, between the lamina |

| | |and facet joint, and the laminae are sequentially cracked back to expand the spinal canal. An iliac crest |

| | |allograft is shaped, fashioned (reported separately), and then fit into the right side osteotomy to keep the |

| | |space open, posteriorly. Absorbable miniplates are then applied to each segment of the posterior cervical |

| | |spine, with the plate spanning the osteotomy and iliac bone allograft. Then 3 mm absorbable screws are placed |

| | |through the plate at each level into the facet and the lamina, securing the plate and maintaining the canal |

| | |expansion. Hemostasis is achieved and the incision is closed in layers. |

|[pic] |

|63101 |  |Clinical Example (63101) |

| | |A 58-year-old man presents with a past history of prostate cancer, a 6-week history of progressive |

| | |thoracolumbar spine pain, a moderate kyphotic deformity over the thoracolumbar junction with tenderness to |

| | |palpation, and recent bilateral leg weakness and numbness requiring a cane for ambulation. He has proximal |

| | |lower extremity weakness and a relative sensory loss is below the T11 level. Plain X-rays showed a T11 |

| | |destructive lesion with pathologic compression fracture with kyphotic angulation of the spine and 60% loss of |

| | |vertebral body height. MRI scan showed retropulsion of bone fragments and soft tissue mass in the spinal canal |

| | |consistent with tumor. There is also tumor extending into the posterior elements. At operation, a thoracic |

| | |vertebral corpectomy is performed using a lateral extracavitary approach. Postoperative hospital care and |

| | |office visits are conducted as necessary through the 90-day global. |

| | |Description of Procedure (63101) |

| | |A midline incision is made with an inferior curve out laterally to allow exposure of the paraspinous muscle |

| | |bundle, centered over the fractured segment. The paraspinous muscles are elevated from the spinous processes |

| | |and laminae with the electrocautery unit. The right side paraspinous muscle bundle is then divided laterally |

| | |and elevated off the ribs allowing for retraction towards the midline. Intraoperative imaging is used to |

| | |correctly identify the tumor at T11 vertebral body and the associated T11 and T12 ribs are dissected from the |

| | |intercostal muscles and underlying pleura bluntly to avoid pneumothorax. The ribs are resected from the |

| | |posterior bend to the costovertebral junction in a single pieces. The intercostal nerves are identified and |

| | |traced back to the neural foramina. The associated transverse process(es), lateral portion of the facet(s) and |

| | |pedicle(s) are removed with the high-speed drill exposing the lateral aspect of the dural sac and the lateral |

| | |aspect of the vertebral body. The parietal pleura is gently depressed with a dampened sponge and retracted, |

| | |exposing the lateral surface of the T11 vertebral body. The T11 nerve root may be divided or gently retracted |

| | |superiorly to allow visualization of the posterior cortical margin. A high-speed drill is then used to remove |

| | |the central portion of the vertebral body and exposing the superior, inferior, and posterior cortical margins. |

| | |A curette is used to deliver the retropulsed bone fragments and tumor mass away from the spinal cord. The |

| | |T11-12 and T12-L1 discs are removed with curettes and pituitary rongeurs exposing the endplates of T11 and L1. |

| | |The exposed surfaces of the thecal sac are carefully examined for dural tears. Hemostasis in the epidural space|

| | |is obtained. (As clinically indicated, an intervertebral fusion or intervertebral body reconstruction is |

| | |performed and reported separately.) A drain is placed in the deep space and a multilayer closure is undertaken.|

|[pic] |

|63102 |  |Clinical Example (63102) |

| | |A 58-year-old man presents with a past history of prostate cancer, a 6-week history of progressive lumbar spine|

| | |pain, with tenderness to palpation, and recent bilateral leg weakness and numbness requiring a cane for |

| | |ambulation. He has proximal lower extremity weakness and a relative sensory loss is below the L3 level. Plain |

| | |X-rays showed an L3 destructive lesion with pathologic compression fracture with kyphotic angulation of the |

| | |spine and 60% loss of vertebral body height. MRI scan showed retropulsion of bone fragments and soft tissue |

| | |mass in the spinal canal consistent with the presence of a tumor. There is also tumor extending into the |

| | |posterior elements. At operation, a lumbar vertebral corpectomy is performed using a lateral extracavitary |

| | |approach. Postoperative hospital care and office visits are conducted as necessary through the 90-day global. |

| | |Description of Procedure (63102) |

| | |A midline incision is made with an inferior curve out laterally to allow exposure of the paraspinous muscle |

| | |bundle, centered over the fractured segment. The paraspinous muscles are elevated from the spinous processes |

| | |and laminae with the electrocautery unit. The right side paraspinous muscle bundle is then divided laterally |

| | |and elevated off the ribs allowing for retraction towards the midline. Intraoperative imaging is used to |

| | |correctly identify the tumor at the L1 vertebral body. The associated rib T12 is dissected from the intercostal|

| | |muscles and underlying pleura and diaphragm bluntly to avoid pneumothorax. The rib is resected from the |

| | |posterior bend to the costovertebral junction in a single piece. The intercostal nerve is identified and traced|

| | |back to the neural foramen. The associated transverse process, lateral portion of the facet and pedicle are |

| | |removed with the high-speed drill exposing the lateral aspect of the dural sac and the dorsolateral aspect of |

| | |the vertebral body. The parietal pleura is gently depressed with a dampened sponge and retracted, exposing the |

| | |lateral surface of the L1 vertebral body. The nerve root may be divided or gently retracted superiorly to allow|

| | |visualization of the posterior cortical margin. A high-speed drill is then used to remove the central portion |

| | |of the vertebral body and exposing the superior, inferior, and posterior cortical margins. A curette is used to|

| | |deliver the retropulsed bone fragments and tumor mass away from the spinal cord. The T12-L1 and L1-L2 discs are|

| | |removed with curettes and pituitary rongeurs exposing the endplates of T12 and L2. The exposed surfaces of the |

| | |thecal sac are carefully examined for dural tears. Hemostasis in the epidural space is obtained. (As clinically|

| | |indicated, intervertebral fusion, spinal instrumentation or vertebral body reconstruction is performed and |

| | |reported separately.) A drain is placed in the deep space and a multilayer closure is undertaken. |

|[pic] |

|63103 |  |Clinical Example (63103) |

| | |A 58-year-old man presents with a past history of prostate cancer, a 6-week history of progressive |

| | |thoracolumbar spine pain, a moderate kyphotic deformity over the thoracolumbar junction with tenderness to |

| | |palpation, and recent bilateral leg weakness and numbness requiring a cane for ambulation. He has proximal |

| | |lower extremity weakness and a relative sensory loss below the T11 level. Plain X-rays showed a T10 and T11 |

| | |destructive lesion with pathologic compression fracture at these levels with kyphotic angulation of the spine |

| | |and loss of vertebral body height. An MRI scan shows retropulsion of bone fragments and soft tissue mass in the|

| | |spinal canal consistent with tumor extending over the two involved segments. There is also tumor extending into|

| | |the posterior elements. At operation, a thoracic vertebral corpectomy of two vertebral segments is performed |

| | |using a lateral extracavitary approach. |

| | |Description of Procedure (63103) |

| | |Utilizing the existing midline curvilinear incision, the elevation of the paraspinous muscle bundle is extended|

| | |rostrally to expose the T10 segment in addition to the T11 segment. The T10 rib is dissected free from the |

| | |intercostals muscles and resected from the posterior bend to the costovertebral junction in a single piece. The|

| | |intercostal nerve is identified and traced back to the neural foramen. The associated transverse process, |

| | |lateral portion of the facet and pedicle are removed with the high-speed drill exposing the lateral aspect of |

| | |the dural sac and the dorsolateral aspect of the vertebral bodies. The parietal pleura is gently depressed with|

| | |a dampened sponge and retracted, exposing the lateral surface of the T10 vertebral body. The 10 nerve root may |

| | |be divided or gently retracted superiorly to allow visualization of the posterior cortical margin. A high-speed|

| | |drill is then used to remove the central portion of the vertebral body and exposing the superior, inferior, and|

| | |posterior cortical margins. A curette is used to deliver the retropulsed bone fragments and tumor mass away |

| | |from the spinal cord. The T9-T10, T10-T11 discs are removed with curettes and pituitary rongeurs exposing the |

| | |endplate of T9. The exposed surfaces of the thecal sac are carefully examined for dural tears. |

|[pic] |

|63295 |  |Clinical Example (63295) |

| | |A 12-year-old boy, undergoing a laminectomy for a cervical spinal cord tumor, is at significant risk for |

| | |developing a postoperative kyphotic deformity. An osteoplastic reconstruction of the dorsal spinal elements is |

| | |performed as an add-on procedure, following the primary laminectomy procedure. |

| | |Description of Procedure (63295) |

| | |Following the closure of the dura, the previously removed dorsal spinal elements (ie, laminae, spinous process |

| | |and supporting ligaments) are returned to an anatomic position for reconstruction. Using a fine drill bit, |

| | |holes are drilled into the lateral aspect of each lamina and heavy sutures, wires, or miniplates are used to |

| | |secure the dorsal elements, fixing the bone in position. |

|[pic] |

|64415 |  |Clinical Example (64415) |

| | |A 36-year-old male suffered a crush injury of his thumb and forefinger on the right hand in an auto accident. |

| | |He has developed marked immobility of these digits and symptoms of reflex sympathetic dystrophy (complex |

| | |regional pain syndrome). He is to receive a series of axillary blocks to both treat the reflex sympathetic |

| | |dystrophy and to allow analgesia for physical therapy to his hand. |

| | |Description of Procedure (64415) |

| | |After obtaining informed consent, the patient's right arm is abducted at the shoulder and flexed at the elbow |

| | |with his hand positioned above his right shoulder. The axilla is prepped with a betadine solution and a |

| | |22-gauge short-bevel needle inserted into the brachial plexus sheath after anesthetizing the skin with a small |

| | |amount of local anesthetic. The proper location of the needle is ascertained with the use of a nerve |

| | |stimulator, the elicitation of paresthesias, or the transarterial technique. An axillary block using the |

| | |injection of 30-40 ml of local anesthetic (usually 1 to 1.5% lidocaine, 0.25 to 0.375% bupivacaine or 1 to 1.5%|

| | |mepivacaine) is now performed after using a small test dose of the local anesthetic and frequent aspiration |

| | |during the injection. The density and function of the block is then assessed over the next 30 minutes. |

| | |Active physical therapy to the hand and digits is administered while the patient's arm and hand are |

| | |anesthetized. |

| | |The complications of an axillary block include possible infection, injury to the axillary artery with hematoma |

| | |formation, systemic local anesthetic toxicity and nerve injury. Fortunately these complications are rare. |

|[pic] |

|64416 |  |Clinical Example (64416) |

| | |A 36-year-old male suffered traumatic amputation of his thumb and forefinger on the right hand in an auto |

| | |accident. He has had these digits replanted under a general anesthetic and five hours of surgery. The digits |

| | |are ischemic in appearance and cold with poor capillary filling despite a good surgical repair and anastomoses |

| | |of the digital arteries. A continuous brachial plexus block using a catheter placed in the brachial plexus at |

| | |the axilla and the infusion of local anesthetic is planned to provide pain relief and to provide vasodilatation|

| | |of the arterial supply to the hand and digits in an effort to improve survival of the re-implanted digits. |

| | |Description of Procedure (64416) |

| | |After obtaining informed consent, the patient is sedated lightly, if necessary, with a small amount of |

| | |midazolam. His right arm is abducted at the shoulder and flexed at the elbow with his hand positioned above his|

| | |right shoulder. The axilla is prepped with a betadine solution and an 18 or 20-gauge 2-inch angiocath-type |

| | |catheter is inserted into the brachial plexus sheath after anesthetizing the skin with a small amount of local |

| | |anesthetic. The proper location of the needle is ascertained with the use of a nerve stimulator, the |

| | |elicitation of paresthesias, or the loss of resistance technique. The needle is removed and the plastic sleeve |

| | |or cannula left in position. Next an epidural-type plastic catheter is inserted through the sleeve into the |

| | |brachial plexus sheath and fixed in place with tape or suture. An axillary block using the injection of about |

| | |30-40 ml of local anesthetic (usually 1 to 1.5% lidocaine, 0.25 to 0.375% bupivacaine or 1 to 1.5% mepivacaine)|

| | |is now performed after using a small test dose of the local anesthetic and frequent aspiration during the |

| | |injection. The density and function of the block is then assessed over the next 30 minutes as well as signs and|

| | |symptoms of local anesthetic toxicity. A continuous infusion of local anesthetic is now started (0.25% |

| | |bupivacaine at 5-10 ml/hr). |

|[pic] |

|64445 |  |Clinical Example (64445) |

| | |A 55-year-old male sustains a tri-malleolar fracture of his left ankle while rock climbing. He undergoes |

| | |surgical repair of his left ankle under general anesthesia. To provide post-operative pain control, a sciatic |

| | |nerve block is performed at the end of surgery. This block will decrease post-op pain, allow earlier |

| | |ambulation, and lessen the amount of post-op analgesic medication required. |

| | |Description of Procedure (64445) |

| | |Informed consent is obtained pre-operatively. In the post-anesthesia recovery room or in the operating room |

| | |after surgery on the foot and ankle is completed, the patient is placed in the right lateral position and the |

| | |thigh flexed on the hip to 45 degrees. The posterior superior iliac spine (PSIS), the greater femoral |

| | |trochanter and sacral hiatus are identified and marked. A line is drawn between the superior and posterior |

| | |aspect of the greater trochanter and the PSIS. The line is bisected and a perpendicular dropped 3-5 cm from the|

| | |midpoint of the line to the needle insertion site. The point of insertion should lie along a third line drawn |

| | |between the greater trochanter and the sacral hiatus. The skin is prepped and draped and a 6-inch 22-gauge, |

| | |short-bevel, insulated nerve stimulator needle advanced perpendicular to the skin. The needle is advanced 6-8 |

| | |cm with a stimulation intensity of 1.5-2.0 mA and adjusted downwards as evoked motor response increases. |

| | |Plantar flexion at less than 0.5 mA is the desired goal and indicates placement of the needle near the medial |

| | |part of the nerve. After a negative aspiration, the needle is held firm and local anesthetic (0.375 to 0.5% |

| | |bupivacaine with epinephrine 1:200,000, 30 ml) injected incrementally. Attention is paid to the presence of |

| | |paresthesias, reflex movement and resistance to injection. Efficacy of the block may be improved by depositing |

| | |the local anesthetic in more than one location, such as laterally (peroneal component) and medially (tibial |

| | |component). The mean duration of analgesia is 14 hours with 0.5% bupivacaine but can range up to 24 hours. |

| | |The complications of a sciatic nerve block include possible infection, injury to the sciatic nerve from |

| | |intraneural injections, and systemic local anesthetic toxicity. Neural ischemia should be considered in |

| | |patients with severe peripheral vascular disease who present with nerve injury following sciatic nerve block. |

|[pic] |

|64446 |  |Clinical Example (64446) |

| | |A 30-year-old male crushed his left foot in an automobile accident. He undergoes major reconstruction of his |

| | |left foot and ankle under general anesthesia. To provide post-operative pain control, a continuous sciatic |

| | |nerve block is performed at the end of surgery. This block will decrease post-op pain, allow earlier |

| | |ambulation, and lessen the amount of post-op analgesic medication required. |

| | |Description of Procedure (64446) |

| | |In the post-anesthesia recovery room or in the operating room after surgery on the foot and ankle is completed,|

| | |the patient is placed in the right lateral position and the thigh flexed on the hip to 45 degrees. The greater |

| | |femoral trochanter and ischial tuberosity are marked and a line drawn from the popliteal fossa to midway |

| | |between the two landmarks. A 20-gauge insulated needle is introduced vertically to the skin, just medial to the|

| | |upper end of the marked line to determine the depth of the sciatic nerve. A brisk motor response in the ankle, |

| | |foot or toes is noted with less than 0.4 mA stimulation. Next an insulated Tuohy needle is advanced from |

| | |approximately 5 cm cephalad and angled to intersect the tip of the first needle. Nerve stimulation is again |

| | |noted, and a catheter then advanced through the Tuohy needle 50 to 100 mm. The electrical connection is then |

| | |transferred to the catheter and nerve stimulation again noted. The Tuohy needle is removed, the catheter |

| | |sutured in place, a bacterial filter is attached and 15-20 ml of 0.5% bupivacaine injected through the |

| | |catheter. Block of the sciatic nerve is then accessed over the next 15-30 minutes and an infusion of 0.375% |

| | |bupivacaine at 0.1 mL/kg/hr (~7 mL/hr) started. Required infusion rates typically range from 2 to 12 mL/hr. |

| | |Occasionally bolus injections (10-15 mL) are required. The infusion is usually stopped at about 48 hours post |

| | |op. The complications of a continuous sciatic nerve block include possible infection, injury to the sciatic |

| | |nerve with neuralgia, and systemic local anesthetic toxicity. |

|[pic] |

|64447 |  |Clinical Example (64447) |

| | |A 30-year-old male undergoes a right anterior cruciate ligament repair under general anesthesia. To provide |

| | |post-operative pain control and increase mobility in his knee, a femoral nerve block is performed. This block |

| | |will allow earlier discharge from the recovery room, decreased post-op pain and earlier ambulation. |

| | |Description of Procedure (64447) |

| | |In the post-anesthesia recovery room or in the operating room prior to general anesthesia, the patient's right |

| | |groin is prepped with a betadine solution and a 22-gauge short-bevel 4 cm needle inserted approximately 1 cm |

| | |lateral to the femoral artery and 1 cm caudad from the inguinal ligament after anesthetizing the skin with a |

| | |small amount of local anesthetic. The proper location of the needle is ascertained with the use of a nerve |

| | |stimulator, the elicitation of paresthesias, the loss of resistance technique, or with a field block technique.|

| | |Next, between 15 and 30 ml of 0.25% to 0.5% bupivacaine with epinephrine 1:200,000 is injected carefully and |

| | |with frequent aspiration to avoid the possibility of intravascular injection. The density and function of the |

| | |block is then assessed. Onset of block may take 30-40 minutes. Postoperative analgesia typically lasts 12 to 24|

| | |hours. The complications of a femoral nerve block include possible infection, injury to the femoral artery with|

| | |hematoma formation, systemic local anesthetic toxicity and nerve injury. Persistent quadriceps weakness |

| | |suggests neural injury. |

|[pic] |

|64448 |  |Clinical Example (64448) |

| | |A 65-year-old male undergoes a right total knee replacement (CPT code 27447) under general anesthesia. To |

| | |provide post-operative pain control and increased mobility in his knee, a continuous femoral nerve block is |

| | |performed. This block will allow earlier discharge from the recovery room, decreased post-op pain, earlier |

| | |ambulation, improved range of motion of the knee and enhanced rehabilitation. |

| | |Description of Procedure (64448) |

| | |In the post-anesthesia recovery room or in the operating room prior to general anesthesia, the patient's right |

| | |groin is prepped with a betadine solution and a 22-gauge short-bevel 10-cm insulated needle is inserted into an|

| | |18-gauge long plastic cannula. The femoral nerve is located approximately 1 cm lateral to the femoral artery |

| | |and 1 cm caudad from the inguinal ligament after anesthetizing the skin with a small amount of local |

| | |anesthetic. The proper location of the needle is ascertained with the use of a nerve stimulator or with the |

| | |elicitation of paresthesias, or both. The plastic cannula is then advanced over the needle into the "sheath" of|

| | |the femoral nerve. Next, between 20 and 30 ml of 0.25% to 0.5% bupivacaine with epinephrine 1:200,000 is |

| | |injected carefully through the cannula and with frequent aspiration to avoid the possibility of intravascular |

| | |injection. A 20-gauge epidural catheter is threaded through the cannula and the cannula removed. The catheter |

| | |is sutured in place and sterilely dressed. Bupivacaine 0.25 to 0.125% at 0.14 mL/kg/hr (~10 mL/hr) is then |

| | |infused. The complications of a continuous femoral nerve block include possible infection, injury to the |

| | |femoral artery with hematoma formation, systemic local anesthetic toxicity and nerve injury from direct trauma,|

| | |intraneural injection or compressive-ischemic injury. Persistent quadriceps weakness suggests neural injury. |

|[pic] |

|64449 |  |Clinical Example (64449) |

| | |A 62-year-old female undergoes a left total knee replacement (CPT code 27447) under general anesthesia. In |

| | |order to provide post-operative pain control and increased mobility in her knee, earlier ambulation, and |

| | |enhanced rehabilitation, a continuous lumbar plexus block (psoas compartment block) is performed. |

| | |Description of Procedure (64449) |

| | |When placing a left lumbar plexus block, the patient is placed in the right lateral decubitus position with the|

| | |thighs and knees flexed. Blood pressure cuff, pulse oximeter and electrocardiographic monitors are applied. |

| | |After an intravenous infusion is initiated and supplemental oxygen is provided, intravenous anxiolytics and |

| | |analgesics are administered. The left low back is prepped with a topical antiseptic. A line is drawn between |

| | |the iliac crests, ie, Tuffier's line. A second line is made 3-5 cm parasagittally to the left. A mark for the |

| | |needle insertion is made where the two lines intersect. After infiltrating the skin and deeper tissues with |

| | |local anesthetic, a needle, designed to allow the introduction of a catheter through the needle and connected |

| | |to a peripheral nerve stimulator, is advanced to obtain stimulation of the lumbar plexus. When a transverse |

| | |process is encountered, the needle is then partially withdrawn and advanced slightly cephalad until it slides |

| | |past the transverse process of the lumbar vertebra. When the needle tip is in the psoas compartment and in the |

| | |proper location, stimulation of the lumbar plexus is recognized by observing the rise of the patella and |

| | |contraction of the quadriceps and sartorius muscles. Generally current of 0.6 to 0.8 mA indicates stimulation |

| | |of the femoral nerve when the needle is correctly positioned. At this point careful aspiration for blood and |

| | |CSF is performed. A test dose of local anesthetic is administered to rule out IV or intrathecal injection. |

| | |Between 15 and 30 mL of dilute local anesthetic is slowly injected through the needle, followed by insertion of|

| | |an infusion catheter through the needle (about 5 cm past the tip of the needle). The patient is observed for |

| | |signs of undesired epidural spread and associated hemodynamic changes, and for analgesia of the left leg and |

| | |hip. The catheter is checked for intravascular and intrathecal placement and secured in place. Once correct |

| | |function of the catheter is confirmed, a continuous infusion of dilute concentration of local anesthetic is |

| | |started at 8-10 mL/hr. Alternatively, a patient controlled infusion may be started with a bolus. Assistance at |

| | |the time of ambulation is essential. The complications of a lumbar plexus block include: intravascular |

| | |injection; intrathecal injection with high level of the resultant spinal block; infection; urethral, venous, or|

| | |renal puncture; intraperitoneal injection; hematoma of the psoas muscle with nerve compression; and extension |

| | |of anesthesia into the epidural space. |

|[pic] |

|64470 |  |A 67-year-old woman presents with a long history of cervical spine pain in her neck and radiating down to her |

| | |shoulders. She has no pain into her fingertips, has no weakness in her arms, and denies any bowel or bladder |

| | |symptoms. She has failed to obtain relief by using various oral medications and physical therapy. A recent |

| | |x-ray showed cervical spondylosis between C5-6. |

|[pic] |

|64472 |  |A 67-year-old woman presents with a long history of cervical spine pain in her neck and radiating down to her |

| | |shoulders. She has no pain into her fingertips, has no weakness in her arms, and denies any bowel or bladder |

| | |symptoms. She has failed to obtain relief by using various oral medications and physical therapy. A recent |

| | |x-ray showed cervical spondylosis between C5-6 and C6-7. |

|[pic] |

|64475 |  |A 67-year-old female presents with a long history of neck pain that radiates down to her shoulders. She has no |

| | |pain into her fingertips. She has no weakness in her arms. She denies any bowel or bladder symptoms. The |

| | |patient had an x-ray that showed cervical spondylosis between C5-6 and C6-7 bilaterally. |

| | |The patient has undergone physical therapy and has had a trial of nonsteroidal anti-inflammatories, as well as |

| | |opiate therapy. Despite all of these treatments, the patient has had no improvements. She then had an MRI, |

| | |which showed facet arthropathy at C5-6 and C6-7 with small disk bulges at both levels. An electromyogram was |

| | |negative. Because of failure of conservative care, diagnostic testing with cervical facet blocks at C5-6 and |

| | |C6-7 levels bilaterally is indicated. |

|[pic] |

|64476 |  |A 67-year-old woman presents with a long history of neck pain that radiates down to her shoulders. She has no |

| | |pain into her fingertips. She has no weakness in her arms. She denies any bowel or bladder symptoms. The |

| | |patient had an x-ray that showed cervical spondylosis between C5-6 and C6-7 bilaterally. |

| | |The patient has undergone physical therapy and has had a trial of nonsteroidal anti-inflammatories, as well as |

| | |opiate therapy. Despite all of these treatments, the patient has had no improvements. She then had an MRI, |

| | |which showed facet arthropathy at C5-6 and C6-7 with small disk bulges at both levels. An electromyogram was |

| | |negative. Because of failure of conservative care, diagnostic testing with cervical facet blocks at C5-6 and |

| | |C6-7 levels bilaterally is indicated. |

|[pic] |

|64479 |  |A 55-year-old man with coronary artery disease and moderate heart failure presents with constant moderately |

| | |severe right arm pain that limits all activity. The patient's history includes a previous laminectomy at C5-6. |

| | |An MRI with gadolinium shows a small bony spur at the right C5-6 foramen compressing the C-6 nerve root, and |

| | |neurodiagnostic studies are compatible with an acute C-6 radiculopathy. He has failed to obtain relief with |

| | |various oral medications, physical therapy, and traction. |

|[pic] |

|64480 |  |A 55-year-old man with coronary artery disease and moderate heart failure presents with constant moderately |

| | |severe right arm pain that limits all activity. The patient's history includes a previous laminectomy at C5-6 |

| | |and C6-7. An MRI with gadolinium, shows small bony spurs at the right C5-6 and C6-7 foramen compressing the C-6|

| | |nerve root; and neurodiagnostic studies are compatible with an acute C-6 radiculopathy. He has failed to obtain|

| | |relief with various oral medications, physical therapy, and traction. |

|[pic] |

|64483 |  |A 71-year-old male with coronary artery disease and moderate heart failure presents with recurrent right leg |

| | |pain, the ability to stand for only 10 minutes and walk less than one block, and minimal problems sitting. The |

| | |patient's history includes a previous laminectomy at L4-5; an MRI with gadolinium, showing a small recurrent |

| | |herniation between L4-5 with scar tissue; and neurodiagnostic studies compatible with an acute L-5 |

| | |radiculopathy. He has failed to obtain relief with various oral medications, physical therapy, and traction. |

|[pic] |

|64484 |  |A 71-year-old man with coronary artery disease and moderate heart failure presents with recurrent right leg |

| | |pain, the ability to stand for only 10 minutes and walk less than one block, and minimal problems sitting. The |

| | |patient's history includes previous laminectomy at L3-4 and L4-5; an MRI with gadolinium, showing a small |

| | |recurrent herniation between L4-5 with scar tissue; and neurodiagnostic studies compatible with an acute L-4 |

| | |and L-5 radiculopathy. He has failed to obtain relief with various oral medications, physical therapy, and |

| | |traction. |

|[pic] |

|64517 |  |Clinical Example (64517) |

| | |A 75-year-old male with known prostatic carcinoma and pelvic metastases is suffering from intractable pelvic |

| | |pain with severe spasms and cramps. Oral medications have not helped him. The patient has been referred to an |

| | |interventional pain specialist for a superior hypogastric plexus block to relieve his intractable pelvic pain. |

| | |Description of Procedure (64517) |

| | |The patient is taken to the operating room or procedure suite. He is placed in the prone position. EKG, blood |

| | |pressure and pulse oximetry are applied. His back is prepared with Betadine. A spinal needle is inserted to the|

| | |anterolateral spine at the L5-S1 interspace. Proper needle location is determined, employing radiological |

| | |imaging guidance (reported separately). Radiographic contrast is then injected demonstrating flow in the |

| | |pre-vertebral space, anterior to the psoas muscle fascia. After careful negative aspiration for blood, urine |

| | |and CSF, local anesthetic is injected on each side. The patient is then transferred to the recovery room where |

| | |he is carefully observed and monitored for early signs of complications. The complications of the procedure |

| | |include puncture of the iliac vessels and bleeding, intravascular injection of local anesthetics with possible |

| | |seizures or cardiovascular collapse, nerve injury to the cauda equina, or exiting spinal nerves, puncture of |

| | |the ureters and other pelvic viscera. Infection is always a possibility, especially in immuno-suppressed cancer|

| | |patients. |

|[pic] |

|64561 |  |Clinical Example (64561) |

| | |A 47-year-old female with intractable and debilitating urge incontinence has been evaluated by history, |

| | |physical examination, endoscopic, radiographic, and urodynamic testing. All available conservative remedies |

| | |have been unsuccessful. A 72-hour voiding diary has been established as a baseline. A test stimulation will be |

| | |performed to determine the effectiveness of transacral neuromodulation for control of her symptoms. |

| | |Description of Procedure (64561) |

| | |The awake patient is positioned in a prone fashion to minimize the lumbar lordosis. Prep is performed and a |

| | |drape is placed in the area over the sacrum in a sterile fashion. The levels of the sacral foramina are |

| | |approximated using bone landmarks or fluoroscopy. The skin and periosteum are anesthetized over and near the |

| | |chosen foramen, and an electrically insulated 3 or 5 inch spinal needle is placed percutaneously into the |

| | |foramen. An external screener (power source) is connected to the foramen needle by a separate cable and |

| | |grounding pad. Specific biologic responses to stimulation are discerned and documented including bellows |

| | |movement of the perineum (inward going of the intergluteal fold) and great toe dorsiflexion for S3; clamp |

| | |movement of the anal sphincter (antero-posterior flattening and twisting) and dorsiflexion of the foot along |

| | |with calf cramping and leg rotation for S2; or bellows response and no lower extremity activity for S4. The |

| | |patient may experience sensation of stimulation in the vagina or rectum. Desired responses are S2 or S3. Once |

| | |achieved, a 3-0 temporary electrode is exchanged through the lumen of the foramen needle, leaving only the |

| | |electrode in place while maintaining the ideal location next to the sacral nerve. Re-testing of the temporary |

| | |lead is performed to confirm the appropriate responses. A sterile dressing is placed to secure the lead and |

| | |grounding pad to the patient. A confirmatory x-ray is obtained to document lead position. Extensive counseling |

| | |is provided to the patient regarding operation of the home screener (external stimulation device which is |

| | |connected to the temporary lead and worn by the patient), along with basic troubleshooting instructions. |

|[pic] |

|64573 |  |A 31-year-old man with a 21-year history of partial complex epilepsy is experiencing 10 to 12 seizures per |

| | |month and considerable side effects from maximal doses of carbamazepine and sodium valproate. His history |

| | |includes previous single-drug and polypharmacy regimens, but in each case, the number, intensity, and duration |

| | |of seizures were intolerable. His history also indicates no evidence of nonepileptic seizures under video EEG |

| | |recording. |

|[pic] |

|64581 |  |Clinical Example (64581) |

| | |A 47-year-old female with intractable and debilitating urge incontinence has undergone a temporary test |

| | |stimulation which documented the effectiveness of sacral nerve (transforaminal) neuromodulation for control of |

| | |her symptoms. There was 50% or greater decrease in the incontinence severity score, number of incontinence |

| | |episodes or pads used per 24 hours. No other conservative remedies have been as successful in controlling her |

| | |symptoms. An electrode and implantable pulse generator (IPG) are to be placed for long-term benefit. |

| | |Description of Procedure (64581) |

| | |The patient is given perioperative antibiotics, and after general anesthesia, she is placed in a prone position|

| | |over a laminectomy frame on the OR table. An extended surgical prep is performed for the prosthetic surgery. A |

| | |midline incision is made over the sacrum, and the posterior surface of the sacrum on the side to be implanted |

| | |is exposed. Three-inch foramen needles are placed and are stimulated using the external screener (power source)|

| | |to determine the pattern of biologic responses. These are compared to the written records of the responses |

| | |obtained from the successful temporary test stimulation. Once the same foramen as tested during the temporary |

| | |trial period is identified, an implant electrode is positioned in the foramen, and retested using the external |

| | |screener to stimulate each of four discrete contact points along the electrode to document its appropriate |

| | |position along the sacral nerve. The electrode must be replaced and retested until the appropriate |

| | |physiological responses are demonstrated at a minimum of two contact points. The implant electrode is then |

| | |sutured to the sacral periosteum at multiple points to avoid lead migration. The lead electrode is tunneled |

| | |under the presacral fascia and subcutaneous tissues to a separate incision where the IPG will be connected via |

| | |a lead electrode extension. The fascia is closed over the lead electrode, and the subcutaneous space must be |

| | |closed in a meticulous fashion to avoid seroma formation. Skin closure and placement of a sterile dressing |

| | |complete the procedure. |

|[pic] |

|64612 |  |Clinical Example(s) (64612) |

| | |A 36-year-old, right-handed man complained of severe cramping of his right hand when trying to write or print. |

| | |This began several years ago but has worsened considerably to the point where his writing is now illegible. |

| | |Examination shows flexion of the fingers. Based on available clinical and electrodiagnostic information, |

| | |involuntary overactivity at the flexor digitorum sublimis, flexor carpi ulnaris and flexor digitorum profundus |

| | |was identified. The specific muscles were identified, and targeted injections using optimal doses of botulinum |

| | |toxin were administered. The cramping was relieved and the patient could subsequently write legibly for long |

| | |periods of time. |

| | |A 71-year-old, right-handed woman with a left hemiparesis following a right lacunar stroke one year earlier |

| | |presents with significant discomfort when wearing her ankle/foot orthotic (AFO) which she requires to ambulate.|

| | |Additionally, she has a painful callus over her navicular bone. She also feels painful spasms in her calve |

| | |muscles. The patient was clinically evaluated. Based on clinical and electrodiagnostic information, the |

| | |appropriate muscles causing inversion and plantar flexion of the foot were selected for injection. Botulinum |

| | |toxin was administered with a marked improvement in patient ability to tolerate her AFO, and hence an improved |

| | |gait. |

| | |A 27-year-old woman was receiving dopamine-receptor blocking agent, Pimozide, for treatment of Tourette's. She |

| | |developed tardive dystonia with severe arching of her back. The patient was unresponsive to or had side effects|

| | |from oral medications. Using clinical examination and available electrodiagnostic information, the erector |

| | |spinae muscles were identified and appropriate doses of botulinum toxin administered. The degree of back |

| | |arching was reduced and the patient was able to resume more normal activities of daily living. |

| | |Description of Procedure |

| | |Physician determines whether botulinum toxin would be of benefit and identifies the appropriate site(s). The |

| | |patient is informed of the procedure, rationale, and risks. The site(s) are prepped and localized. Injection(s)|

| | |of botulinum toxin is administered to the multiple sites along the muscle. Several muscles are usually |

| | |injected. A report is dictated and communicated to the referring physician as appropriate. |

|[pic] |

|64613 |  |Clinical Example |

| | |Physician time is recorded only for practice expense purposes. |

|[pic] |

|64622 |  |A 65-year-old woman received a flexion-extension injury in an automobile accident. She was treated and on |

| | |imaging studies was found to have minimal degenerative disk disease at C4-5 and C5-6 with no facet arthropathy.|

| | |The patient has undergone 6 weeks of extensive physical therapy, nonsteroidal anti-inflammatory drugs, and |

| | |trigger point injections with poor results. She then underwent two series of cervical medial branch blocks with|

| | |1% PF Xylocaine that gave her 2 hours of 100% relief of her neck pain. The pain then returned. Because of the |

| | |success of two separate trials with medial branch blocks, the patient is an ideal candidate for radiofrequency |

| | |rhizotomy of the C-4 and C-5 medial branch nerves. Because of problems only on the right side, this would be |

| | |performed on the right at C-4 and C-5. Physical therapy and medication therapy have failed. On two separate |

| | |occasions medial branch blocks significantly decreased the pain for the duration of the anesthetic, confirming |

| | |that simpler, less invasive treatments have been unsuccessfully tried and are not applicable for this patient. |

|[pic] |

|64623 |  |A 65-year-old woman received a flexion-extension injury in an automobile accident. She was treated and on |

| | |imaging studies was found to have minimal degenerative disk disease at C4-5 and C5-6 with no facet arthropathy.|

| | |The patient has undergone 6 weeks of extensive physical therapy, nonsteroidal anti-inflammatory drugs, and |

| | |trigger point injections with poor results. She then underwent two series of cervical medial branch blocks with|

| | |1% PF Xylocaine that gave her two hours of 100% relief of her neck pain. The pain then returned. Because of the|

| | |success of two separate trials with medial branch blocks, the patient is an ideal candidate for radiofrequency |

| | |rhizotomy of the C-4 and C-5 medial branch nerves. Because of problems only on the right side, this would be |

| | |performed on the right at C-4 and C-5. Physical therapy and medication therapy have failed. On two separate |

| | |occasions medial branch blocks significantly decreased the pain for the duration of the anesthetic, confirming |

| | |that simpler, less invasive treatments have been unsuccessfully tried and are not applicable for this patient. |

|[pic] |

|64626 |  |A 65-year-old woman with flexion-extension injury from an automobile accident presents with constant neck pain.|

| | |The patient's history includes imaging studies that found minimal degenerative disk disease at C4-5 with no |

| | |facet arthropathy and no relief with physical therapy, nonsteroidal anti-inflammatory drugs, or trigger point |

| | |injection. Previously, two trials of cervical medial branch block gave her 2 hours of 100% relief of her neck |

| | |pain. She undergoes radiofrequency rhizotomy of the right C-4 medial branch nerves. |

|[pic] |

|64627 |  |A 65-year-old woman with flexion extension injury from an automobile accident presents with constant neck pain.|

| | |The patient's history includes imaging studies that found minimal degenerative disease at C4-5 and C5-6 with no|

| | |facet arthropathy and no relief with physical therapy, nonsteroidal anti-inflammatory drugs, or trigger point |

| | |injections. Previously two trials of cervical medial branch blocks gave her 2 hours of 100% relief of her neck |

| | |pain. She undergoes radiofrequency rhizotomy of the right C-4 and C-5 medial branch nerves. |

|[pic] |

|64650 |  |Clinical Example |

| | |A 26-year-old female patient presents with profuse sweating under the arms since puberty. She reports |

| | |interference in performing her duties in the workplace, interference with interactions with others in the |

| | |workplace and elsewhere, and multiple daily changes of clothes. She has not responded to over-the-counter or |

| | |prescription-strength antiperspirants. A decision was made to perform botulinum toxin injections in both |

| | |axillae. |

| | |Description of Procedure |

| | |The patient is positioned and draped. Prior to administering botulinum toxin type A, the locations of excessive|

| | |sweating are mapped to maximize treatment effectiveness. The physician paints the prepared axillae areas with |

| | |an iodine solution and, when dry, dusts the areas with starch powder. Within a 10- to 15-minute period, the |

| | |presence of sweat will cause the prepped areas to turn a dark purple. The physician outlines the reactive area |

| | |of excessive sweating with a surgical marking pen and removes the starch-iodine compound. With the surgical |

| | |marking pen, the physician marks a nonlinear staggered pattern of sites 1.5 cm apart because botulinum toxin |

| | |type A diffuses under the skin to a diameter of approximately 2 cm and this ensures uninterrupted coverage of |

| | |the entire treatment area. The physician preps the area with antimicrobial solution. |

| | |The physician reconstitutes the vacuum-dried botulinum toxin type A (100 U per vial) with 4 ml sterile saline |

| | |solution and draws four separate 1-ml syringes. The physician administers a series of 12 to 15 intradermal |

| | |injections per axilla to distribute 50 U evenly among the injection sites. At a 10° to 30° angle, the physician|

| | |slowly injects an aliquot of botulinum toxin type A into the dermis to obtain a visible wheal that confirms |

| | |placement and avoids puncturing the skin at the mapping marks so as not to carry any ink into the skin. |

| | |Compression is held to facilitate hemostasis. The physician discusses the follow-up assessment. He also |

| | |addresses pain management, dressings if required, and care of the treated skin area. The physician monitors for|

| | |pain as well as skin surface reaction throughout the process. |

|[pic] |

|64653 |  |Clinical Example |

| | |A 66-year-old male patient undergoes a surgical excision of a mixed-cell tumor of the left parotid gland. |

| | |Following surgery, he develops a complication of gustatory hyperhidrosis where he has excessive sweating when |

| | |he smells or eats certain foods. He is referred for evaluation and treatment of excessive sweating on the left |

| | |cheek. A decision was made to perform botulinum toxin injections in the affected area. |

| | |Description of Procedure |

| | |The patient is positioned and draped. Prior to administering botulinum toxin type A, the locations of excessive|

| | |sweating are mapped to maximize treatment effectiveness. The physician paints the area(s) with an iodine |

| | |solution and, when dry, dusts the area(s) with starch powder. Within a 10- to 15-minute period, the presence of|

| | |sweat will cause the prepped areas to turn a dark purple. The physician outlines the reactive area of excessive|

| | |sweating with a surgical marking pen, and removes the starch-iodine compound. With the surgical marking pen, |

| | |the physician marks a nonlinear staggered pattern of sites 1.5 cm apart because botulinum toxin type A diffuses|

| | |under the skin to a diameter of approximately 2 cm and this ensures uninterrupted coverage of the entire |

| | |treatment area. The physician preps the area(s) with antimicrobial solution. |

| | |The physician reconstitutes the vacuum-dried botulinum toxin type A (100 U per vial) with 4 ml sterile saline |

| | |solution and draws four separate 1-ml syringes. The physician administers a series of 12 to 15 intradermal |

| | |injections per area to distribute 50 U evenly among the injection sites. At a 10° to 30° angle, the physician |

| | |slowly injects an aliquot of botulinum toxin type A into the dermis to obtain a visible wheal that confirms |

| | |placement and avoids puncturing the skin at mapping marks so as not to carry any ink into the skin. Compression|

| | |is held to facilitate hemostasis. The physician monitors for pain as well as skin surface reaction throughout |

| | |the process. |

| | |Description of Procedure |

| | |The correct surgical site is confirmed. A marking pen is used to delineate the planned six incisions in the |

| | |eyelid and above the brow. Antibiotic ointment and a protective device (eg, protective shell) are placed on the|

| | |cornea. Lidocaine with epinephrine is infiltrated for hemostasis and for anesthesia. Five minutes are allowed |

| | |to pass. |

| | |A traction suture is placed through the upper eyelid margin and clamped inferiorly. The eyelid incisions are |

| | |made just above the lash line through skin and orbicularis oculi muscle. The suprabrow incisions are made to |

| | |the level of periosteum. A superiorly directed pocket is created at each suprabrow incision. |

| | |A fascia needle is used to thread the banked fascia between the incisions in the eyelids and brow forming two |

| | |rectangles with two pieces of fascia. The eyelid incisions are closed with absorbable 7-0 suture. The upper |

| | |eyelid traction suture is removed. The protective device is removed. Tension on the two fascia ends that |

| | |finally exit the suprabrow incision is adjusted until optimal eyelid height and contour are obtained. Square |

| | |knots are tied in the fascia, secured with suture, and buried deep in the suprabrow wounds. |

| | |The suprabrow incisions are closed in layers with 7-0 absorbable suture. The eyelid incisions may be closed |

| | |according to the surgeon’s preference. Antibiotic ointment is placed on the wounds and in the conjunctival |

| | |cul-de-sac. A traction suture is placed in the lower lid margin and taped to the brow with adhesive strips. |

| | |Description of Procedure |

| | |The correct surgical site and the site for harvesting the fascia autograft are confirmed. The thigh is |

| | |positioned. An incision is made in the thigh approximately 2.5 in above the knee joint. The incision is carried|

| | |through skin and subcutaneous tissue until the fascia lata is identified. Three cuts in the fascia are made to |

| | |create a U shape. The fascia is separated from the underlying muscle. A ligature is placed on the free end of |

| | |the fascia. The free end of the fascia is threaded into the fascia stripper. The stripper is directed |

| | |superiorly beneath the skin for about 20 cm in a line from the head of the fibula to the iliac crest. The |

| | |fascia is cut superiorly by activating the cutting mechanism of the stripper. The fascia and stripper are |

| | |removed. The skin wound is closed in layers and the thigh is dressed with a pressure dressing. |

| | |The fascia is cleaned of subcutaneous tissue and fat and cut to produce two strips of appropriate size. |

| | |A marking pen is used to delineate the planned six incisions in the eyelid and above the brow. Antibiotic |

| | |ointment and a protective device (eg, protective shell) are placed on the cornea. Lidocaine with epinephrine is|

| | |infiltrated for hemostasis. Five minutes are allowed to pass. A traction suture is placed through the upper |

| | |eyelid margin and clamped inferiorly. The three eyelid incisions are made just above the lash line through skin|

| | |and orbicularis oculi muscle. The three suprabrow incisions are made to the level of periosteum. A superiorly |

| | |directed pocket is created above each suprabrow incision. |

| | |A fascia needle is used to thread the two pieces of fascia between the incisions in the eyelids and brow, |

| | |forming two rectangles. The eyelid incisions are closed with absorbable 7-0 suture. The upper eyelid traction |

| | |suture is removed. The protective device is removed. Tension on the two fascia ends that exit two of the |

| | |suprabrow incisions is adjusted until optimal eyelid height and contour are obtained. Square knots are tied in |

| | |the fascia, secured with suture, and buried deep in the suprabrow wounds. |

| | |The suprabrow incisions are closed in layers with 7-0 absorbable sutures. Antibiotic ointment is placed on |

| | |wounds and in the conjunctival cul-de-sac. A traction suture is placed in the lower lid margin and taped to the|

| | |brow with adhesive strips. |

|[pic] |

|64681 |  |Clinical Example (64681) |

| | |A 75-year-old male with known prostatic carcinoma and pelvic metastases is suffering from intractable pelvic |

| | |pain with severe spasms and cramps. Oral medications have not helped him. The patient had been referred to an |

| | |interventional pain specialist for a superior hypogastric plexus block to relieve his intractable pelvic pain. |

| | |The patient had a superior hypogastric plexus block which demonstrated 95% pain relief for 6 hours. Thereafter |

| | |his pain gradually returned to the original intensity. With the success of a local anesthetic block of the |

| | |superior hypogastric plexus, the patient is being admitted for a neurolytic block for long-term pain control. |

| | |Description of Procedure (64681) |

| | |The patient is transferred to the operating room or procedure room. EKG, pulse oximeter and non-invasive blood |

| | |pressure monitors are applied. Intravenous sedation is titrated to effect. His back is prepared with Betadine. |

| | |Under imaging guidance (reported separately) a spinal needle is inserted to the ventral lateral surface of the |

| | |spine at the L5-S1 interspace. Once needle position is confirmed using imaging guidance, radiographic contrast |

| | |is injected on each side to document needle position in the pre-vertebral space just ventral to the psoas |

| | |fascia. This further demonstrates that the flow is not intra-vascular. The neurolytic block is then performed |

| | |with alcohol solution with local anesthetic or Phenol solutions. The patient is then transferred to the |

| | |recovery room for observation for several hours. He will be monitored for early complications of the procedure |

| | |as well as recovery from conscious sedation. The complications of the procedure include puncture of the iliac |

| | |vessels and bleeding, intravascular injection of local anesthetics and neurolytic substances, with seizures, |

| | |and cardiovascular collapse, nerve injury to the cauda equina or exiting spinal nerves, puncture of the ureters|

| | |and other pelvic viscera. Infection is always a possibility, especially in immuno-suppressed cancer patients. |

|[pic] |

|64821 |  |Clinical Example (64821) |

| | |A 40-year-old female with Raynaud's disease is treated with a radial artery sympathectomy. |

| | |Description of Procedure (64821) |

| | |An incision is made over the radial artery. Careful dissection is carried out using loupe magnification. Care |

| | |is taken to protect the branches of the superficial branches of the radial nerve. The radial artery is exposed.|

| | |The operating microscope is then brought into position. The adventitia of the radial artery is meticulously |

| | |removed, taking care not to injure the deeper structures of the radial artery. This dissection is carried out |

| | |over a distance of approximately 4 to 6 cm. The dissection is carried out into the region of the snuff box. The|

| | |superficial branch of the radial nerve must be respected in this area as do the adjacent extensor tendons. The |

| | |tourniquet is released. Hemostasis is achieved. The wound is then closed in layers. |

|[pic] |

|64822 |  |Clinical Example (64822) |

| | |A 40-year-old female with Raynaud's disease is treated with a ulnar artery sympathectomy. |

| | |Description of Procedure (64822) |

| | |An incision is made over the ulnar artery extending into Guyon's canal. The incision is made so as not to cross|

| | |the wrist flexion crease at a right angle. Careful dissection is carried out using loupe magnification. The |

| | |ulnar nerve is carefully protected. The operating microscope is then brought into position. The adventitia of |

| | |the ulnar artery is removed using microsurgical technique. This dissection extends from approximately 3 cm |

| | |proximal to the wrist flexion crease to the superficial palmar arch. Once the sympathectomy is completed, the |

| | |tourniquet is released and hemostasis is achieved. The wounds are irrigated and the skin is approximated in |

| | |layers in the forearm and with interrupted sutures in the hand. |

|[pic] |

|64823 |  |Clinical Example (64823) |

| | |A 40-year-old female with Raynaud's disease is treated with a superficial palmar arch sympathectomy. |

| | |Description of Procedure (64823) |

| | |An incision is made over the superficial palmar arch in the palm. Careful dissection is carried out using loupe|

| | |magnification. The palmar fascia is incised. The digital neurovascular bundles are identified, as well as the |

| | |superficial palmar arch. Great care is taken to protect these underlying structures. The operating microscope |

| | |is brought into position. Microsurgical technique is then used to remove the adventitia from the superficial |

| | |palmar arch. Once this is completed, the tourniquet is released and hemostasis achieved. The wound is |

| | |irrigated, and the wound is sutured. |

|[pic] |

|64910 |  |Clinical Example (64910) |

| | |A 2-cm gap in the median nerve in the forearm of a 26-year-old male is repaired with a synthetic nerve conduit |

| | |using the microsurgical technique. |

| | |Description of Procedure (64910) |

| | |An incision is made over the site of the nerve injury and dissection is carried out to expose the median nerve |

| | |ends. The operating microscope is brought into position and the ends of the median nerve are freshened. The |

| | |diameter of the nerve is measured as well as the size of the gap between the nerve ends. An appropriately sized|

| | |synthetic conduit is selected. The conduit is placed in the nerve gap and each end of the nerve is sutured |

| | |inside the conduit using the microsurgical technique. The wound is irrigated and closed in layers. |

|[pic] |

|64911 |  |Clinical Example (64911) |

| | |A 2-cm gap in the median nerve in the forearm of a 26-year-old male is repaired with an interposition vein |

| | |graft using the microsurgical technique. |

| | |Description of Procedure (64911) |

| | |Under anesthesia, an incision is made over the area of the nerve injury and the median nerve ends are exposed. |

| | |The operating microscope is brought into position and the ends of the median nerve are freshened. The diameter |

| | |of the nerve is measured as well as the size of the gap between the nerve ends. A second incision is made, |

| | |either on the dorsal or palmar aspect of the forearm, and the vein graft is harvested. The vein graft donor |

| | |site is then closed in layers. The vein graft is placed between the nerve ends, which are sutured inside the |

| | |graft using the microsurgical technique. The wound is irrigated and closed in layers. |

|[pic] |

|65780 |  |Clinical Example (65780) |

| | |A 48-year-old woman with neurotrophic keratopathy has a persistent corneal epithelial defect which has failed |

| | |to heal after treatment with lubricants and a bandage contact lens. There is significant corneal thinning with |

| | |a high risk of perforation. |

| | |Description of Procedure (65780) |

| | |A plastic adhesive drape is applied to the operative eye and incised. A lid speculum is inserted so that the |

| | |lid margins and lashes are isolated from the operative field. The operating microscope is swung into position |

| | |and adjusted. Sponges and forceps are used to debride necrotic corneal epithelium. Preserved human amniotic |

| | |membrane is first removed from the storage medium and peeled from the nitrocellulose filter paper on which it |

| | |is supplied. A piece of membrane is trimmed with scissors to fit the area of corneal thinning. The smooth |

| | |basement membrane surface is distinguished from the sticky stromal surface by touching it with a sponge. The |

| | |membrane is placed with the basement membrane surface up, and is anchored into place with multiple interrupted |

| | |sutures. The suture ends are trimmed and rotated flush with or below the surface of the corneal epithelium. |

| | |Additional pieces of amniotic membrane (2-4) are trimmed to fit the area of thinning, placed basement membrane |

| | |surface up, and anchored into place with interrupted sutures until the area of thinning is flush with |

| | |surrounding normal-thickness cornea. All of the knots are buried. The lid speculum and drapes are removed. A |

| | |bandage contact lens is placed with topical antibiotic-steroid ointment. |

|[pic] |

|65781 |  |Clinical Example (65781) |

| | |The patient is a 47-year-old male with severe corneal scarring secondary to Stevens-Johnson syndrome and |

| | |insufficient viable conjunctival epithelium remaining to allow healing. |

| | |Description of Procedure (65781) |

| | |A plastic adhesive drape is applied to the operative eye and incised. A lid speculum is inserted so that the |

| | |lid margins and lashes are isolated from the operative field. A lateral canthotomy is performed, if necessary, |

| | |to enable expansion of the lid speculum and attain adequate exposure. The operating microscope is swung into |

| | |position and adjusted. |

| | |The cadaveric keratolimbal allografts are then prepared from the donor corneoscleral rim. The central donor |

| | |cornea is excised with a trephine, avoiding trauma to the limbal stem cells. The remaining corneoscleral rim is|

| | |sectioned into equal halves. Scissors are used to dissect excess peripheral tissue, leaving approximately 1 mm |

| | |of sclera peripheral to the limbus. The posterior one half to two thirds of each hemisection is removed under |

| | |the operating microscope by lamellar dissection using a sharp rounded steel crescent blade, while an assistant |

| | |stabilizes the tissue with forceps. The remaining grafts are placed epithelial side up in storage media |

| | |solution while awaiting placement later in the procedure. |

| | |A 360-degree limbal conjunctival peritomy is performed on the recipient. In areas of symblepharon, conjunctival|

| | |tissue is first recessed at the limbus and then undermined to allow the tissue to fall back. The symblepharon |

| | |are used to reconstruct the fornix and provide epithelium for the palpebral surface. Adherent areas of |

| | |conjunctiva are excised, along with a limbal skirt of subconjunctival scar tissue and Tenon's capsule. The |

| | |conjunctiva is resected to expose bare sclera for 4-5 mm posterior to the limbus for 360 degrees. Wet-field |

| | |cautery, topical adrenergics, and thrombin are used to arrest bleeding from the highly vascularized field if |

| | |waiting for normal clotting mechanisms does not result in adequate hemostasis. Significant bleeding may |

| | |necessitate dissection of the conjunctiva one quadrant at a time. |

| | |Abnormal fibrovascular pannus and corneal epithelium are then removed from the underlying corneal stroma, using|

| | |blunt dissection with cellulose surgical microsponges, followed by semi-sharp lamellar dissection with a |

| | |rounded steel blade or scissors to create a smooth surface. Care is taken to maintain an anterior lamellar |

| | |dissection, leaving deeper stromal layers intact. Topical adrenergics and thrombin are used to control |

| | |bleeding. |

| | |The two living-donor conjunctival limbal allografts, previously harvested in a separate procedure, are sutured |

| | |into place at 6 and 12 o'clock with the limbal edge at the recipient limbus, using interrupted sutures. The two|

| | |previously prepared crescents of cadaveric keratolimbal tissue are sutured into place, centered at 3 and 9 |

| | |o'clock, with interrupted sutures so that the corneal edges of the donor material just overly the recipient |

| | |limbus. The recipient limbus should be covered with donor limbal tissue for 360 degrees. Viscoelastics and |

| | |balanced salt solution are used to prevent dessication of the donor tissue during suturing. The free edges of |

| | |the recessed recipient conjunctiva are sutured to the posterior edges of the donor tissue. The lid speculum and|

| | |drapes are removed. The eye is patched with antibiotic and corticosteroid ointment, and covered with a shield. |

|[pic] |

|65782 |  |Clinical Example (65782) |

| | |The patient is a 27-year-old with history of alkalai burn of the eye with corneal and conjunctival scarring. |

| | |The cornea is thinned and the surface has not reepithelialized with appropriate medical therapy. |

| | |Description of Procedure (65782) |

| | |Plastic adhesive drapes are applied to both eyes, and the one over the recipient eye is incised. A lid speculum|

| | |is inserted so that the lid margins and lashes are isolated from the operative field. A lateral canthotomy is |

| | |performed, if necessary, to enable expansion of the lid speculum and attain adequate exposure. The operating |

| | |microscope is swung into position and adjusted. |

| | |A 360-degree limbal conjunctival peritomy is performed on the recipient eye. In areas of symblepharon, |

| | |conjunctival tissue is first recessed at the limbus and then undermined to allow the tissue to fall back. The |

| | |symblepharon are used to reconstruct the fornix and provide epithelium for the palpebral surface. Adherent |

| | |areas of conjunctiva are excised with scissors, along with a limbal skirt of subconjunctival scar tissue and |

| | |Tenon's capsule. The conjunctiva is resected posteriorly 2-3 mm from the limbus for 360 degrees with scissors. |

| | |Wet-field cautery, topical adrenergics, and thrombin are used to arrest bleeding from the highly vascularized |

| | |field if waiting for normal clotting mechanisms does not result in adequate hemostasis. Significant bleeding |

| | |may necessitate dissection of the conjunctiva one quadrant at a time. |

| | |The recipient beds are prepared for the limbal and conjunctival donor tissue by removing recipient conjunctival|

| | |tissue to expose two areas of bare sclera 5-8 mm posterior to the limbus and approximately 8 mm (3 clock hours)|

| | |horizontally, centered on 6 and 12 o'clock. Abnormal fibrovascular pannus and corneal epithelium are then |

| | |removed from the underlying corneal stroma, using blunt dissection with cellulose surgical microsponges, |

| | |followed by semi-sharp lamellar dissection with a rounded steel blade or scissors to create a smooth surface. |

| | |Care is taken to maintain an anterior lamellar dissection, leaving deeper stromal layers intact. Topical |

| | |adrenergics and thrombin are used to control bleeding. The surface is moistened, the speculum removed, and the |

| | |lids are closed while the autografts are harvested from the fellow eye. |

| | |The plastic adhesive drape on the donor eye is incised and the speculum is placed so as to isolate the lashes |

| | |and lid margins from the operative field. The operating microscope is re-centered. A violet surgical marking |

| | |pen is used to mark the conjunctival borders of the grafts at 12 and 6 o'clock, with the same dimensions as the|

| | |recipient beds. The conjunctiva at 12 o'clock is elevated from Tenon's layer with a subconjunctival injection |

| | |of balanced salt solution or anesthetic. Radial incisions are made with scissors along the lateral borders of |

| | |the grafts. Using blunt dissection, the tissue is undermined between the lateral edges, then the posterior edge|

| | |is incised. The graft is reflected anteriorly over the cornea and blunt dissection is carried anteriorly to the|

| | |conjunctival insertion at the limbus. A Tooke blade or other blunt scarifier is used to carry the blunt |

| | |dissection further anterior into the peripheral cornea 1 mm beyond the peripheral corneal vascular arcades. The|

| | |depth of the dissection is limited to a superficial epithelial keratectomy of the limbus and peripheral cornea,|

| | |and does not include sclera or corneal stroma. The epitheliectomy is completed with a sharp crescent blade or |

| | |scissors. The free graft is transferred, epithelial side up, to a Petri dish and covered with corneal storage |

| | |medium or balanced salt solution. The posterior conjunctiva is advanced to 2 mm posterior to the limbus and |

| | |anchored to episclera with interrupted sutures. The same procedure is repeated at the 6 o'clock position to |

| | |produce a second graft. The lid speculum is removed from the donor eye, the surface is moistened, topical |

| | |antibiotic and steroid solutions are instilled, and the lids are closed. |

| | |The speculum is then placed in the recipient eye and the autografts sutured into position one at a time, with |

| | |the graft limbal tissue placed at the recipient limbus. Multiple interrupted sutures are used, first at the |

| | |corners of the graft at the limbus, then along the conjunctival portions. Viscoelastics and balanced salt |

| | |solution are used to prevent dessication of the donor tissue during suturing. The suture ends are cut on the |

| | |knot and rotated flush with the corneal surface. The lid speculum and drapes are removed, and the donor eye is |

| | |patched with antibiotic and corticosteroid ointment, and covered with a shield. |

|[pic] |

|66711 |  |Clinical Example (66711) |

| | |A 66-year-old patient with a history of chronic glaucoma has progressive optic nerve damage and elevated |

| | |intraocular pressure that has not been controlled by medical therapy and a previous filtering operation. The |

| | |patient is pseudophakic with a miotic pupil. |

| | |Description of Procedure (66711) |

| | |Anesthesia is begun with periocular local anesthetic. A cleansing prep is performed of the conjunctiva, |

| | |followed by placement of a drape. A lid speculum is inserted to allow adequate visualization. A clear corneal |

| | |incision is made with the diamond blade approximately 3.4 mm in width, usually temporally. Viscoelastic |

| | |material is injected into the anterior chamber over the pupil and lens to increase and maintain anterior |

| | |chamber depth. Viscoelastic is then injected under the iris for 180° to visualize the ciliary body processes |

| | |with the endoscope. The endoscope is inserted through the temporal incision viewing the nasal ciliary |

| | |processes. The ciliary processes are coagulated through the endoscope with the endpoint of shrinkage and |

| | |whitening. The endoscope is moved in an arc allowing treatment of the processes over an arc of 180°. A second |

| | |corneal incision is made 90° away and 180° of ciliary processes are treated. At the end of the procedure, the |

| | |surgeon has completed coagulation of 270° of angle. After completion of laser therapy, the viscoelastic |

| | |material is removed from the anterior segment of the eye with an irrigation and aspiration device to prevent |

| | |intraocular pressure spikes. The eye is reformed with balanced salt solution. The wounds are checked for |

| | |leakage and if necessary sutures are placed to seal the wound. |

|[pic] |

|66982 |  |Clinical Example (66982) |

| | |A 76-year-old woman has suffered slowly progressive and painless loss of vision due to cataract. The patient |

| | |has a 20-year history of primary open angle glaucoma, including chronic therapy with pilocarpine. This |

| | |treatment has resulted in a pupil of 2.0 mm which will not dilate to more than 3.0 mm with mydriatics. |

| | |Clinical Example (66982) |

| | |A 5-year-old child is noted to have developed traumatic cataract with 20/200 vision following blunt trauma |

| | |three months prior to surgery. An extracapsular extraction with IOL implantation is performed under general |

| | |anesthesia. Post-op vigorous amblyopia therapy is begun. |

| | |Description of Procedure (66982) |

| | |The patient is draped and prepped in the usual sterile manner and the operating microscope is swung into place.|

| | |A fornyx based flap is then performed and a scleral groove is made for the phacoemulsification port. A side |

| | |port incision is then made. Despite vigorous dilation, the pupil remains fixed at 2.5 mm, so, under |

| | |viscoelastic, a spatula is used to lyse all posterior synechiae. Four incisions are then made for the |

| | |Grieshaber hooks which are inserted and the iris is then retracted to 6 mm. The phacoemulsification then |

| | |proceeds in the usual manner. The hooks are then removed and the four wounds are then checked for water |

| | |tightness. The eye is then dressed after the usual subconjunctival injections. |

| | |Description of Procedure (66982) |

| | |The child is draped in the usual sterile manner and the microscope swung into place. After anterior |

| | |capsulotomy, the usual automated aspiration technique is used to remove the soft nuclear opacity. A posterior |

| | |capsulotomy is performed prior to IOL insertion. The eye is then dressed in the usual sterile manner after |

| | |antibiotic injections are given. |

|[pic] |

|66990 |  |Clinical Example (66990) |

| | |A 72-year-old male, 16 months post-op phacoemulsification, who had a posterior chamber lens inserted in the |

| | |sulcus at the time of surgery due to a broken posterior capsule, presents with glare, poor vision and multiple |

| | |images due to a "sunset syndrome." A repositioning of the intraocular lens is performed. During the procedure |

| | |ophthalmic endoscopy is performed to aid in planning and ensuring adequate capsular support. |

| | |Description of Procedure (66990) |

| | |Two stab incisions are made with a #75 blade at the supero-nasal and temporal surgical limbus. Using a blunt |

| | |cannula, the anterior segment is filled with viscoelastic material. The viscoelastic material is then gently |

| | |injected under the iris and in front of the implant to allow visualization of the capsular bag. The sulcus is |

| | |examined 360 degrees. The zonules are noted to be absent below but intact above. The lower haptic of the |

| | |intraocular lens is noted to be subluxated into the anterior vitreous. A repositioning is planned based on the |

| | |anatomy. After the intraocular lens is repositioned and rotated, the endoscope is then reinserted to ensure |

| | |that there is adequate capsular support for the implant before the completion of the surgical procedure. |

|[pic] |

|67220 |  |Clinical Example (67220) |

| | |A 69-year-old patient with a juxtafoveal choroidal neovascular membrane is treated with photocoagulation using |

| | |a slit lamp biomicroscopic delivery system. The location of treatment application are guided by reference |

| | |during the procedure to the results of a preoperative fluorescein angiogram. Recovery and visual acuity are |

| | |monitored. |

| | |Description of Procedure (67220) |

| | |Laser photocoagulation is performed, using projection of fluorescein angiogram as a guide. The lesion area is |

| | |subjected to multiple laser burns. For each burn, the surgeon assesses and responds to the patient's motion, |

| | |anterior segment opacity affecting the intensity of laser reaching lesion, thickness of lesion, and tissue |

| | |reaction to treatment. The surgeon pauses frequently between burns to ensure continued steadiness of both |

| | |patient and surgeon. |

|[pic] |

|67221 |  |Clinical Example (67221) |

| | |A 68-year-old woman returns for follow-up evaluation of a slow, but progressive loss of central field vision |

| | |due to age-related macular degeneration. |

| | |Description of Procedure (67221) |

| | |Verteporfin is infused intravenously for ten minutes. Fifteen minutes after the start of the infusion, laser |

| | |light is applied for 83 seconds using a contact lens and a special slit lamp. Patient follow-up consisted of a |

| | |phone call two to four days after treatment. Routine return was scheduled for three months, although return for|

| | |re-exam was requested if an adverse event was suspected. |

|[pic] |

|67225 |  |Clinical Example (67225) |

| | |A 67-year-old woman with age-related macular degeneration has reduced vision in both eyes. She has been |

| | |evaluated and has been found to have the clinical appearance of a subfoveal choroidal neovascular membrane. |

| | |Fluorescein angiography revealed the presence of a predominantly 'classic' choroidal neovascular membrane which|

| | |lay immediately under the center of the foveal avascular zone of each eye. A decision was made to treat with |

| | |OPT. |

| | |Description of Procedure (67225) |

| | |First Eye: The patient comes to the office. An appropriate drug dosage is calculated and the drug is mixed. |

| | |Discussion with the patient of the treatment of the potential complications of anaphylaxis, extravasation, or |

| | |back pain during infusion. The problems with light exposure for the five days following drug injection, and |

| | |post-operative symptoms which would necessitate a call to the office following the treatment are reviewed. They|

| | |are also informed of the possibility of sudden visual loss within a few days of treatment and the need for |

| | |follow-up treatments when the vast majority of cases is every three months for up to two years is discussed. |

| | |Contraindications are reviewed after the history is taken. The informed consent is obtained. |

| | |An IV line is placed, the drug is infused using an automated infusion pump, and the infusion takes place over |

| | |exactly 10 minutes. There is then a 5 minute waiting time. The physician tests and calibrates the laser. The |

| | |physician must be present during the infusion. |

| | |The physician projects and reviews the fluorescein angiogram and then measures the greatest linear diameter |

| | |(GLD) in microns. The physician then determines the correct contact lens based on lesion size. The laser |

| | |dosimetry is calculated based on lesion GLD plus 1000 microns. The laser spot size, fluence, time and |

| | |magnification are set. The patient is seated at the laser, anesthetic drops applied to the eye, and contact |

| | |lens placed on the cornea. The laser is focused on the lesion and the location is confirmed on the projected |

| | |fluorescein angiogram. At exactly 5 minutes after conclusion of the infusion, laser energy is applied for 83 |

| | |seconds insured by an automated timer. Precise laser application is essential since moving the beam can cause |

| | |damage to the optic nerve or adjacent retina. The contact lens is removed and the cornea is copiously irrigated|

| | |to remove the goniosol. |

| | |Second Eye: The physician projects and reviews the fluorescein angiogram of the second eye and measures the GLD|

| | |in microns. The physician then determines the correct contact lens based on lesion size. The laser dosimetry is|

| | |calculated based on lesion GLD plus 1000 microns. As soon as the laser application to the first eye is |

| | |completed, the contact lens is moved to the cornea of the second eye. The laser spot size, fluence, time and |

| | |magnification are set. Laser energy is applied for 83 seconds insured by an automated timer. Precise laser |

| | |application is essential since moving the beam can cause damage to the optic nerve or adjacent retina. The |

| | |contact lens is removed and the cornea is copiously irrigated to remove the goniosol. |

|[pic] |

|67912 |  |Clinical Example (67912) |

| | |A 50-year-old male presents with a permanent facial nerve palsy following resection of an ipsilateral acoustic |

| | |neuroma. The patient has symptomatic exposure keratopathy, which does not respond adequately to the use of |

| | |hourly topical lubricants. |

| | |Description of Procedure (67912) |

| | |A traction suture is placed through the lid margin. A lid crease incision is made. Dissection of lid structures|

| | |is performed demonstrating the orbital septum and the anterior surface of the tarsus. The previously determined|

| | |gold weight is centered over the bare superior tarsal surface and then sutured into position. The wound is |

| | |irrigated with antiobiotic solution. Obicularis oculi muscle is closed over the implant. The traction suture is|

| | |removed. Skin is closed over the obicularis oculi muscle, including several passes through the superior border |

| | |of the tarsus to restore the superior eyelid crease. Antibiotic ointment is placed over the wound and a double |

| | |eye pad is applied. |

|[pic] |

|69424 |  |Clinical Example (69424) |

| | |A five-year-old child had tympanostomy (ventilating) tubes placed at age 2 for recurring acute otitis media |

| | |with effusion. The left tube extruded 1 year ago and that ear has been free of infection and fluid since then. |

| | |The right tube has failed to extrude and has granulation tissue around it that has been unresponsive to topical|

| | |antimicrobial therapy. The surgeon who originally placed the tube has followed the child since placement and |

| | |feels the remaining indwelling tympanostomy tube should be removed. |

| | |Description of Procedure (69424) |

| | |The surgeon who originally placed the tympanostomy (ventilating) tubes brings the patient to the outpatient |

| | |facility. Under general anesthesia and utilizing an operating microscope, the surgeon creates a relaxing |

| | |incision. The surgeon removes the tube with surrounding granulation tissue, thus creating an optimal situation |

| | |for closure of the perforation in which the tube was situated. Monitoring of the ear in the office setting |

| | |revealed the perforation to have closed within several weeks' time. |

|[pic] |

|69714 |  |Clinical Example (69714) |

| | |An 8-year-old male presents for an osseointegrated implant to restore hearing that has diminished due to |

| | |chronic otitis media. Previous trials with a hearing aid prosthetic device in the ear resulted in additional |

| | |infections. At operation, the bone and overlying skin are prepared and the integrated implant and abutment are |

| | |fitted. |

| | |Description of Procedure (69714) |

| | |The site is measured and marked to optimal placement of the titanium fixture. An injection of xylocaine with |

| | |epinephrine is administered for anesthetic and hemostasis. The skin is incised to expose the mastoid cortex, |

| | |creating an overlying skin flap, periosteal flap, and to drill a pilot hole. Lack of dural contact and lack of |

| | |sigmoid sinus exposure is ascertained. The pilot hole is enlarged with spiral drilling to achieve a 3.5 mm |

| | |opening. Final site preparation is performed with controlled tapping of the implantation site. The fixture is |

| | |placed and the abutment subsequently secured to the fixture. After perforating the overlying skin flap, the |

| | |surrounding soft tissues are reduced to a maximal thickness of less than 3 mm. |

|[pic] |

|69715 |  |Clinical Example (69715) |

| | |An 8-year-old male presents for an osseointegrated implant to restore hearing that has diminished due to |

| | |chronic otitis media. Previous trials with a hearing aid prosthetic device in the ear resulted in additional |

| | |infections. At operation, a mastoidectomy is performed to address the chronic mastoid infections; the temporal |

| | |bone and overlying skin are prepared, and the integrated implant and abutment are fitted. |

| | |Description of Procedure (69715) |

| | |The site is measured and marked to optimal placement of the titanium fixture. An injection of xylocaine with |

| | |epinephrine is administered for anesthetic and hemostasis. The skin is incised to expose the mastoid cortex, |

| | |creating an overlying skin flap and periosteal flap. A mastoidectomy is performed for excision of disease and |

| | |exposure of nonaerated segments of the mastoid air cell system. A pilot hole is drilled to ascertain lack of |

| | |dural contact and lack of sigmoid sinus exposure. The pilot hole is enlarged with spiral drilling to achieve a |

| | |3.5 mm opening. Final site preparation is performed with controlled tapping of the implantation site. The |

| | |fixture is placed and the abutment subsequently secured to the fixture. After perforating the overlying skin |

| | |flap, the surrounding soft tissues are reduced to a maximal thickness of less than 3 mm. |

|[pic] |

|69717 |  |Clinical Example (69717) |

| | |A 16-year-old male presents for removal and replacement of an osseointegrated implant. At operation, the |

| | |implant is removed, the bone and overlying skin are revised for fitting with a new integrated implant and |

| | |abutment. |

| | |Description of Procedure (69717) |

| | |The site is measured and marked to optimal placement of the titanium fixture. An injection of xylocaine with |

| | |epinephrine is administered for anesthetic and hemostasis. The skin is incised to expose the mastoid cortex, |

| | |creating an overlying skin flap and periosteal flap. Remove existing implant with incision of surrounding soft |

| | |tissue or drill out of surrounding bone. A pilot hole is drilled to ascertain lack of dural contact and lack of|

| | |sigmoid sinus exposure. The pilot hole is enlarged with spiral drilling to achieve a 3.5 mm opening. Final site|

| | |preparation is performed with controlled tapping of the implantation site. The fixture is placed and the |

| | |abutment subsequently secured to the fixture. After perforating the overlying skin flap, the surrounding soft |

| | |tissues are reduced to a maximal thickness of less than 3 mm. |

|[pic] |

|69718 |  |Clinical Example (69718) |

| | |A 16-year-old male presents for removal and replacement of an osseointegrated implant. At operation, a |

| | |mastoidectomy is performed to address the chronic mastoid infections, the implant is removed, and the bone and |

| | |overlying skin are revised for fitting with a new integrated implant and abutment. |

| | |Description of Procedure (69718) |

| | |The site is measured and marked to optimal placement of the titanium fixture. An injection of xylocaine with |

| | |epinephrine is administered for anesthetic and hemostasis. The skin is incised to expose the mastoid cortex, |

| | |creating an overlying skin flap and periosteal flap. Remove existing implant with incision of surrounding soft |

| | |tissue or drill out of surrounding bone. Perform mastoidectomy for excision of disease and exposure of |

| | |nonaerated segments of the mastoid air cell system. A pilot hole is drilled to ascertain lack of dural contact |

| | |and lack of sigmoid sinus exposure. The pilot hole is enlarged with spiral drilling to achieve a 3.5 mm |

| | |opening. Final site preparation is performed with controlled tapping of the implantation site. The fixture is |

| | |placed and secured to the abutment to the fixture is performed. After perforating the overlying skin flap, the |

| | |surrounding soft tissues are reduced to a maximal thickness of less than 3 mm. |

|[pic] |

|70496 |  |Clinical Example (70496) |

| | |The patient is a 52-year-old woman with suspected intracranial aneurysm. |

|[pic] |

|70498 |  |Clinical Example (70498) |

| | |The patient is a 74-year-old man with previous myocardial infarction and permanent pacemaker (precluding MRA) |

| | |presents with two transient ischemic attacks (TIAs) to be evaluated for carotid stenosis. |

|[pic] |

|70542, |  |Clinical Example (70542 and 70543) |

|70543 | |The patient, a 72-year-old man with neck mass and biopsy positive for squamous cell carcinoma, is referred for |

| | |MR for staging to determine extent of nodal involvement, which will require imaging. Patient brings with him |

| | |unenhanced scan. |

|[pic] |

|70544 |  |Clinical Example (70544) |

| | |The patient is a 45-year-old man presenting with a family history of cerebral aneurysm. His aunt and father |

| | |both died of ruptured cerebral aneurysms, which places him in a high-risk group. Rather than undergoing an |

| | |invasive cerebral angiogram with attendant risks and costs, his physician orders an MRA of the brain to exclude|

| | |cerebral aneurysm. |

| | |Description of Procedure (70544) |

| | |Currently the MRA procedure entails a 3-D time-of-flight gradient echo sequence sensitive to blood flow |

| | |covering the vertebrobasilar and the circle of Willis to the proximal middle cerebral M1 and M2 branches. The |

| | |data obtained would consist of between 64 and 128 images at 1-2 mm in thickness which are then processed by an |

| | |array algorithm to produce a "maximum intensity projections" (MIPs) which are the MRA equivalents of |

| | |subtraction angiograms. Various regions of interest delineated by radiologists are then performed on this data |

| | |set by the technologist to produce "coned down" views of the arterial tree. Typically these would include |

| | |separate postprocessing of the left and right internal carotid, middle and anterior cerebral arteries as well |

| | |as the vertebrobasilar system. From 12-18 MIPs at various angles around an artery per region are produced. |

| | |These would then be reviewed with the 128 partitions (separate images) by the radiologist. The post-processing |

| | |and post-service time usually requires approximately 20 - 30 minutes of technical time followed by |

| | |interpretation by the physician. |

|[pic] |

|70545 |  |Clinical Example (70545) |

| | |The patient is a 45-year-old woman with an unresectable arteriovenous malformation presenting for stereotactic |

| | |gamma knife radiotherapy. The morning of her examination she is placed in a stereotactic head frame by a |

| | |neurosurgeon. A MR angiogram through the region of her arteriovenous malformation is then obtained using 3D |

| | |time-of-flight (TOF) following intravenous administration of contrast material. An intravenous line had been |

| | |placed in the forearm connected to a power injector (injection procedure coded separately, 90780). It has been |

| | |shown that intravenous contrast material increases the conspicuity of cerebral arteriovenous malformations and |

| | |is the optimal technique for localizing the arteriovenous malformation nidus prior to stereotactic radiation |

| | |therapy. |

| | |After her MR and MRA study, the patient was then transferred to the radiation therapy suite where her images |

| | |are transferred to the radiation oncology computer. Both the post-contrast enhanced MRA partition views |

| | |(approximately 60-100 images), as well as maximum intensity projections of the nidus using post-processing |

| | |techniques, are interpreted by the radiologist. |

|[pic] |

|70546 |  |Clinical Example (70546) |

| | |The patient is a 63-year-old man presenting with headache and blurred vision. MR imaging using T1 and |

| | |T2-weighted images had revealed the suspicion of an aneurysm of the carotid artery within or adjacent to the |

| | |cavernous sinus. The decision to operate depends in part on the access to carotid aneurysm. If the aneurysm is |

| | |above the carotid ring, the fibrous roof of the cavernous sinus, then the patient is at risk of developing |

| | |subarachnoid hemorrhage if the aneurysm ruptures and the access by the surgeon is possible. If the aneurysm |

| | |neck is within the blood filled cavernous sinus, surgery is contraindicated as the access to the cavernous |

| | |sinus is limited and the risk of subarachnoid hemorrhage is low. Routine angiography cannot differentiate the |

| | |carotid ring, as it cannot detect the cavernous sinus and its relationship to the aneurysm. |

| | |Description of Procedure (70546) |

| | |A non-contrast followed by a contrast enhanced MRA is ordered and performed with the 3D time of flight |

| | |technique (injection procedure 90780 is coded separately). This permits verification of the carotid ring |

| | |aneurysm. The contrast enhanced MRA opacifies the cavernous sinus permitting visualization of the aneurysm in |

| | |relation to the cavernous sinus. 3D reformatted images are performed in the axial, coronal and sagittal plane, |

| | |in addition to the routine maximum intensity projections. These verify that the aneurysm is indeed arising |

| | |within the opacified cavernous sinus. An endovascular approach is taken with successful coiling of the |

| | |aneurysm. |

|[pic] |

|70547 |  |Clinical Example (70547) |

| | |The patient is a 62-year-old woman presenting with a transient ischemic attack involving the left side of her |

| | |body with decrease in right vision. This occurred transiently several times over a two-week period. A Doppler |

| | |ultrasound was obtained and was non-diagnostic due to calcification. A MR angiography of the carotid artery was|

| | |ordered. A 2D and 3D time-of-flight MR angiography was performed without contrast material. This was performed |

| | |using an anterior neck coil. |

| | |Description of Procedure (70547) |

| | |2D time-of-flight (TOF) images were obtained from the supraaortic vasculature through the proximal circle of |

| | |Willis. 3D TOF imaging of the carotid bifurcation was performed to increase the accuracy and spatial |

| | |resolution. The data obtained would consist of between 64 and 128 images at 1-2 mm in thickness which are then |

| | |processed by an array algorithm to produce "maximum intensity projections" (MIPs) which are the MRA equivalents|

| | |of subtraction angiograms. Various regions of interest delineated by radiologists are then performed on this |

| | |data set by the technologist to produce "coned down" views of the arterial tree. Typically these would include |

| | |separate post-processing of the left and right internal carotid arteries. This data set can be rotated around |

| | |the vessel to allow a 3D view of the vascular tree. This demonstrated a 75% stenosis of the internal carotid |

| | |artery just distal to the carotid bifurcation. Patient then went on to endarterectomy on the basis of the MRA. |

|[pic] |

|70548 |  |Clinical Example (70548) |

| | |The patient is a 72-year-old man who was referred for evaluation of his carotid arteries following an |

| | |endarterectomy for a high-grade carotid stenosis. He had a history of recurrent transient ischemic attacks |

| | |(TIAs). Prior MRAs had been performed but the image quality was degraded by patient motion. Doppler ultrasound |

| | |demonstrated equivocal findings of recurrent stenosis. It was elected to perform a contrast enhanced MRA of the|

| | |carotid circulation using dynamic bolus and dynamic 3D short time of repetition (TR) and short flip angle |

| | |sequences. |

| | |Description of Procedure (70548) |

| | |The patient was placed on the MR scanner with an anterior neck coil and a 2D localizing sequence obtained prior|

| | |to the administration of contrast material. An intravenous line had been placed in the forearm connected to a |

| | |power injector (injection procedure 90780 is coded separately). This was followed by a test bolus of contrast |

| | |material of 2cc followed by imaging obtained at the level of the bifurcation every second until the contrast |

| | |appears. This indicated the circulation time required for contrast arrival at the bifurcation. The 3D |

| | |time-of-flight MRA sequence was then performed using a slab 40mm thick centered at the carotid bifurcation. 2 |

| | |MRA sequences are performed successively during the intravenous injection of 0.2 mm/kg of intravenous |

| | |gadolinium contrast material administered at a rate of 5cc per second. The 3D slab was repeated twice during |

| | |the bolus of contrast. The coronal partitions were visualized independently and also post-processed into a data|

| | |set of maximum intensity projections (MIPS) which are then viewed by the radiologist. This required |

| | |approximately 20-30 minutes of post-processing and post-service time by technologists. The radiologist must be |

| | |present for the test injection and the localization of the carotid bifurcation, as well as the acquisition |

| | |during power injection of 5cc of gadolinium over the course of approximately 15 seconds. |

|[pic] |

|70549 |  |Clinical Example (70549) |

| | |The patient is a 72-year-old man who was referred for evaluation of his carotid arteries following a small |

| | |watershed infarction of his left hemisphere. He had a prior history of TIA's. 2D TOF followed by 3D TOF MRA of |

| | |the carotid bifurcation revealed suggestion of a higher grade stenosis of 80%, however patient motion degraded |

| | |the image quality. Doppler ultrasound demonstrated heavy calcification at the carotid bifurcation. It was |

| | |elected to perform a contrast enhanced MRA of the carotid circulation using dynamic bolus and dynamic 3D short |

| | |TR and short angle sequences. |

| | |Description of Procedure (70549) |

| | |The patient was placed on the MR scanner with an anterior neck coil and a 2D and 3D TOF sequence obtained prior|

| | |to the administration of contrast material. An intravenous line had been placed in the forearm connected to a |

| | |power injector (injection procedure 90780 is coded separately). A pre-contrast localizer study was performed to|

| | |locate the carotid bifurcation. Generally a physician must be present for this portion of the examination. This|

| | |was followed by a test bolus of contrast material of 2 cc followed by imaging obtained at the level of the |

| | |bifurcation every second until the contrast appears. This indicated the circulation time required for contrast |

| | |arrival at the bifurcation. The 3D TOF MRA sequence was then performed using a slab 40 mm thick centered at the|

| | |carotid bifurcation. Two MRA sequences are performed successively during the intravenous injection of 0.2 mm/kg|

| | |of intravenous gadolinium contrast material administered at a rate of 5 cc per second. The 3D slab was repeated|

| | |twice during the bolus of contrast. The coronal partitions were visualized independently and also |

| | |post-processed into a data set of maximum intensity projections (MIPS) which are then viewed by the |

| | |radiologist. This required approximately 20-30 minutes of post-processing and post-service time by |

| | |technologists. The radiologist must be present for the test injection, the localization of the carotid |

| | |bifurcation, as well as the acquisition during power injection of 5 cc of gadolinium over the course of |

| | |approximately 15 seconds. This patient was found to have a high-grade stenosis of the carotid bifurcation |

| | |requiring endarterectomy. Conventional angiography was not required. |

|[pic] |

|70554 |  |Clinical Example (70554) |

| | |A 60-year-old male presents with a grand mal seizure and right upper extremity weakness secondary to an |

| | |intra-axial mass in the left frontal lobe. The relationship between the tumor and the precentral gyrus (the |

| | |expected location of motor function) is difficult to define. The neurosurgeon requests an fMRI scan to |

| | |determine the relationship of the tumor to the motor strip area. The patient's clinical status does not require|

| | |neurofunctional testing administered by a physician or psychologist during the fMRI and the tests are |

| | |administered by a non-physician. |

| | |Description of Procedure (70554) |

| | |A physical examination is performed to determine the ability of the patient to perform the planned test tasks. |

| | |The planned tasks are modified according to the patients clinical deficits and ability to perform the selected |

| | |tasks. The patients questions are answered. A quality control review of the postprocessing analysis is |

| | |performed, with interpretation of the acquired fMRI data and the coregistered fMRI images. The report is |

| | |dictated. |

|[pic] |

|70555 |  |Clinical Example (70555) |

| | |A 62-year-old male presents with a headache secondary to a 5-cm intra-axial solid mass involving the left |

| | |temporoparietal junction (superior temporal, supramarginal, and angular gyri) with extension superiorly to the |

| | |left precentral gyrus. The neurosurgeon requests a functional MRI (fMRI) for pre-operative mapping of language |

| | |function and motor function and to determine their anatomic location relative to the tumor. The patient's |

| | |clinical status requires neurofunctional testing administered by a physician or psychologist (code 96020 is |

| | |separately reported) during the fMRI (70555). |

| | |Description of Procedure (70555) |

| | |The fMRI analysis and statistical analysis are performed. The physician reviews the neurofunctional testing |

| | |report. The acquired fMRI data and the coregistered fMRI images are interpreted. The report is dictated. |

|[pic] |

|70557 |  |Clinical Example (70557) |

| | |A 40-year-old right handed male with new onset tonic-clonic seizures associated with postictal aphasia and |

| | |right hemiparesis was found to have a well-circumscribed mass in his left fronto-temporal (insular) region. |

| | |Previous biopsy demonstrated an oligodendroglioma. The neurosurgeon has recommended complete resection of the |

| | |tumor using intraoperative MRI (iMRI) for guidance. From review of preoperative studies, it was determined |

| | |complete resection can be accomplished without IV contrast. During the surgical procedure the appropriate MRI |

| | |scan sequences are performed and interpreted to evaluate and facilitate the optimal resection of the tumor with|

| | |the interpretation communicated to the surgeon during the surgical procedure. |

| | |Description of Procedure (70557) |

| | |Supervision and interpretation of preliminary scans is performed. Following intraoperative determination of |

| | |eloquent cortex, supervision and interpretation of iMRI sequences designed to determine the relation of the |

| | |lesion to the eloquent cortex are performed. Following operative exposure of the lesion, supervision and |

| | |interpretation of iMRI sequences designed to reevaluate the relation of the lesion to the eloquent cortex by |

| | |comparison to the previous images and determination of potential shifts that may have occurred during exposure |

| | |are performed. Following the operative resection of all visible tumor, supervision and interpretation of iMRI |

| | |sequences designed to assess the adequacy of tumor resection and determination of whether any residual gross |

| | |tumor is present are performed. Supervision and interpretation are performed of all additional iMRI sequences |

| | |designed to reassess the adequacy of tumor resection and determination of whether any residual tumor is present|

| | |following the additional resections of tumor identified on iMRI sequences, including those sequences obtained |

| | |in the operating room at the end of the surgical procedure. Intraservice work includes all communications |

| | |between the interpreting physician and operating physician that occur during the procedure. |

|[pic] |

|70558 |  |Clinical Example (70558) |

| | |A 40-year-old right handed male with new onset tonic-clonic seizures associated with postictal aphasia and |

| | |right hemiparesis was found to have a well-circumscribed mass in his left fronto-temporal (insular) region. |

| | |Previous biopsy demonstrated an oligodendroglioma. The operating surgeon has recommended complete resection of |

| | |the tumor using iMRI for guidance. From review of preoperative studies, it was determined that IV contrast will|

| | |be necessary for assuring complete resection, but no nonenhanced scans are required. During the surgical |

| | |procedure the appropriate MRI scan sequences are performed and interpreted to evaluate and facilitate the |

| | |optimal resection of the tumor with the interpretation communicated to the surgeon during the surgical |

| | |procedure. |

| | |Description of Procedure (70558) |

| | |Supervision and interpretation of precontrast scans are performed. Following intraoperative determination of |

| | |eloquent cortex, supervision and interpretation of contrast enhanced iMRI sequences designed to determine the |

| | |relation of the lesion to the eloquent cortex are performed. Following operative exposure of the lesion, |

| | |supervision and interpretation of contrast enhanced iMRI sequences designed to reevaluate the relation of the |

| | |lesion to the eloquent cortex by comparison to the previous images and determination of potential shifts that |

| | |may have occurred during exposure are performed. Following the operative resection of all visible tumor, |

| | |supervision and interpretation of contrast enhanced iMRI sequences designed to assess the adequacy of tumor |

| | |resection and determination of whether any residual gross tumor is present are performed. Supervision and |

| | |interpretation of all additional iMRI sequences designed to reassess the adequacy of tumor resection and |

| | |determination of whether any residual tumor is present following the additional resections of tumor identified |

| | |on iMRI sequences, including those sequences obtained in the operating room at the end of the surgical |

| | |procedure are performed. Intraservice work includes all communications between interpreting physician and |

| | |operating physician that occur during the procedure. |

|[pic] |

|70559 |  |Clinical Example (70559) |

| | |A 40-year-old right handed male with new onset tonic-clonic seizures associated with postictal aphasia and |

| | |right hemiparesis was found to have a well-circumscribed mass in his left fronto-temporal (insular) region. |

| | |Previous biopsy demonstrated an oligodendroglioma. The operating surgeon has recommended complete resection of |

| | |the tumor using iMRI for guidance. From review of preoperative studies, it was determined complete resection |

| | |will require the use of both nonenhanced and contrast enhanced scans. During the surgical procedure the |

| | |appropriate MRI scan sequences are performed and interpreted to evaluate and facilitate the optimal resection |

| | |of the tumor with the interpretation communicated to the surgeon during the surgical procedure. |

| | |Description of Procedure (70559) |

| | |Supervision and interpretation of precontrast scans are performed. Following intraoperative determination of |

| | |eloquent cortex, supervision and interpretation of contrast enhanced iMRI sequences designed to determine the |

| | |relation of the lesion to the eloquent cortex are performed. Following operative exposure of the lesion, |

| | |supervision and interpretation of contrast enhanced iMRI sequences designed to reevaluate the relation of the |

| | |lesion to the eloquent cortex by comparison to the previous images and determination of potential shifts that |

| | |may have occurred during exposure are performed. Following the operative resection of all visible tumor, |

| | |supervision and interpretation of contrast enhanced iMRI sequences designed to assess the adequacy of tumor |

| | |resection and determination of whether any residual gross tumor is present are performed. Supervision and |

| | |interpretation of all additional iMRI sequences designed to reassess the adequacy of tumor resection and |

| | |determination of whether any residual tumor is present following additional resections of tumor identified on |

| | |iMRI sequences, including those sequences obtained in the operating room at the end of the surgical procedure |

| | |are performed. Intraservice work includes all communications between interpreting physician and operating |

| | |physician that occur during the procedure. |

|[pic] |

|71275 |  |Clinical Example (71275) |

| | |A 34-year-old female presents with chronic arm pain, paresthesia and muscle wasting and is evaluated for |

| | |possible thoracic outlet obstruction. |

| | |Description of Procedure (71275) |

| | |Scout views of the area to be imaged are obtained and interpreted. Non-contrast computed tomography (CT) images|

| | |to localize the vascular phase sequence and to screen those patients who are not candidates for the arterial |

| | |phase component of the study are obtained and reviewed. The low or iso-osmolar contrast injection is |

| | |supervised. The arterial phase CT images are obtained and reviewed to ensure adequate anatomic coverage. The |

| | |delayed parenchymal phase CT images are obtained and reviewed. A two-dimensional reconstruction of the |

| | |vasculature and associated organs are supervised and/or created. The projection of the three-dimensional |

| | |reconstructions are adjusted to optimize visualization of the anatomy or pathology. The axial source images of |

| | |the pre-contrast sequence, arterial phase sequence, parenchymal phase sequence, and the two- and |

| | |three-dimensional reformatted images resulting from the study are interpreted, often including cine review. The|

| | |results are compared to all pertinent available prior studies. |

|[pic] |

|72195, |  |Clinical Example (72195-72197) |

|72196, | |The patient, a 63-year-old woman with dysfunctional bleeding, has dilatation and curretage (D & C) results |

|72197 | |positive for endometrial carcinoma. She is referred for MRI of the pelvis for staging and assessment of |

| | |myometrial invasion. |

|[pic] |

|72275 |  |A 45-year-old man with extensive rectal carcinoma involving the left lumbosacral plexus has intractable left |

| | |perirectal pain but has lost much of his control of both bladder and bowel function. Various systemic |

| | |medications (oral narcotic and nonnarcotic), physical therapy, radiation therapy, and chemotherapy have all |

| | |failed to provide significant long-term pain relief. There is no further operative resection possible for the |

| | |tumor. This patient is a good candidate for a neurolytic injection because of the severity of the pain and the |

| | |diminished control of bladder and bowel function. A neurolytic injection to ablate the left S2-4 nerve roots is|

| | |recommended. |

|[pic] |

|72285 |  |A 33-year-old man with known scoliosis has severe right-sided pain. Correlation is made with a previous MR |

| | |imaging study of the thoracic spine. Preliminary AP and lateral radiograph scout views reveal 13 ribs with 5 |

| | |subjacent lumbar segments. There is scoliosis of the upper thoracic spine to the left with a moderate |

| | |rotational lower thoracic and upper lumbar curve to the right. There is moderate rotational midlumbar curvature|

| | |to the left. |

|[pic] |

|73070, |  |Clinical Example (73070, 73090, 73100, 73550, 73590, 73600, 73620) |

|73090, | |Male or female presenting with trauma to the elbow, forearm, wrist, femur, tibia, fibula, ankle or foot. |

|73100, | | |

|73550, | | |

|73590, | | |

|73600, | | |

|73620 | | |

|[pic] |

|73206 |  |Clinical Example (73206) |

| | |The patient is a 29-year-old construction worker for assessment of upper extremity vasculature due to |

| | |crush-injury. |

|[pic] |

|73218, |  |Clinical Example (73218-73120, 73221-73223) |

|73219, | |The patient, a 18-year-old baseball pitcher with persistent shoulder pain and a question of instability on exam|

|73220, | |is referred for a shoulder MR arthrogram to evaluate the glenoid labrum. |

|73221, | | |

|73222, | | |

|73223 | | |

|[pic] |

|73542 |  |A 42-year-old man with history of lumbosacral fusion presents with severe chronic low back, buttock, and groin |

| | |pain. Imaging studies of the spine, pelvis, and sacroiliac joints are unremarkable, showing a solid lumbosacral|

| | |fusion. The patient undergoes diagnostic and therapeutic sacroiliac arthrography, both to study intrinsic joint|

| | |anatomy and to assess, by means of monitoring the joint blockade, whether the joint is the major source of his |

| | |clinical pain. |

|[pic] |

|74175 |  |Clinical Example (74175) |

| | |The patient is a 50-year-old man for evaluation as a potential kidney donor to daughter. |

| | |Clinical Example (74175) |

| | |The patient is a 62-year-old man with renal cell carcinoma for pre-operative and metastatic evaluation prior to|

| | |tumor resection. |

| | |Clinical Example (74175) |

| | |The patient is a 66-year-old man with suspected aortic aneurysm. Evaluation in anticipation of non-operative |

| | |stent graft therapy. |

| | |Clinical Example (74175) |

| | |The patient is a 42-year-old man with hepatitis B leading to end-stage liver disease, pre-operative evaluation |

| | |for transjugular intrahepatic portosystemic shunt (TIPS) placement or liver transplantation. |

|[pic] |

|74181, |  |Clinical Example (74181-74183) |

|74182, | |The patient, a 37-year-old woman with an indeterminate right renal mass discovered on gall bladder ultrasound. |

|74183 | |She has a history of severe allergic reaction to iodinated contrast so that contrast CT cannot be performed. |

| | |She is referred for a MRI of the abdomen/kidneys to characterize the mass. This will involve imaging both |

| | |without and with MRI contrast. |

|[pic] |

|75900 |  |Clinical Example |

| | |A 58-year-old man is undergoing thrombolytic therapy for a thrombosed left femoral-popliteal graft. Urokinase |

| | |has been infusing into the proximal portion of the graft for 14 hours, via a catheter placed from the right |

| | |groin. There has been some clinical improvement. A routine follow-up angiogram has shown clearing of the clot |

| | |in the graft but there has been embolization of the thrombus to the tibial trifurcation. |

| | |Description of Procedure |

| | |In order to treat the distal occlusion, a guidewire is manipulated into the distal popliteal artery and the |

| | |infusion catheter is exchanged for a new catheter, which has its tip positioned within the distal thrombus. The|

| | |catheter is secured in the right groin and covered with a sterile dressing, and the infusion is continued. |

|[pic] |

|75901, |  |Clinical Example (75901 and 75902) |

|75902 | |A 68-year-old male with gastric cancer and a subcutaneous port presents with a poorly functioning port. |

| | |Infusion/injection cannot be aspirated. |

|[pic] |

|75952 |  |Clinical Example (75952) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, has a 5.8 cm. aortic aneurysm. Imaging studies (typically a combination of CT scan, MRI,|

| | |IVUS, and/or angiography) indicate that the aneurysm is infrarenal and has an adequate neck to allow successful|

| | |deployment of an endovascular prosthesis. Other anatomic considerations such as size, tortuosity, and |

| | |calcification of the iliac arteries and presence of thrombus, plaque, and/or heavy calcification in the landing|

| | |zones has also been evaluated. |

| | |Description of Procedure (75952) |

| | |• Angiographic "road-mapping" of aortic anatomy. |

| | |• Fluoroscopic guidance of guidewires, catheters, endovascular prosthesis, and docking limbs (if utilized). |

| | |• Fluoroscopic confirmation of appropriate placement of prosthesis and docking limbs, with or without contrast.|

| | |• Fluoroscopic guidance of intra-prosthesis balloon dilatation, if necessary. |

| | |• Supervision and interpretation of post-deployment aortogram for graft position, patency of appropriate |

| | |branches (renals and hypogastrics), presence or absence of endoleaks, and patency of lumbar, hypogastric or |

| | |inferior mesenteric arteries that may contribute to persistent endoleaks. |

| | |• Interpretation of films and fluoroscopic imaging. |

| | |• Balloon dilatation and/or intra-device stenting to ensure proper seating, to fully open the graft, and/or to |

| | |treat endoleak (if present). |

|[pic] |

|75953 |  |Clinical Example (75953) |

| | |A 67-year-old man with chronic obstructive pulmonary disease and coronary artery disease, status post |

| | |myocardial infarction, underwent endovascular repair of a 5.8 cm. diameter abdominal aortic aneurysm. A distal |

| | |anastomotic endoleak was discovered by CT scan one year later, and its exact nature is confirmed with |

| | |angiography (separately reportable). A distal endovascular extension will be placed to correct the endoleak. |

| | |Description of Procedure (75953) |

| | |• Angiographic "road-mapping" of aortic anatomy. |

| | |• Fluoroscopic guidance of guidewires, catheters, endovascular extension(s). |

| | |• Fluoroscopic guidance of deployment of endovascular extension(s), with or without contrast. |

| | |• Fluoroscopic guidance of intra-extension balloon dilatation, and/or stent placement, if necessary. |

| | |• Supervision and interpretation of post-deployment aortogram for extension position, patency of appropriate |

| | |branches (renals and hypogastrics), presence or absence of endoleaks, and patency of lumbar, hypogastric or |

| | |inferior mesenteric arteries that may contribute to persistent endoleaks. |

|[pic] |

|75956 |  |Clinical Example |

| | |A 68-year-old male with hypertension, a 50-pack-per-year smoking habit, and previous myocardial infarction is |

| | |found to have a 7.0-cm diameter descending thoracic aortic aneurysm that begins immediately beyond the origin |

| | |of the left subclavian artery. Risks and benefits of open surgical repair, endovascular repair, and watchful |

| | |waiting have been discussed, and the patient has chosen endovascular repair. Perioperative risk evaluation, |

| | |including cardiac workup, indicated suitability for the endovascular approach. Imaging studies (typically a |

| | |combination of computed tomography scan, magnetic resonance imaging, and/or angiography) demonstrate that the |

| | |aneurysm is within acceptable parameters for endovascular repair if the left subclavian artery origin is |

| | |covered by the endoprosthesis. Endovascular repair of the descending thoracic aortic aneurysm is performed. The|

| | |proximal extent of the endoprosthesis covers the left subclavian artery origin. |

| | |Description of Procedure |

| | |The physician directs the technical personnel throughout the procedure. He or she interprets imaging of the |

| | |vessel being treated, including complete views of the target vessel in all projections necessary. Accurate |

| | |radiological views, exposures, shielding, image size, and injection sequences are ensured, and radiation |

| | |protection for the patient and staff are managed. Real-time analysis of all imaging occurs during the |

| | |procedure, including pretreatment imaging, fluoroscopic and angiographic imaging throughout the procedure as |

| | |required to perform the procedure, and postprocedure fluoroscopic and angiographic imaging. This includes all |

| | |imaging to manipulate the wires, catheters, and devices into position as well as to correct positioning and |

| | |deployment, open balloons, and assess postoperative success and complications. Quantitative measurements of the|

| | |lesion, target vessel, and landing zones are obtained to confirm appropriate prosthesis and balloon sizes. |

| | |Continuous fluoroscopic imaging is provided during all catheter or stent manipulations to assess proper |

| | |position. |

|[pic] |

|75957 |  |Clinical Example |

| | |A 68-year-old male with hypertension, a 50-pack-per-year smoking habit, and previous myocardial infarction is |

| | |found to have a 7.0-cm diameter descending thoracic aortic aneurysm that begins several centimeters beyond the |

| | |left subclavian artery origin. Risks and benefits of open surgical repair, endovascular repair, and watchful |

| | |waiting have been discussed, and the patient opted for endovascular repair. Perioperative risk evaluation |

| | |including cardiac workup indicated suitability for an endovascular approach. Imaging studies (typically a |

| | |combination of computed tomography scan, magnetic resonance imaging, and/or angiography) demonstrate that the |

| | |aneurysm is within acceptable parameters for endovascular repair. Endovascular repair of his descending |

| | |thoracic aortic aneurysm is performed. The proximal portion of the endoprosthesis does not cover the left |

| | |subclavian artery origin. |

| | |Description of Procedure |

| | |The physician directs the technical personnel throughout the procedure. He or she interprets imaging of the |

| | |vessel being treated, including complete views of the target vessel in all projections necessary. Accurate |

| | |radiological views, exposures, shielding, image size, and injection sequences are ensured, and radiation |

| | |protection for the patient and staff are managed. Real-time analysis of all imaging occurs during the |

| | |procedure, including pretreatment imaging, fluoroscopic and angiographic imaging throughout the procedure as |

| | |required to perform the procedure, and postprocedure fluoroscopic and angiographic imaging. This includes all |

| | |imaging to manipulate the wires, catheters, and devices into position as well as to correct positioning and |

| | |deployment, open balloons, and assess postoperative success and complications. Quantitative measurements of the|

| | |lesion, target vessel, and landing zones are obtained to confirm appropriate prosthesis and balloon sizes. |

| | |Continuous fluoroscopic imaging is provided during all catheter or stent manipulations to assess proper |

| | |position. |

|[pic] |

|75958 |  |Clinical Example |

| | |A 68-year-old male with hypertension, a 50-pack-per-year smoking habit, and previous myocardial infarction |

| | |underwent endovascular repair of the descending thoracic aortic aneurysm 1 year ago. On the follow-up computed |

| | |tomography (CT) scan, he is found to have a proximal endoleak. Risks and benefits of endovascular endoleak |

| | |repair have been discussed, and he opted to proceed. Perioperative risk evaluation, including cardiac workup, |

| | |indicated suitability for endovascular repair. Imaging studies (typically a combination of CT scan, magnetic |

| | |resonance imaging, and/or angiography) demonstrate that the endoleak is suitable for an endovascular approach. |

| | |A proximal endovascular extension is deployed. |

| | |Description of Procedure |

| | |The physician directs the technical personnel throughout the procedure. He or she interprets imaging of the |

| | |vessel being treated, including complete views of the target vessel in all projections necessary. Accurate |

| | |radiological views, exposures, shielding, image size, and injection sequences are ensured, and radiation |

| | |protection for the patient and staff are managed. Real-time analysis of all imaging occurs during the |

| | |procedure, including pretreatment imaging, fluoroscopic and angiographic imaging throughout the procedure as |

| | |required to perform the procedure, and postprocedure fluoroscopic and angiographic imaging. This includes all |

| | |imaging to manipulate the wires, catheters, and devices into position as well as to correct positioning and |

| | |deployment, open balloons, and assess postoperative success and complications. Quantitative measurements of the|

| | |lesion, target vessel, and landing zones are obtained to confirm appropriate prosthesis and balloon sizes. |

| | |Continuous fluoroscopic imaging is provided during all catheter or stent manipulations to assess proper |

| | |position. |

|[pic] |

|75959 |  |Clinical Example |

| | |A 68-year-old male with hypertension, a 50-pack-per-year smoking habit, and previous myocardial infarction |

| | |underwent endovascular repair of the descending thoracic aortic aneurysm 1 year ago. On the follow-up computed |

| | |tomography scan, he is found to have a distal endoleak. Placement of a distal extension is undertaken to seal |

| | |the leak. |

| | |Description of Procedure |

| | |The physician directs the technical personnel throughout the procedure. He or she interprets imaging of the |

| | |vessel being treated, including complete views of the target vessel in all projections necessary. Accurate |

| | |radiological views, exposures, shielding, image size, and injection sequences are ensured, and radiation |

| | |protection for the patient and staff are managed. Real-time analysis of all imaging occurs during the |

| | |procedure, including pretreatment imaging, fluoroscopic and angiographic imaging throughout the procedure as |

| | |required to perform the procedure, and postprocedure fluoroscopic and angiographic imaging. This includes all |

| | |imaging to manipulate the wires, catheters, and devices into position as well as to correct positioning and |

| | |deployment, open balloons, and assess postoperative success and complications. Quantitative measurements of the|

| | |lesion, target vessel, and landing zones are obtained to confirm appropriate prosthesis and balloon sizes. |

| | |Continuous fluoroscopic imaging is provided during all catheter or stent manipulations to assess proper |

| | |position. |

|[pic] |

|75989 |  |Clinical Example #1 (75989) |

| | |A 54-year-old woman, two week post-hysterectomy with persistent pelvic pain but no fever. Diagnostic CT scan |

| | |demonstrates a 4 x 5 cm low density mass in the surgical bed just posterior and superior to the bladder. The |

| | |patient is referred for percutaneous drainage. Under CT guidance, Seldinger technique is used to place a 5 |

| | |French catheter into this fluid collection. A total of 50 cc of dark fluid consistent with old blood is |

| | |aspirated. A gram stain reveals no bacteria or white cells. When the collection has been completely evacuated, |

| | |the catheter is removed. The patient is observed for four hours and discharged. |

| | |Clinical Example #2 (75989) |

| | |A 27-year-old male, seven days post-laparotomy for ruptured appendix is referred for percutaneous drainage of a|

| | |right paracolic gutter 4 x7 cm collection containing gas. Under CT guidance, the collection is punctured and |

| | |frankly purulent aspirate is obtained. Using Seldinger technique, 8 French pigtail catheter is placed in the |

| | |cavity which is completely evacuated. Due to the purulent aspirate, the catheter is left indwelling to suction |

| | |bulb drainage. The patient is returned to the surgical ward with drain in place. |

|[pic] |

|75998 |  |Clinical Example (75998) |

| | |Patient is referred for placement of a tunneled central venous catheter. To facilitate advancement of catheter |

| | |and ensure accurate placement, fluoroscopy is used. |

| | |Description of Procedure (75998) |

| | |Following achievement of venous access (if fluoroscopic guidance is used for venous access, this is included), |

| | |fluoroscopy is used to guide the guidewire and subsequently catheter into central venous position. Any contrast|

| | |injection through access site (via needle, catheter or sheath) for venographic evaluation and mapping of |

| | |appropriate path is included. Spot film or other radiographic confirmation of final catheter position is |

| | |performed. Description of all aspects of fluoroscopic guidance are reported with procedure. |

|[pic] |

|76005 |  |A 45-year-old man has severe pain (rated at 8 on a scale of 0-10, where 10 is the worst pain imaginable) |

| | |involving both legs and the lower back after multiple back operations during a 10-year period. Various systemic|

| | |medications (oral narcotic and nonnarcotic) and physical therapy have all failed to provide significant |

| | |long-term pain relief. There are no further operations on his spine that are felt likely to provide further |

| | |relief. |

|[pic] |

|76012 |  |Clinical Example |

| | |A 75-year-old white female who had been living independently develops sudden, severe low back pain after |

| | |bending over to retrieve a laundry item. Her family physician orders a plain film spine series that reveals an |

| | |acute compression fracture of L2. He prescribes bedrest and narcotic analgesic to be taken as needed. The pain |

| | |is unrelieved with medication, and immobilization provides minimal relief. The medication is increased to 4 to |

| | |6 times daily, with no significant change. After 2 weeks of immobilization and narcotic analgesics, the patient|

| | |remains bed-ridden with a clouded sense of sensorium from narcotics. No improvement in pain or mobility is |

| | |seen. |

| | |Description of Procedure |

| | |The patient is placed in the prone position on the angiography-fluoroscopy table. The left L2 pedicle is |

| | |fluoroscopically localized. Needle placement is monitored fluoroscopically to confirm needle position within |

| | |the trabecular space. Injection of contrast is monitored fluoroscopically to obtain the epidural venogram. |

| | |Injection of polymethyl-methacrylate (PMMA) is monitored to ensure no migration occurs into or towards the |

| | |outlined venous plexus. This procedure is repeated if bilateral pedicular injections are required. Radiologist |

| | |review of final anterior-posterior and lateral images of the lumbar spine show PMMA within the vertebral body |

| | |with no migration into the surrounding veins. |

|[pic] |

|76013 |  |Clinical Example #2 |

| | |A 70-year-old man with a history of hypernephroma presents with severe thoraco-lumbar junction pain. Two years |

| | |previously, he had undergone a nephrectomy, spinal radiation and chemotherapy. His oncologist orders an MRI |

| | |that reveals tumor infiltration of the T12 through L3 vertebrae. Tumor has destroyed the posterior cortex at |

| | |all levels and there is mild spinal canal encroachment. The patient is almost non-ambulatory due to pain. The |

| | |oncologist prescribes a narcotic analgesic, but this causes excessive sedation at doses that only partially |

| | |relieve the patient's pain. The oncologist feels that additional chemotherapy will be ineffective and poorly |

| | |tolerated. Additional radiation therapy is not possible because the maximum spinal dose has already been given.|

| | |A spine surgeon is consulted. He feels that the patient would not survive a complex anterior and posterior |

| | |approach for multilevel corpectomy and fixation, due to the patient's cachexia and the vascular nature of the |

| | |tumor. He also states there is a high probability that spinal column collapse may occur with continued weight |

| | |bearing, likely resulting in paraparesis and incontinence. An interventional neuroradiologist is consulted |

| | |regarding percutaneous vertebroplasty. |

|[pic] |

|76013 |  |Clinical Example (76013) |

| | |A 70-year-old man with a history of hypernephroma presents with severe thoraco-lumbar junction pain. Two years |

| | |previously, he had undergone a nephrectomy, spinal radiation and chemotherapy. His oncologist orders an MRI |

| | |that reveals tumor infiltration of the T12 through L3 vertebrae. The tumor has destroyed the posterior cortex |

| | |at all levels and there is mild spinal canal encroachment. The patient is almost non-ambulatory due to pain. |

| | |The oncologist prescribes a narcotic analgesic, but this causes excessive sedation at doses that only partially|

| | |relieve the patient's pain. The oncologist feels that additional chemotherapy will be ineffective and poorly |

| | |tolerated. Additional radiation therapy is not possible because the maximum spinal dose has already been given.|

| | |A spine surgeon is consulted. He feels that the patient would not survive a complex anterior and posterior |

| | |approach for multilevel corpectomy and fixation, due to the patient's cachexia and the vascular nature of the |

| | |tumor. He also states there is a high probability that spinal column collapse may occur with continued weight |

| | |bearing, likely resulting in paraparesis and incontinence. An interventional neuroradiologist is consulted |

| | |regarding percutaneous vertebroplasty. |

| | |Although there is severe bony destruction at multiple levels (a relative contraindication to vertebroplasty) |

| | |and a mild degree of spinal canal compromise caused by tumor invasion, the radiologist feels that |

| | |vertebroplasty may be performed safely using a combination of CT and fluoroscopic guidance. The radiologist |

| | |performs a physical examination, confirming that the patient does not have signs of spinal cord compression. He|

| | |informs the patient and his family that vertebroplasty will likely provide significant spinal column stability |

| | |for some weeks or months, depending upon the rate of tumor growth. Based upon his previous experience, the |

| | |radiologist tells them that there is a 50% to 60% likelihood that the patient will experience a significant |

| | |degree of pain relief. The patient and his family understand that his condition is terminal and that palliative|

| | |treatment is being offered primarily to prevent incontinence and paraparesis. |

| | |Description of Procedure (76013) |

| | |The vertebroplasty procedure is performed under general anesthesia to control the patient's severe pain and to |

| | |minimize patient motion. After induction, the patient is placed prone upon the CT table. The back is prepped |

| | |and sterile drapes placed. Using sequential CT scans for guidance (code 76360 separately), 11G needles are |

| | |placed through the left and right pedicles at T12 and L1. The patient is withdrawn from the CT gantry. A |

| | |portable C-arm digital angiography unit (covered with sterile drapes) is positioned to allow lateral |

| | |visualization. Intraosseous venography performed at each level with injection of 5mL iohexol 300 non-ionic |

| | |contrast confirms satisfactory needle positions and that the tumor is highly vascular. PMMA cement is mixed and|

| | |slowly injected at T 12 under fluoroscopic control. After injection of 3 mL, cement is suspected to have |

| | |reached the posterior third of the vertebra. The patient is quickly advanced into the CT scanner and images of |

| | |T12 obtained. Only a very small amount of cement has reached the posterior third of the vertebra and injection |

| | |of additional cement is indicated. The patient is withdrawn from the CT gantry and 1.0 mL of cement injected |

| | |under fluoroscopic control. A new batch of cement is prepared for injection of the L1 vertebra. After injection|

| | |of 5.5 mL, cement appears to have reached the posterior vertebral body. CT scans obtained through T12 and L1 |

| | |show filling of only the left half of T12 and adequate bilateral filling of the L1 vertebra. No cement has |

| | |reached the spinal canal or neural foramen. Using sequential CT scans for guidance, another needle is placed |

| | |into the right side of T12. Intraosseous venography and cement injection are performed as described above. CT |

| | |images of T12 are again obtained to assess for adequate cement filling and to guide needles placed at the L2 |

| | |and L3 levels using CT. |

| | |As described above, cement is injected into the L2 and L3 vertebrae using fluoroscopy and CT as necessary. A |

| | |final CT confirms adequate cement filling at all four levels without encroachment upon the spinal canal or |

| | |neural foramen. The patient is recovered from anesthesia and observed for pain management and neurological |

| | |monitoring. No complications occur and the patient is discharged to home. |

|[pic] |

|76071 |  |Clinical Example (76071) |

| | |A 55-year-old menopausal woman with a family history of osteoporosis is considering estrogen therapy. Lumbar |

| | |spine hardware prevents obtaining a CT bone mineral density study of the spine. |

|[pic] |

|76075 |  |Clinical Example (76075) |

| | |A 55-year-old menopausal female presents with a family history of osteoporosis, and is considering estrogen |

| | |therapy. |

| | |Description of Procedure (76075) |

| | |Calibration and quality control (eg, measurement of phantom) of the device is performed. Anatomic markings are |

| | |appropriately displayed and are in proper position. |

|[pic] |

|76077 |  |Clinical Example (76077) |

| | |A 65-year-old female, 15 years post-menopause, undergoes a bone mineral density exam (DXA scan) to determine |

| | |her bone density diagnosis (World Health Organization definition of normal, osteopenia, osteoporosis) and |

| | |assessment of her relative and absolute risk for a future osteoporotic fracture. The DXA scan results disclose |

| | |a T-score of -1.9 at the lumbar spine and total hip (the T-score is a comparison to a young adult mean in |

| | |standard deviations). The patient's diagnosis is osteopenia by World Health Organization criteria. This patient|

| | |has a 5- and 6-fold increased risk of future fracture at the lumbar spine and total hip respectively (site |

| | |specific), and a 2-fold increased risk of future fracture anywhere in the body (global risk) as compared to an |

| | |age-matched female with a T-score of 0.0. The National Osteoporosis Foundation suggests that postmenopausal |

| | |women with a bone density T-score of less than -2 should be treated. Thus the value of this patient's T-score |

| | |of -1.9 (osteopenia) would not necessarily be an indication for medical therapy. A vertebral fracture |

| | |assessment using DXA equipment was used to obtain an image of the patient's thoracic and lumbar spine to |

| | |determine if a previous thoracic and lumbar spine vertebral fracture had occurred. Although the patient had no |

| | |history of spinal pain, 2 compression fractures were found by vertebral fracture assessment. The presence of 2 |

| | |prevalent vertebral fractures using Vertebral Fracture Assessment (VFA) by DXA imaging indicates a 7-fold |

| | |increased risk for future vertebral fractures independent of the patient's bone mineral density. |

| | |Pharmacological intervention is indicated due to the presence of prevalent, vertebral fractures. |

| | |Description of Procedure (76077) |

| | |The physician reviews the VFA images obtained and the post-processed measurements to assure that the |

| | |measurements were accurately done and that scanning technique was satisfactory. The physician interprets the |

| | |VFA thoracic and lumbar images (anterior/posterior (AP) and lateral views) using accepted fracture assessment |

| | |methodology, the Semiquantitative Analysis of Genant and Quantitative Morphometry, to determine the number and |

| | |severity of fractures present. The physician compares the results of the VFA interpretation to previous |

| | |radiographic or VFA images to determine if a significant change in vertebral anatomy has occurred in the |

| | |interim. The physician dictates the report for the medical record. |

|[pic] |

|76085 |  |Clinical Example (76085) |

| | |A 55-year-old woman is referred to the mammography department complaining of a lump at the two o'clock position|

| | |of her left breast, corroborated by her referring physician. Her last screening mammogram was taken 22 months |

| | |ago. |

| | |Description of Procedure (76085) |

| | |A bilateral diagnostic mammogram is performed with two full-breast views of both the right and left breasts. |

| | |The film mammograms are loaded into the CAD system, digitized, and analyzed by the software for regions of |

| | |interest (ROIs). During his review of the films, the physician activates the CAD system display, using the |

| | |marked ROIs to ensure a thorough review of all breast tissue. |

| | |The service includes the time for the clinic staff to load the films into the CAD system and for the physician |

| | |to activate the CAD display and re-review the mammograms at the location of the marked ROIs. |

|[pic] |

|76362 |  |Clinical Example (76362) |

| | |A 73-year-old man with colon cancer developed two metastatic lesions to the liver. Lesions were 2 cm x 2 cm and|

| | |4 cm x 4 cm. Because the lesions were not surgically resectable due to their location, the patient's oncologist|

| | |referred him for evaluation for radiofrequency (RF) ablation. The patient was evaluated by the treating |

| | |physician, and the lesions were determined to be amenable to percutaneous RF ablation. |

| | |Description of Procedure (76362) |

| | |Preliminary CT images are acquired to assess the appropriate approach to the tumor(s). CT guidance is carried |

| | |out to direct the RF needle electrode to the tumor(s). CT monitoring is carried out for needle electrode |

| | |repositioning within the lesion, if and as necessary for multiple ablations to coagulate the lesion. CT is |

| | |carried out to confirm satisfactory coagulative necrosis of the lesion(s) and for comparison to pre-ablation |

| | |images. CT of liver is carried out for post-ablation bleeding. |

|[pic] |

|76376 |  |Clinical Example |

| | |A 27-year-old female patient Grava 2 Para 1 has previously delivered an infant with a cleft lip and palate. The|

| | |obstetrician performs a pelvic exam and concludes that the uterine size appears consistent with a 20- to |

| | |22-weeks gestation. The patient is scheduled for a 2-dimensional (2D) ultrasound examination to confirm fetal |

| | |dating of the pregnancy and to evaluate for possible fetal abnormalities including a possible facial cleft |

| | |malformation. |

| | |An ultrasound technologist scans the patient in a conventional ultrasound unit that has 2D ultrasound |

| | |capabilities. Sagittal and transverse images of the pregnant uterus are obtained in 2D ultrasound (coded |

| | |separately). The attending physician evaluates the images and concludes that the images generated from the 2D |

| | |ultrasound are not able to confidently exclude or identify a facial cleft anomaly. A 3-dimensional (3D) |

| | |ultrasound is ordered to better visualize the facial structures in 3D shaded surface rendering. |

| | |Description of Procedure |

| | |The physician supervises the technologist in creating the 3D images, interprets the images, and dictates a |

| | |report for the medical record. |

|[pic] |

|76377 |  |Clinical Example |

| | |A 50-year-old male presented to his physician with hematuria. Renal ultrasound (coded separately) identified a |

| | |3-cm lower pole, right renal mass consistent with renal cell carcinoma, previously diagnosed with ultrasound. |

| | |The patient is a possible candidate for nephron-sparing partial nephrectomy, and a computerized tomographic |

| | |(CT) scan of the abdomen is ordered by the patient’s urologist. Three-dimensional (3D) rendering is requested |

| | |for further evaluation. |

| | |A CT examination of the abdomen, both before and after the use of contrast media, is performed (coded |

| | |separately). Subsequent postprocessing and 3D reconstruction is performed demonstrating the patient is a |

| | |candidate for partial nephrectomy. |

| | |Description of Procedure |

| | |The physician supervises and/or creates 3D reconstructions of the organs of interest using an independent |

| | |workstation. He or she adjusts the projection of the 3D reconstructions to optimize visualization of the |

| | |anatomy or pathology. The physician interprets the 3D reformatted images resulting from the study, typically |

| | |including cine review. The images are compared to all pertinent available prior studies and a report is |

| | |dictated for the medical record. |

|[pic] |

|76393 |  |Cinical Vignette (76393) |

| | |45-year-old man with known colon cancer is discovered to have a solid mass within the liver, best visualized on|

| | |MRI. He is being considered for segmental hepatic resection with no other identifiable metastatic disease. He |

| | |is referred for a percutaneous core biopsy of the mass. Because it is best seen on MRI, this modality is used |

| | |for guidance of the biopsy (biopsy procedure reported separately, 47000 - Biopsy of liver, needle; |

| | |percutaneous). |

|[pic] |

|76394 |  |Clinical Example (76394) |

| | |A 73-year-old man with colon cancer developed two metastatic lesions to the liver. Lesions were 2 cm x 2 cm and|

| | |4 cm by 4 cm. Because the lesions were not surgically resectable due to their location, the patient's |

| | |oncologist referred him for evaluation for radiofrequency (RF) ablation. The patient was evaluated by the |

| | |treating physician, and the lesions were determined to be amenable to percutaneous RF ablation. |

| | |Description of Procedure (76394) |

| | |Preliminary MRI images are acquired to access the appropriate approach to the tumor(s). MRI guidance is carried|

| | |out to direct the RF needle electrode to the tumor(s). MRI monitoring is carried out for needle electrode |

| | |repositioning within the lesion, if and as necessary for multiple ablations to coagulate the lesion. MRI is |

| | |carried out to confirm satisfactory coagulative necrosis of the lesion(s) and for comparison to pre-ablation |

| | |images. MRI of the liver is carried out for post-ablation bleeding. |

|[pic] |

|76490 |  |Clinical Examples (76490) |

| | |Typical Patient Treated By Laparoscopic Cryosurgical Ablation |

| | |The patient is a 44-year-old man who underwent a left colon resection for adenocarcinoma one and one-half years|

| | |ago. Following the left colon surgery, he received systemic chemotherapy. After six months of treatment, the |

| | |patient's CEA begins to rise. CT imaging of the liver reveals three lesions along the anterior, inferior |

| | |surface of the right lobe of the liver. All three lesions were confirmed on ultrasound examination and were |

| | |thought to be superficial and accessible by laparoscopy. The lesions measure 4 cm, 2.0 cm and 2.5 cm in |

| | |diameter. The patient undergoes laparoscopy and cryosurgical ablation of all three liver tumors. |

| | |Typical Patient Treated By Open Radiofrequency Ablation |

| | |An 82-year-old gentleman was diagnosed with colon cancer and underwent a right hemi-colectomy in May of 1994. |

| | |He had a Dukes C2 lesion with positive lymph nodes. Recently he was seen in follow-up and found to have an |

| | |elevated CEA of 34. A CT scan revealed two hepatic metastases in the right lobe of the liver and one in the |

| | |medial segment of the left lobe. The two lesions in the right lobe were 3 cm and 2 cm, and the lesion in the |

| | |left lobe was 3.5 cm. These findings were confirmed by ultrasound. The remainder of the metastatic workup |

| | |revealed no other spread in the abdomen, retroperitoneum, lung, bone, or brain. A recent follow-up colonoscopy |

| | |was also negative for recurrent cancer. Because of the bilaterality and multiplicity of the lesions, biopsy and|

| | |radiofrequency thermal ablation was determined most appropriate. The patient underwent an exploratory |

| | |laparotomy and one of the liver lesions was proven malignant by core needle biopsy. No extra-hepatic disease |

| | |was found. All three lesions were ablated with radiofrequency thermal technique, using sonographic guidance and|

| | |confirmation of lesion destruction. |

| | |Typical Patient Treated By Percutaneous Radiofrequency Ablation |

| | |A 73-year-old man with colon cancer developed two metastatic lesions to the liver. Lesions were 2 cm x 2 cm and|

| | |4 cm x 4 cm. Because the lesions were not surgically resectable due to their location, the patient's oncologist|

| | |referred him for evaluation for radiofrequency (RF) ablation. The patient was evaluated by the treating |

| | |physician, and the lesions were determined to be amenable to percutaneous RF ablation. |

| | |Description of Procedure (76490) |

| | |Preliminary ultrasound is used to assess percutaneous or the various intraoperative transhepatic approach(es) |

| | |to the tumor(s). Intraoperative ultrasound examination is performed of each hepatic segment until satisfactory |

| | |exposure has been achieved to confirm expected location(s) of the lesion(s). Ultrasound guidance is used to |

| | |direct RF or cryosurgical needle electrode ablation of liver tumors by percutaneous or intraoperative |

| | |transhepatic approach. Needle electrode repositioning is ultrasound-monitored within the lesion, if/and as |

| | |necessary for each of the multiple ablations or freeze-thaw cycles required to completely ablate the lesion. |

| | |Ultrasound is performed to confirm satisfactory ablation of the lesion(s) and to compare preablation images. |

| | |The liver is then imaged for postablation bleeding. |

|[pic] |

|76510 |  |Clinical Example (76510) |

| | |A 67-year-old, white male is found to have a mass in the temporal retina and is referred for diagnostic |

| | |ultrasound evaluation. |

| | |Description of Procedure (76510) |

| | |The B-scan probe is then placed on the cornea and the lesion localized. Multiple views are taken in all |

| | |quadrants. Any shadowing and reflected patterns are documented. The nature of the mass is evaluated and |

| | |possible extension is documented. The presence and nature of vitreous cells and overlying retinal detachment is|

| | |evaluated and documented. Multiple images are taken and clinical correlation is done. The B-scan probe is |

| | |removed and the physician places an A-scan probe on the globe with the beam passing perpendicularly through the|

| | |lesion. Multiple images in all quadrants are examined to determine diameter, elevation, and nature of internal |

| | |reflectivity. Possible breach of Bruch's membrane and choroidal extension is determined. Appropriate views are |

| | |documented during the scan. Integration of ultrasound findings with clinical presentation is evaluated. The |

| | |physician formulates the clinical diagnosis. |

|[pic] |

|76511 |  |Clinical Example (76511) |

| | |A 68-year-old white male is found to have a mass in the temporal retina and is referred for a diagnostic A-scan|

| | |to include measurement of the height, internal reflectivity, and dimensions of the lesion. |

| | |Description of Procedure (76511) |

| | |The lesion is inspected and the cornea is anesthetized. The physician places an A-scan probe on the lids or |

| | |globe with the beam passing perpendicularly through the lesion. Multiple images in all quadrants are examined |

| | |to determine diameter, elevation, and nature of internal reflectivity. Possible breach of Bruch's membrane and |

| | |choroidal extension is determined. Appropriate views are documented during the scan. Integration of ultrasound |

| | |findings with clinical presentation is evaluated. The physician formulates a clinical diagnosis. |

|[pic] |

|76512 |  |Clinical Example (76512) |

| | |A 68-year-old white male is found to have elevated retina in the temporal posterior segment and is referred for|

| | |a diagnostic contact B-scan. |

| | |Description of Procedure (76512) |

| | |The lesion is inspected and the cornea is anesthetized. The physician places an A-scan probe on the lids or |

| | |globe with the beam passing perpendicularly through the lesion. Multiple images in all quadrants are examined |

| | |to determine diameter, elevation, and nature of internal reflectivity. Possible breach of Bruch's membrane and |

| | |choroidal extension is determined. Appropriate views are documented during the scan. Integration of ultrasound |

| | |findings with clinical presentation is evaluated. The physician formulates a clinical diagnosis. |

|[pic] |

|76513 |  |A 27-year-old man is hit in the left eye with a tennis ball and sustains a total hyphema with light perception |

| | |vision. However, the eye is hypotonous with intraocular pressure only 0 to 1 mm Hg. A routine B-scan ultrasound|

| | |examination is performed, since there is no view of the posterior segment, and reveals no retinal detachment or|

| | |choroidal effusion. No anterior segment abnormalities are revealed. UBM reveals both an iridodialysis and |

| | |cyclodialysis that are not clinically visible. The patient is sent to the operating room several days later for|

| | |anterior chamber washout and cyclodialysis repair simultaneously, avoiding the need for two surgeries. Repeat |

| | |UBM is performed several weeks later, which confirms complete closure of the cleft. |

|[pic] |

|76514 |  |Clinical Example (76514) |

| | |A 50-year-old patient is found to have an apparent increased intraocular pressure (IOP) that measured 26 mm Hg |

| | |in each eye by applanation tonometry. There was no family history of glaucoma and the optic nerves appeared |

| | |healthy. A measurement of corneal thickness was ordered and performed in order to determine its possible |

| | |influence on the IOP readings. |

| | |Description of Procedure (76514) |

| | |The patient is instructed to fixate on a distant target. The ultrasound probe is aligned with the center of the|

| | |cornea and then brought into contact with the center of the cornea. Five consecutive readings are obtained. The|

| | |high and low readings are discarded and an average thickness measurement in microns is determined. The |

| | |physician interprets the possible effect of the corneal thickness on the intraocular pressure measurements |

|[pic] |

|76776 |  |Clinical Example (76776) |

| | |A 60-year-old female presents for routine clinical follow-up 6 months after an uneventful renal transplant. The|

| | |patient's creatinine and blood pressure are elevated and she is sent for an ultrasound of the transplanted |

| | |kidney, including real-time, color, and spectral Doppler. |

| | |Description of Procedure (76776) |

| | |The sonographer performing the exam is supervised. The 2D data for renal anatomy, collecting system dilation, |

| | |perirenal fluid, and cortical echogenicity is analyzed. The vascular and Doppler information for renal artery |

| | |stenosis, pseudoaneurysm, venous obstruction, acute tubular necrosis, and rejection is analyzed. The exam is |

| | |compared and correlated with the findings from previous studies. The report is dictated for the medical record.|

|[pic] |

|76813 |  |Clinical Example (76813) |

| | |A 40-year-old female is referred for genetic risk assessment. She has previously undergone a first-trimester |

| | |ultrasound examination in her referring obstetrician's office. She is quoted a 1 in 110 age-related risk of |

| | |giving birth to an infant with Down syndrome, but when advised of the 0.5% to 1.0% risk of miscarriage with the|

| | |suggested invasive procedures, she requests a noninvasive alternative. |

| | |Description of Procedure (76813) |

| | |First-trimester fetal nuchal translucency sonographic measurement is performed. The transducer is oriented |

| | |until a midsagittal view of the embryo is obtained. The embryo is observed at high magnification until the |

| | |embryonic neck is in a neutral position and spontaneous embryonic movement allows for differentiation between |

| | |the outer edge of nuchal skin and the amnion. At least three separate measurements of the shortest distance |

| | |between the inner edges of the nuchal translucency are performed. The largest measurement from an acceptable |

| | |image is compared to crown-rump length and gestational agespecific medians and a new risk of Down syndrome is |

| | |calculated. |

|[pic] |

|76814 |  |Clinical Example (76814) |

| | |A 40-year-old female is referred for genetic risk assessment. She has previously undergone first-trimester |

| | |ultrasound examination in her referring obstetrician's office that indicates twin gestation. She is quoted a 1 |

| | |in 110 age-related risk of giving birth to infants with Down syndrome, but when advised of the 0.5% to 1.0% |

| | |risk of miscarriage with the suggested invasive procedures, she requests a noninvasive alternative. |

| | |Description of Procedure (76814) |

| | |After completion of the nuchal translucency measurement on the first fetus, the second embryo of the twin-fetal|

| | |gestation is identified separate from the original embryo. Nuchal translucency measurement is performed on the |

| | |second fetus. The transducer is oriented until a midsagittal view of the second embryo is obtained. The embryo |

| | |is observed at high magnification until the embryonic neck is in a neutral position and spontaneous embryonic |

| | |movement allows for differentiation between the outer edge of nuchal skin and the amnion. At least three |

| | |separate measurements of the shortest distance between the inner edges of the nuchal translucency are |

| | |performed. The largest measurement from an acceptable image is compared to crown-rump length and gestational |

| | |agespecific medians and a new risk of Down syndrome is calculated. A report is dictated, transcribed, and |

| | |signed. |

|[pic] |

|76818, |  |Clinical Example (76818, 76819) |

|76819 | |A 27-year-old woman at 42 weeks gestation, two weeks past her due date, who needs evaluation of fetal |

| | |well-being in order to facilitate a decision on whether to induce labor or not. |

| | |Description of Procedure (76818, 76819) |

| | |The patient is placed in a recumbent position on an examing table or stretcher with her abdomen exposed and |

| | |prepped with conducting gel. An abdominal ultrasound transducer is passed over the abdomen to view the fetus, |

| | |and obtain the following four variables: |

| | |• Fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more |

| | |within 30 minutes). |

| | |• Fetal movements (three or more discrete body or limb movements within 30 minutes). |

| | |• Fetal tone (one or more episodes of fetal extremity extension with return to flexion). |

| | |• Quantification of amniotic fluid volume (a pocket of amniotic fluid that measures at least 1 cm in two planes|

| | |perpendicular to each other). |

| | |These four variables are evaluated according to a numerical grading system, ranging from zero to ten with the |

| | |higher scores indicating fetal normality. Evaluation of these variables requires intermittent ultrasound |

| | |imaging of the fetus in utero over a 30-to-40 minute period of time. |

|[pic] |

|76820 |  |Clinical Example (76820) |

| | |A 23-year-old female is referred for evaluation of uterine size less than dates. Her current gestational age is|

| | |32 weeks. Review of her history demonstrates a certain last menstrual period confirmed by a 10 week ultrasound |

| | |performed at the time of her first prenatal visit. Uterine size had been consistent with menstrual dates up |

| | |until approximately 20 weeks. Since that time there has been a progressive lag in uterine size as compared to |

| | |her known menstrual age. An obstetrical ultrasound examination is performed. That study demonstrates composite |

| | |fetal measurements consistent with 29 weeks and significant head/abdomen circumference discrepancy suggesting |

| | |asymmetric fetal growth retardation. The amniotic fluid volume is normal. Doppler velocimetry of the umbilical |

| | |artery is performed to further evaluate fetal well-being and determine the need for further intervention. |

| | |Description of Procedure (76820) |

| | |The physician reviews the prenatal records and reviews previous ultrasound reports and/or films. Next, a |

| | |visualization is obtained of a segment of the umbilical cord, and a duplex Doppler sampling gate is placed over|

| | |a portion of an umbilical artery most perpendicular to the axis of the gate. Gain and filters are adjusted to |

| | |ensure adequate recording of diastolic flow. Two to four waveforms are recorded during period when fetus is |

| | |inactive and fetal breathing is absent. Electronic calipers are used to measure peak systolic and end diastolic|

| | |frequency shift. One of several commonly used indices is then calculated. |

| | |An average of the results of two to four waveforms is obtained, and comparison of specific normal values to |

| | |gestational age is made. |

|[pic] |

|76821 |  |Clinical Example (76821) |

| | |The patient is a 25-year-old gravida 3, para 1, ab 1 female who became Rh-D sensitized when she did not receive|

| | |Rhesus immune globulin at the time of a spontaneous miscarriage in her first pregnancy. In her second pregnancy|

| | |she had minimal elevation of anti-D titers. In the current (third) pregnancy, the patient's initial antibody |

| | |screen at 20 weeks' gestation revealed an anti-D titer of 1:128. Middle cerebral artery Doppler studies are |

| | |performed at 22 weeks gestation in order to assess the risk of ongoing anemia and need for further |

| | |intervention. |

| | |Description of Procedure (76821) |

| | |A review of the prenatal records, laboratory data, and/or previous ultrasound reports and/or films is provided.|

| | |A real time ultrasound is performed to locate the fetal head. In addition, the anterior wing of the sphenoid |

| | |bone is identified. Color flow Doppler is used to image the Circle of Willis. A pulsed Doppler gate is placed |

| | |over the middle cerebral artery near its origin from the Circle of Willis, and transducer probe orientation or |

| | |gate orientation is adjusted to ensure angle of insonance is close to zero degrees. Two to four measurements |

| | |are then obtained and the highest velocity is recorded. A comparison of peak systolic velocity is performed to |

| | |published gestational age-specific norms. The patient is informed of the results. The results are then |

| | |communicated, and recommendations made to the referring physician. The written report is then prepared and |

| | |signed. |

|[pic] |

|76873 |  |A 68-year-old man with PSA of 6.1 ng/mL and Gleason 5 prostate cancer has elected interstitial brachytherapy |

| | |(prostate seed implant). |

|[pic] |

|76937 |  |Clinical Example (76937) |

| | |A patient requires internal jugular (IJ) central venous catheter placement. The physician decides that |

| | |ultrasound guidance is necessary for safe IJ venous access. |

| | |Description of Procedure (76937) |

| | |Potential access sites are examined with ultrasound and an acceptable patent access site selected. Permanent |

| | |documentation of sites examined is recorded. After sterile field has been established, the ultrasound probe is |

| | |covered with sterile sleeve. Aquasonic gel is applied and real-time ultrasound is performed monitoring the |

| | |advancement of the access needle into the lumen of the selected vessel. This position is also recorded. |

| | |Description of the guidance process is included in the final procedure report. |

|[pic] |

|76940 |  |Clinical Example (76940) |

| | |The three clinical examples below describe typical patients referred for laparoscopic, open, and percutaneous |

| | |procedures. Patients undergoing open or laproscopic procedures may receive either radiofrequency or |

| | |cryosurgical ablation. |

| | |Typical Patient Treated By Laparoscopic Cryosurgical Ablation |

| | |The patient is a 44-year-old man who underwent a left colon resection for adenocarcinoma one and one-half years|

| | |ago. Following the left colon surgery, he received systemic chemotherapy. After six months of treatment, the |

| | |patient's CEA begins to rise. CT imaging of the liver reveals three lesions along the anterior, inferior |

| | |surface of the right lobe of the liver. All three lesions were confirmed on ultrasound examination and were |

| | |felt to be superficial and accessible by laparoscopy. The lesions measure 4 cm, 2.0 cm and 2.5 cm in diameter. |

| | |The patient undergoes laparoscopy and cryosurgical ablation of all three liver tumors. NOTE: The ultrasound |

| | |guidance, supervision and interpretation are separately reportable. |

| | |Typical Patient Treated By Open Radiofrequency Ablation |

| | |An 82-year-old gentleman was diagnosed with colon cancer and underwent a right hemi-colectomy in May of 1994. |

| | |He had a Dukes C2 lesion with positive lymph nodes. Recently he was seen in follow-up and found to have an |

| | |elevated CEA of 34. A CT scan revealed two hepatic metastases in the right lobe of the liver and one in the |

| | |medial segment of the left lobe. The two lesions in the right lobe were 3 cm and 2 cm, and the lesion in the |

| | |left lobe was 3.5 cm. These findings were confirmed by ultrasound. The remainder of the metastatic workup |

| | |revealed no other spread in the abdomen, retroperitoneum, lung, bone, or brain. A recent follow-up colonoscopy |

| | |was also negative for recurrent cancer. Because of the bilaterality and multiplicity of the lesions, biopsy and|

| | |radiofrequency thermal ablation was determined most appropriate. The patient underwent an exploratory |

| | |laparotomy and one of the liver lesions was proven malignant by core needle biopsy. No extra-hepatic disease |

| | |was found. All three lesions were ablated with radiofrequency thermal technique, using sonographic guidance and|

| | |confirmation of lesion destruction. NOTE: The ultrasound guidance, supervision and interpretation, are |

| | |separately reportable. |

| | |Typical Patient Treated By Percutaneous Radiofrequency Ablation |

| | |A 73 year old man with colon cancer developed two metastatic lesions to the liver. Lesions were 2 cm x 2 cm and|

| | |4 cm x 4 cm. Because the lesions were not surgically resectable due to their location, the patient's oncologist|

| | |referred him for evaluation for radiofrequency (RF) ablation. The patient was evaluated by the treating |

| | |physician, and the lesions were determined to be amenable to percutaneous RF ablation. |

| | |Description of Procedure (76940) |

| | |A preliminary ultrasound is performed to assess percutaneous or the various intraoperative transhepatic |

| | |approach(es) to the tumor(s). An intraoperative ultrasound examination of each hepatic segment is performed |

| | |until satisfactory exposure has been achieved to confirm expected location(s) of the lesion(s). Ultrasound |

| | |guidance is then performed to direct RF or cryosurgical needle electrode(s) to tumor(s), percutaneous or |

| | |intraoperative transhepatic. There is ultrasound monitoring of needle electrode repositioning within lesion, if|

| | |and as necessary for each of the multiple ablations or freeze-thaw cycles required to completely ablate the |

| | |lesion. An ultrasound to confirm satisfactory ablation of the lesion(s) and comparison to pre-ablation images |

| | |and imaging of liver for post-ablation bleeding is then performed. |

|[pic] |

|77301 |  |Clinical Example (77301) |

| | |A 68-year-old male presents with T1C adenocarcinoma of the prostate. Gleason score 6-7/10. The patient is not a|

| | |surgical candidate because of morbid obesity. Patient is set up for 3-D conformal radiation therapy to 5040 cGy|

| | |to pelvis. The patient is subsequently scheduled for IMRT boost to 8100 cGy. The patient was immobilized and |

| | |taken to CT for virtual simulation. The targets and critical avoidance structures are outlined on axial images.|

| | |The IMRT plan is obtained and verified with film phantom. Seventeen fractions are delivered with 3 |

| | |arcs/fraction via Peacock or 5 fields with 5 intensity steps per field via MLC delivered to the target at 180 |

| | |cGy/fraction, for a total dose of 3060 cGy to the gland, while keeping the anterior rectal wall and bladder |

| | |dose below tolerance levels. |

| | |Description of Procedure (77301) |

| | |The patient is immobilized in the treatment position for tumor volume localization CT. The planning CT scan |

| | |used for tumor localization is correlated with other imaging studies, including MRI, PET, contrast-enhanced |

| | |plain film studies, and ultrasound imaging studies. The critical normal tissues are enumerated within and |

| | |adjacent to the tumor volume. The partial dose/volume tolerances for these normal tissues are defined. The |

| | |tumor area is identified and segmented on each CT slice within the tumor volume. Each critical normal tissue |

| | |within each CT slice within and adjacent to tumor volume is identified and segmented. Normal tissue and tumor |

| | |dose constraints for inverse planning algorithm are explicitly developed. A determination of 1 or 2 cm index |

| | |slice thickness for Peacock planning is made. Cooperative work is performed with the physicist to suggest |

| | |initial gantry and table angles for field families for the multi-leaf collimator. A re-evaluation of the |

| | |initial plan is performed for goodness of fit for tumor and normal tissue dose constraints with a possible |

| | |modification. If necessary, a reassessment of the plan is performed with the physicist to modify tumor and |

| | |normal tissue dose constraints. The plan is continuously re-run until the dose constraints are acceptable. Dose|

| | |volume histograms are compared specifically for tumor and critical normal tissues. The phantom/film, TLD, or |

| | |diode dosimetry performed by physicist are reviewed to confirm correct plan parameters compared with graphical |

| | |plan. |

|[pic] |

|77371 |  |Clinical Example (77371) |

| | |A 64-year-old male smoker with a diagnosis of squamous cell carcinoma of the lung and a KPS of 80 presents with|

| | |two metatastic lesions in the brain diagnosed on MRI scan after the patient complained of right sided weakness.|

| | |One lesion was 2.5 cm in size and was noted to be 2 cm from the optic apparatus while the other was 1.5 cm in |

| | |size with associated edema and was situated in the primary motor strip on the left. No metastases to the |

| | |brainstem were identified. Patient was started on dexamethasone therapy and whole brain radiotherapy was |

| | |commenced. After 30 Gy given in 10 fractions an MRI scan was obtained which revealed a partial response |

| | |characterized by 60% shrinkage of both lesions and resolution of the edema. Single fraction stereotactic |

| | |radiation boost was prescribed to both lesions to gain local control of the lesions. |

| | |Description of Procedure (77371) |

| | |For cranial lesions, a team consisting of the radiation oncologist, neurosurgeon and medical physicist is |

| | |responsible for supervising the patient positioning and proper alignment of treatment beams involved in SRS. |

| | |Immobilization via rigid system placed by the neurosurgeon or by a replaceable system placed by the radiation |

| | |oncologist or neurosurgeon is applied to the patient before treatment. Alignment of the patient and correlation|

| | |with computer generated treatment plan is analyzed to assure proper delivery of the radiation beam(s). In all |

| | |cases of SRS, extreme precision of patient positioning is essential for accurate treatment delivery and is |

| | |achieved through rigid immobilization, such as with a head frame or "frameless" image-based immobilization and |

| | |localization. |

| | |Thereafter the complete course of treatment is delivered as described by the proposed codes with the radiation |

| | |oncologist, radiation therapist, and neurosurgeon in attendance. |

|[pic] |

|77372 |  |Clinical Example (77372) |

| | |A 64-year-old male smoker with a diagnosis of squamous cell carcinoma of the lung and a KPS of 80 presents-with|

| | |two metatastic lesions in the brain diagnosed on MRI scan after the patient complained of right sided weakness.|

| | |One lesion was 2.5 cm in size and was noted to be 2 cm from the optic apparatus while the other was 1.5 cm in |

| | |size with associated edema and was situated in the primary motor strip on the left. No metastases to the |

| | |brainstem were identified. Patient was started on dexamethasone therapy and whole brain radiotherapy was |

| | |commenced. After 30 Gy given in 10 fractions an MRI scan was obtained which revealed a partial response |

| | |characterized by 60% shrinkage of both lesions and resolution of the edema. Single fraction stereotactic |

| | |radiation boost was prescribed to both lesions to gain local control of the lesions. |

| | |Description of Procedure (77372) |

| | |For cranial lesions, a team consisting of the radiation oncologist, neurosurgeon and medical physicist is |

| | |responsible for supervising the patient positioning and proper alignment of treatment beams involved in SRS. |

| | |Immobilization via rigid system placed by the neurosurgeon or by a replaceable system placed by the radiation |

| | |oncologist or neurosurgeon is applied to the patient before treatment. Alignment of the patient and correlation|

| | |with computer generated treatment plan is analyzed to assure proper delivery of the radiation beam(s). In all |

| | |cases of SRS, extreme precision of patient positioning is essential for accurate treatment delivery and is |

| | |achieved through rigid immobilization, such as with a head frame or "frameless" image-based immobilization and |

| | |localization. |

| | |Thereafter the complete course of treatment is delivered as described by the proposed codes with the radiation |

| | |oncologist, radiation therapist, and neurosurgeon in attendance. |

|[pic] |

|77373 |  |Clinical Example (77373) |

| | |A 60-year-old female is diagnosed with a 3.5-cm non-small cell lung cancer in the periphery of the right upper |

| | |lobe of lung. Staging, including CT of mediastinum and upper abdomen and positron emission tomography shows |

| | |only localized disease (stage T2, N0, M0). She is medically inoperable secondary to poor pulmonary reserve. |

| | |Treatment options include limited pulmonary resection with risk of severe pulmonary insufficiency, conventional|

| | |fractionated radiation that will expose a large lung volume to ionizing radiation with a very limited curative |

| | |potential, or stereotactic body radiation therapy (SBRT). SBRT is selected to enhance local control and cure |

| | |and decrease treatment related morbidity. |

| | |Description of Procedure (77373) |

| | |Treatment planning is performed in advance of SBRT delivery (coded separately). The treatment delivery requires|

| | |numerous beam arrangements consisting of 8 to 10 fields or arcs that are arranged to deliver a high focal dose |

| | |to the target with steep dose gradients to surrounding normal tissue. |

| | |Under the direct supervision of the radiation oncologist, the patient is set up on the treatment table and all |

| | |treatment parameters are verified. The physician selects and validates the method used to account for |

| | |respiratory motion or other types of patient motion and correlates these findings with the parameters of the |

| | |accepted treatment plan. Then, the radiation oncologist analyzes the set up for potential collisions of the |

| | |apparatus with the patient, treatment couch, or other devices and makes appropriate modifications. The |

| | |physician assesses and approves all of the ongoing images used for localization, tumor tracking, any gating |

| | |application, as well as single (beams eye) view localization images for each of the 8 to 10 fields or arcs. |

| | |Adjustments in patient positioning are made and approved by the radiation oncologist. The radiation oncologist |

| | |remains in attendance throughout the delivery of the radiation treatment, which may last for 1 to 2 hours, to |

| | |manage the execution of the treatment and make real-time adjustments in response to patient motion, target |

| | |movement, or equipment issues to ensure accuracy and safety. The entire treatment process is repeated for each |

| | |treatment fraction. |

|[pic] |

|77421 |  |Clinical Example |

| | |A 60-year-old male presented with prostate cancer. The patient opted for external beam radiotherapy, and the |

| | |plan is to deliver 78 Gy at 2 Gy per fraction to the prostate and seminal vesicles using highly conformal |

| | |radiotherapy. Service includes acquisition and review of positioning X rays and physician-directed |

| | |repositioning as necessary. |

| | |Description of Procedure |

| | |A radiation oncologist oversees the patient preparation, including placement of infrared markers. The infrared |

| | |markers are placed either on the patient to monitor the patient’s position or on the treatment couch to |

| | |localize the position of the couch. Two sets of X rays are acquired to visualize internal anatomy or implanted |

| | |marker positions immediately prior to treatment. This is done using kV or MV X-ray units that may be a |

| | |combination of two kV X-ray units and two amorphous silicon flat panel detectors or an X-ray unit attached to |

| | |the gantry or MV X rays with an electronic portal imaging device (EPID), which takes two orthogonal images. |

| | |These two high-resolution X rays are acquired prior to treatment delivery in order to visualize the internal |

| | |anatomy or implanted markers. |

| | |The stereoscopic X-ray images are compared with the imported digital reconstructed radiographs (DRRs) from the |

| | |treatment planning system or generated DRRs from the stored computed tomography treatment planning scan data, |

| | |which are in the same plane as the X rays taken. The DRRs serve as a reference for identifying rotational or |

| | |movement discrepancies, positioning, and guidance for the delivery of radiation and enable real-time analysis |

| | |of the targeted area. |

| | |Alignment, registration, and fusion of the two images are done manually or automatically using previously |

| | |implanted markers, direct visualization of the target volume, or surrounding bony anatomy. These procedures are|

| | |done under the supervision of the radiation oncologist. |

| | |The rotational errors of the patient setup and the table movement necessary to optimally align the patient’s |

| | |target volume at the isocenter in longitudinal, lateral, and vertical directions are calculated. The |

| | |deviations, if present, are determined and corrected by adjusting the patient’s treatment position to the |

| | |treatment target volume isocenter. This is performed by applying the required translational shifts to the |

| | |treatment couch performed by the therapist and done under physician supervision. |

| | |The radiation oncologist reviews the images daily and compares with previous shifts. Feedback by the physician |

| | |is given to the therapists about the adequacy of registrations and, if necessary, about the steps necessary to |

| | |improve future registrations as well as for required treatment modifications. |

|[pic] |

|77427 |  |61-year-old woman found to have a 4 cm near-circumferential, moderately differentiated adenocarcinoma of the |

| | |rectum (8 to 12 cm above the anal verge) on evaluation of 3 months rectal bleeding, 4 weeks of dys-pareunia, |

| | |and 2 weeks of dull lower pelvic pain. Workup findings included anemia (Hct 33%, Hgb 10.9 g/dL), CEA 7.3, and |

| | |no evidence of adenopathy or distant metastasis on CTs of pelvis and abdomen and chest x-ray. KPS was 80%. She |

| | |did well after low anterior resection, with pathologic findings of tumor into perirectal fat, three of eight |

| | |nodes involved (TNM stage III). Recommentations for adjuvant chemotherapy and radiotherapy were accepted. |

| | |Four weeks later after Mediport placement and simulation, treatment began with continuous 24-hour infusion (for|

| | |4 weeks), 5-FU, and concurrent three-field pelvic radiotherapy to an intended total dose of 4500 cGy in 25 |

| | |daily treatments over 5 weeks, with a planned boost thereafter to the posterior pelvis of 540 cGy in three |

| | |daily treatments, all with 10-mV photons. |

| | |Treatment in the prone position ("belly board" technique) was in the first week awkward and uncomfortable for |

| | |the patient because of the infusion pump, incisional pain, and hip osteoarthritis. Analgesic drugs and dosing |

| | |were modified. |

| | |Mild nausea in the second week was controlled with a phenothiazine antiemetic prn. Nutrition was appropriate. |

| | |Nausea increased during the third week, and intermittent semi-watery diarrhea developed. Mild neutropenia |

| | |appeared. Weight dropped by 2 pounds. Postoperative oral iron therapy was stopped. Strict adherence to a |

| | |low-residue diet, frequent smaller feedings, and nutritional supplements were advised. Atropine sulfate and |

| | |diphenoxylate hydrochloride (Lomotil) was prescribed in the fourth week. The patient's symptoms were stable. |

| | |Mild neutropenia persisted. Radiodermatitis in the gluteal cleft was topically managed. |

| | |In week 5, watery diarrhea, urinary frequency, dysuria, and mild stomatitis developed. WBC was 2500/nL, |

| | |platelets 100,000/nL. Stool culture for Clostridium difficile was negative, urinalysis/culture confirmed UTI, |

| | |antibiotic was prescribed, and inflamed hemorrhoids were topically treated. Treatment was not given Thursday |

| | |and Friday to give the irradiated bowel a 4-day rest from therapy. Chemotherapy infusion was completed. |

| | |The patient's GI status was improved in the fifth week; stools were semiformed, one to three times per day with|

| | |some tenesmus. Moist desquamation in the gluteal cleft was treated with mupirocin. WBC was 2800/nL. |

| | |Stomatitis/uL and cystitis resolved. |

| | |Posterior pelvic boost completed the patient's treatment in week 6. GI function was unchanged from week 5. At |

| | |end of radiotherapy, net weight loss was 5 pounds, and KPS was 80%. She was seen 2 and 4 weeks after |

| | |radio-therapy, with progressive recovery. |

| | |Chemotherapy resumed 4 weeks after radiotherapy. When the patient was seen again 2 months after radiotherapy, |

| | |skin was healed, GI symptoms were mild and controlled by minor diet adjustments. Sexual counseling was given. |

| | |Return visit in 6 months was scheduled. |

|[pic] |

|77435 |  |Clinical Example (77435) |

| | |A 55-year-old male is diagnosed with a 3.0-cm non-small cell lung cancer in the periphery of the left lower |

| | |lobe of the lung and his metastatic work is negative. He is medically inoperable secondary to poor pulmonary |

| | |reserve. SBRT is selected to enhance local control and to cure and decrease treatment-related morbidity. The |

| | |prescription is to deliver 20 Gy per fraction for three fractions. After simulation and appropriate conformal |

| | |treatment planning, he presents to the department for SBRT. |

| | |Description of Procedure (77435) |

| | |Under the direct supervision of the radiation oncologist, the patient is set up on the treatment table and all |

| | |of the treatment parameters are verified. Image guidance with respiratory correlation may be achieved through a|

| | |variety of methods, all of which are supervised, corrected, and approved in real time by the physician. The |

| | |radiation oncologist remains available throughout SBRT treatment to manage the execution of the treatment and |

| | |to make real-time adjustments in response to patient motion, target movement, or equipment issues to ensure |

| | |accuracy and safety. |

| | |After positioning the patient and turning on the breath coordination equipment or optical tracking equipment |

| | |(for monitoring the respiration signals), time is allowed for the patient to become acquainted with the audio |

| | |or visual instructions. Gated (manually or automatic) setup radiographs (kilovolt [kV] or millivolt [MV]) are |

| | |taken and compared by the physician with digitally reconstructed radiographs to detect patient shifts. The |

| | |patient position is adjusted if the films show a misalignment greater than a predetermined threshold. An |

| | |on-board image series (orthogonal kV or computed tomography [CT] scan) is acquired or a CT simulation can be |

| | |done if this is not available and the radiation oncologist reviews images with the medical physicist to verify |

| | |that the internal isocenter in the reconstructed 3D volume is positioned appropriately in reference to the |

| | |observed tumor location in accordance with the previously designed treatment plan. Once the beam is turned on |

| | |the respiration signal, patient position and target location are continuously monitored during the delivery of |

| | |image-guided SBRT. Multiple images are taken throughout the course of the treatment to verify target |

| | |localization. These images are contemporaneously approved by the physician before the beam can be turned on |

| | |again. Each time the patient coughs or shifts, the treatment has to be interrupted and reinitiated after |

| | |relocalization and repeat image guidance and correlation. The beam is turned on when the image guidance |

| | |confirms that the target lesion is in the treatment zone. The physician assesses and approves all of the |

| | |ongoing images used for localization, tumor tracking, and any gating application, and reviews any complementary|

| | |single (beam's eye) view localization images for any of the fields or arcs that are arranged to deliver a dose.|

| | |At all points of decision-making with regard to patient setup, the radiation oncologist confers with the |

| | |medical physicist and approves the final setup. The radiation oncologist remains in attendance for the delivery|

| | |of the radiation treatment (which may last for 1 to 2 hours). |

|[pic] |

|77520 |  |A 32-year-old woman presented with a history of decreased vision in the left eye. Examination showed a large |

| | |melanoma inferiorly involving the ciliary body and peripheral choroid with a slit-like area of infiltration |

| | |seen at the junction of the iris and sclera inferiorly. The location and dimensions of the tumor were |

| | |determined with ultrasound examination. The patient was taken to the OR, where surgical clips were placed at |

| | |the periphery of the lesion. The positions of the clips, the clip-to-clip dimensions, and the relative position|

| | |and distance of the clip nearest to the macula were measured in the OR and recorded for treatment planning |

| | |purposes. Two to three days after the OR procedure, the patient was taken to the proton treatment facility for |

| | |simulation of the treatment prior to the actual treatment delivery. The treatment plan was calculated and |

| | |presented to the physician for review and approval. The treatment planning system also calculated the design of|

| | |the treatment aperture and transferred the fabrication data to the automatic milling machine. During the review|

| | |of the treatment plan, the physician determined the adequacy of the model used to represent the eye and the |

| | |tumor, the tumor dose coverage, and the dose sparing of the normal optical structures. A template was |

| | |calculated from the approved treatment plan that showed the relative positions of the treatment beam axes, the |

| | |treatment aperture, and the surgical clips. Two weeks after the simulation, the patient returned to the proton |

| | |treatment facility for her first treatment and received five treatments over 5 treatment days. The patient |

| | |returned at 6 weeks for a treatment follow-up examination by the physician and yearly thereafter. |

|[pic] |

|77523 |  |A 32-year-old woman presented with a 3-year history of progressive paraparesis and was diagnosed with chordoma.|

| | |The patient experienced sacral numbness and stress incontinence following normal delivery of her first baby. A |

| | |year later she experienced a pressure sensation in the skull and spine while lying down. An MRI of the |

| | |lumbosacral spine revealed an increased number and slightly increased size of the nerve roots throughout the |

| | |spinal canal. An EMG was consistent with bilateral lumbosacral polyradiculopathy, most prominent at S-1 but |

| | |involving L5-S4 area. During a second pregnancy, the patient continued to have progressive lower-extremity |

| | |weakness and new hip pain. Repeat MRI revealed increased number and size of the nerve roots in the lumbosacral |

| | |spine. An L4-L5 laminectomy and biopsy located two growths on the nerve roots with pathology consistent with |

| | |chordoma. After delivery of her second baby, she continued to have significant worsening of her lower-extremity|

| | |weakness and became unable to walk without assistance. The patient began to note hearing loss in the right ear |

| | |and progressive blurring of vision. Review of MRI images revealed a mass causing destruction of the distal |

| | |third of the clivus and a second mass above the principal mass causing erosion of the cortex of the clivus. |

| | |Subsequent pathology showed this to be chordoma. There were metastases found in the right middle cerebellar |

| | |peduncle and in the pulvinar of the thalamus on the right, as well as pathology of the nerve root, dura, and |

| | |arachnoid with chordoma. The primary lesion in the clivus provided the primary focus. The patient was |

| | |recommended for definitive radiation therapy of the craniospinal axis. The prescribed treatment plan was |

| | |whole-brain irradiation with x-rays to 55 Gy followed by a proton boost to the primary tumor in the lower |

| | |clivus, a metastasis in the right middle cerebellar peduncle, and a metastasis in the pulvinar of the thalamus |

| | |on the right, for a total of 76.6 cobalt gray equivalent; cervical/thoracic spine treated with x-rays to 55.5 |

| | |Gy; and the lumbar/sacral spine treated with x-rays to 65Gy followed by a proton boost to the cauda equina and |

| | |the paraspinal soft tissue metastases for a total of 79 Gy cobalt gray equivalent. |

|[pic] |

|77761, |  |Clinical Example (77761, 77776, 77789, 77790) |

|77776, | |A patient presents with an intra-abdominal or interstitial tumor. A needle is placed into the tumor and an |

|77789, | |interstitial radiation probe is advanced to the site of the tumor. The radiation source is emitted as |

|77790 | |prescribed by the radiation oncologist and the physicist's calculation and the treatment plan developed by the |

| | |radiation oncologist. Subsequent to irradiation, the probe is removed. |

|[pic] |

|78267 |  |Clinical Example (78267) |

| | |A 39-year-old female has had epigastric pain for 3 weeks, and had reached a level of severity which led her to |

| | |seek consultation with her primary care physician. Her doctor referred her for evidence of H. pylori infection,|

| | |and ordered a urea breath test. The first part of the procedure, the acquisition of the breath sample, is |

| | |normally administered by a technologist under the guidance of a physician; the second part of the procedure is |

| | |the analysis, which involves measurement of the level of radioactivity in the sample using a liquid |

| | |scintillation counter; the physician supervises the quality of the measurement, reviews the results and reports|

| | |on the significance of the results to the attending physician. |

| | |Description of Procedure (78267) |

| | |The physicain supervises data acquisition and processing of data. Next, the data is analyzed and reprocessed as|

| | |necessary. The study is monitored and an interpretation of the results is provided. The physician then compares|

| | |the results in relation to current diagnosis and past treatment or examination, if appropriate. |

|[pic] |

|78456 |  |A 70-year-old women with diabetes, and a history of DVT in the left leg presents with left leg swelling, |

| | |redness, pain, and calf tenderness. Ultrasound shows venous disease in the left leg, but old and new clot |

| | |cannot be distinguished from the images. |

|[pic] |

|78457 |  |A 65-year-old man has congestive heart failure, pedal edema, and right calf pain and tenderness. Ultrasound is |

| | |equivocal for deep vein thrombosis. Initially the physician determines the appropriateness of this test for |

| | |possible acute venous thrombosis in the lower extremities. |

|[pic] |

|78707 |  |Clinical Example 1 (78707) |

| | |A 24-year-old woman who had a renal transplantaiton five days previously, is referred for her third |

| | |post-operative radionuclide renal study because of decreasing urine output and rising creatine. |

| | |Clinical Example 2 (78707) |

| | |A 78-year-old man who has chronic left ventricular failure and recent development of atrial fibrillation is |

| | |referred for a renal evaluation because of onset of risng creatinine and decreasing urine output. |

| | |Description of Procedure (78707) |

| | |The physician obtains and interprets vascular flow, functions, and imaging data. |

|[pic] |

|78708 |  |Clinical Example 1 (78708) |

| | |A 43-year-old woman with persistent hypertension that has not responded to treatment is referred for possible |

| | |renovascular hypertension. |

| | |Clinical Example 2 (78708) |

| | |A 7-year-old female with a history of surgically treated ureteral reflux and residual right-sided |

| | |hydronephrosis is referred for evaluation of renal urinary obstruction. |

| | |Description of Procedure (78708) |

| | |For performance of a study for hypertension, the basal blood pressures are obtained. An ACE-inhibitor (oral or |

| | |intravenous) is administered and the patient's blood pressure monitored for up to one hour. The vascular flow |

| | |and function and imaging data are obtained and interpreted, following administration of an ACE-inhibitor. In |

| | |the presence of urinary obstruction, the kidney is monitored for function during the procedure and the time of |

| | |diuretic injection designated. |

|[pic] |

|78709 |  |Clinical Example (78709) |

| | |A 43-year-old woman with recent onset of hypertension is referred for possible renovascular hypertension. |

| | |Description of Procedure (78709) |

| | |The vascular flow, function and imaging data are obtained and interpreted. Several hours later, the basal blood|

| | |pressures are obtained. A slow drip of 0.5N saline is started via an intravenous line followed by |

| | |administration of an ACE-inhibitor (oral or intravenous) and monitoring of the patient's blood pressure for up |

| | |to one hour. A repeat renal imaging study is performed and the vascular flow interpreted, with function and |

| | |imaging data, comparing results from both sets of studies. |

|[pic] |

|78730 |  |Clinical Example (78730) |

| | |A 2-year-old female with a history of urinary tract infection and documented vesicoureteral reflux is referred |

| | |for nuclear ureteral reflux study (separately reported). Determination of residual bladder volume was also |

| | |requested and is performed. |

| | |Description of Procedure (78730) |

| | |After the ureteral reflux study (78740) is complete and the patient has voided, the physician supervises a |

| | |certified technologist who instructs the patient on the additional imaging for the procedure and obtains the |

| | |postvoid images. The activity in the bladder is measured on pre- and postvoid images by placing a region of |

| | |interest around the bladder and determining the difference. The physician supervises the technologist in the |

| | |acquisition and reconstruction of the data. Additionally, the voided volume of urine is measured directly. This|

| | |information is used to calculate the residual bladder volume. The physician reviews the study for adequacy and |

| | |the need for additional acquisitions. Alternatively, the reference direct volume measurement used in the |

| | |calculation can be the volume of saline infused into the bladder during the reflux study. Images are |

| | |interpreted by the physician with correlation with prior or related imaging studies. The physician dictates a |

| | |report for the medical record. |

|[pic] |

|78802 |  |Clinical Example (78802) |

| | |A 69-year-man, who is one year post therapy for Hodgkin's lymphoma and now has recurrent fever and weight loss,|

| | |is referred for restaging. Imaging is concluded in a single day. |

| | |Description of Procedure (78802) |

| | |Regulatory documentation, review and oversight for ordering and administering radioactive materials is carried |

| | |out. Preliminary review of images during acquisition, to assure that all needed images are acquired free of |

| | |motion and artifacts, including determination if image filter is necessary if performed. The imaging data is |

| | |interpreted. Comparison is made of previous pertinent imaging studies. A report is dictated for the medical |

| | |record. |

|[pic] |

|78804 |  |Clinical Example (78804) |

| | |A 62-year-old man with long-standing histologically confirmed B-cell non-Hodgkin's lymphoma has relapsed with |

| | |fever and pain, and has tumor recurrence confirmed by chest x-ray and CT studies. He has failed other prior |

| | |radiation and chemotherapy treatment. Treatment with Y90 Zevalin is contemplated, and he is referred for a |

| | |radiopharmaceutical distribution imaging required prior to Zevalin treatment. |

| | |Description of Procedure (78804) |

| | |Regulatory documentation, review and oversight for ordering and administering radioactive materials is carried |

| | |out. The provider personally supervises a slow infusion of the indium-111 labeled antibody, paying particular |

| | |attention for potential reaction. Preliminary review is performed, at the time of acquisition, 24-hour images |

| | |and 48-hour images, to assure that all needed images are acquired free of motion and artifacts, including |

| | |determination if image filter is necessary. Two to three sets of image data are interpreted. Qualitative |

| | |assessment of biodistribution and determination of feasibility of treatment with monoclonal antibody are |

| | |provided. Comparison of previous pertinent imaging studies is performed. A report is dictated for the medical |

| | |record. |

|[pic] |

|78811 |  |Clinical Example (78811) |

| | |The patient is a 42-year-old female with a history of invasive, ductal carcinoma of the left breast. The |

| | |initial tumor was 4.5 cm in largest diameter by mammography. She has now completed neoadjuvant chemotherapy and|

| | |assessment of treatment response is requested prior to surgical resection. A limited PET scan of the chest is |

| | |performed. |

| | |Description of Procedure (78811) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the technologist in the acquisition and reconstruction of the data in multiple|

| | |planes including transmission scans, and for the non-attenuation corrected and attenuation corrected emission |

| | |scans. The physician reviews the study for adequacy and need for additional acquisitions. All images are |

| | |interpreted by the physician including correlation with prior imaging studies. Quantification of an abnormality|

| | |is made by the calculation of the standardized uptake value (SUV) when clinically indicated. The physician |

| | |dictates the report for the medical record. |

|[pic] |

|78812 |  |Clinical Example (78812) |

| | |A 59-year-old male with a long history of smoking presents with a new 2.0 cm nodule on chest x-ray. A computed |

| | |tomography (CT) scan of the chest is performed and demonstrates an indeterminate solitary pulmonary nodule. A |

| | |transthoracic needle aspiration biopsy demonstrates a non-small, cell, lung cancer. A position emission |

| | |tomography (PET) scan is performed from skull base to mid thigh for initial staging of the lung cancer. |

| | |Description of Procedure (78812) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assesses the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the technologist in the acquisition and reconstruction of the data in multiple|

| | |planes including transmission scans, and for the non-attenuation corrected and attenuation corrected emission |

| | |scans. The physician reviews the study for adequacy and need for additional acquisitions. All images are |

| | |interpreted by the physician including correlation with prior imaging studies. Quantification of an abnormality|

| | |is made by the calculation of the standardized uptake value (SUV) when clinically indicated. The physician |

| | |dictates the report for the medical record. |

|[pic] |

|78813 |  |Clinical Example (78813) |

| | |The patient is a 33-year-old male with a history of a malignant melanoma resected from his back, inferior to |

| | |the right scapula, eight months previously. A small, non-painful, left axillary lymph node has developed in the|

| | |previous month. All recent laboratory and imaging studies have been unremarkable. He is referred for staging |

| | |prior to left, axillary resection. A whole-body PET scan is performed. |

| | |Description of Procedure (78813) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the technologist in the acquisition and reconstruction of the data in multiple|

| | |planes including transmission scans, and for the non-attenuation corrected and attenuation corrected emission |

| | |scans. The physician reviews the study for adequacy and need for additional acquisitions. All images are |

| | |interpreted by the physician including correlation with prior imaging studies. Quantification of an abnormality|

| | |is made by the calculation of the standardized uptake value (SUV) when clinically indicated. The physician |

| | |dictates the report for the medical record. |

|[pic] |

|78814 |  |Clinical Example (78814) |

| | |The patient is a 52-year-old male with a remote history of adenoid, cystic carcinoma of the left, parotid |

| | |gland. The patient recently re-presents with facial weakness and paresthesia. Magnetic resonance imaging (MRI) |

| | |shows abnormal tissue in the parotid bed, but it is unclear whether this is recurrent tumor or post-operative |

| | |scar. A PET-CT scan of the head/neck and chest is performed to evaluate the extent of recurrent tumor and |

| | |document precise anatomic distribution prior to consideration for surgery and/or radiation therapy. |

| | |Description of Procedure (78814) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the acquisition of CT data in the areas of interest. The physician supervises |

| | |the technologist in the acquisition and reconstruction of the PET data in multiple planes including |

| | |transmission scans, and for the non-attenuation corrected and attenuation corrected emission scans. The |

| | |interpreting physician, using a computer workstation, creates or directly supervises the creation of composite |

| | |images for anatomic correlation by precisely overlying PET and CT images. The physician reviews 3 sets of |

| | |images: emission PET scans, the CT anatomical localization data, and a fusion of the two images which contains |

| | |the PET and CT data anatomically superimposed over each other. PET images are interpreted by the physician and |

| | |correlated with the CT localization data obtained as well as with relevant prior imaging studies. |

| | |Quantification of an abnormality is made by the calculation of the standardized uptake value (SUV) when |

| | |clinically indicated. The physician dictates the report for the medical record. |

|[pic] |

|78815 |  |Clinical Example (78815) |

| | |A 67-year-old female with colon carcinoma has had a right hemicolectomy, radiation, and chemotherapy, and is |

| | |asymptomatic but now has rising carcinoembryonic antigen (CEA) tumor markers. A positron emission |

| | |tomography-computed tomography (PET-CT) scan from skull base to mid thigh is performed to assess tumor |

| | |recurrence and document precise anatomic distribution. |

| | |Description of Procedure (78815) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the acquisition of CT data in the areas of interest. The physician supervises |

| | |the technologist in the acquisition and reconstruction of the PET data in multiple planes including |

| | |transmission scans, and for the non-attenuation corrected and attenuation corrected emission scans. The |

| | |interpreting physician, using a computer workstation, creates or directly supervises the creation of composite |

| | |images for anatomic correlation by precisely overlying PET and CT images. The physician reviews 3 sets of |

| | |images: emission PET scans, the CT anatomical localization data, and a fusion of the two images which contains |

| | |the PET and CT data anatomically superimposed over each other. PET images are interpreted by the physician and |

| | |correlated with the CT localization data obtained as well as with relevant prior imaging studies. |

| | |Quantification of an abnormality is made by the calculation of the standardized uptake value (SUV) when |

| | |clinically indicated. The physician dictates the report for the medical record. |

|[pic] |

|78816 |  |Clinical Example (78816) |

| | |A 47-year-old female had a malignant melanoma resected from her scalp 14 months previously, followed by right, |

| | |supraclavicular, nodal recurrence eight months later. Imaging studies, including a positron emission tomography|

| | |(PET) scan, were abnormal only in that known, recurrence site. She has undergone further resection and is now |

| | |referred for evaluation of her response to chemotherapy and for whole body restaging. A whole body positron |

| | |emission tomography-computed tomography (PET-CT) scan is performed. |

| | |Description of Procedure (78816) |

| | |An appropriate dose of radiopharmaceutical is prescribed by the physician. The physician supervises a certified|

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and |

| | |injects the radiopharmaceutical in a designated injection room where the patient remains during the uptake |

| | |period. The physician supervises the acquisition of CT data in the areas of interest. The physician supervises |

| | |the technologist in the acquisition and reconstruction of the PET data in multiple planes including |

| | |transmission scans, and for the non-attenuation corrected and attenuation corrected emission scans. The |

| | |interpreting physician, using a computer workstation, creates or directly supervises the creation of composite |

| | |images for anatomic correlation by precisely overlying PET and CT images. The physician reviews 3 sets of |

| | |images: emission PET scans, the CT anatomical localization data, and a fusion of the two images which contain |

| | |the PET and CT data anatomically superimposed over each other. PET images are interpreted by the physician and |

| | |correlated with the CT localization data obtained as well as with relevant prior imaging studies. |

| | |Quantification of an abnormality is made by the calculation of the standardized uptake value (SUV) when |

| | |clinically indicated. The physician dictates the report for the medical record. |

|[pic] |

|79005 |  |Clinical Example (79005) |

| | |A 56-year-old female presents with symptoms of hyperthyroidism. On physical examination, she had an enlarged, |

| | |nodular, thyroid gland. The 24-hour thyroid uptake was 43% and a thyroid scan indicated a diffusely enlarged |

| | |gland with multiple areas of both increased and decreased activity bilaterally. She was referred for I131 |

| | |therapy for toxic multinodular goiter. |

| | |Description of Procedure (79005) |

| | |An appropriate dose of radiopharmaceutical is prescribed. The qualified physician supervises a certified |

| | |technologist who assays the dose of the radiopharmaceutical, instructs the patient on the procedure, and in a |

| | |designated therapy room assists the patient in drinking the radiolabeled drug, mixed in water. The physician |

| | |reviews post therapy, exposure measurements. The physician discharges the patient with instructions. |

|[pic] |

|79101 |  |Clinical Example (79101) |

| | |A 67-year-old male presents with known prostate carcinoma and has extensive skeletal metastases. He complains |

| | |of increasing pain in the chest, mid-thoracic and lumbar spine, and legs. He has had spot external beam |

| | |radiation but now has more diffuse and generalized bone pain and requires narcotics throughout the day to |

| | |obtain some relief. He also requires narcotics to sleep through the night. He is referred for Strontium 89 |

| | |therapy as palliation for painful, bony metastases. |

| | |Description of Procedure (79101) |

| | |An appropriate dose of radiopharmaceutical is prescribed. The qualified physician supervises a certified |

| | |technologist who assays the dose of the radiopharmaceutical and obtains intravenous (IV) access. The |

| | |radiopharmaceutical is administered slowly by the physician. (It typically takes up to 10 minutes.) The |

| | |physician reviews post therapy, exposure measurements. The physician discharges the patient with instructions. |

|[pic] |

|79403 |  |Clinical Example (79403) |

| | |A 62-year-old man with long standing histologically confirmed B-cell Non-Hodgkins Lymphoma has relapsed with |

| | |fever and pain, and has tumor recurrence confirmed by chest x-ray and CT studies. He has failed other prior |

| | |radiation and chemotherapy treatment. |

| | |Description of Procedure (79403) |

| | |The patient has been evaluated during consultation and found suitable for radiolabeled monoclonal antibody |

| | |therapy. That consultation included a review of medical records, and reports of histology for appropriate |

| | |antigen; assessment of suitability for outpatient as opposed to inpatient treatment (living conditions, |

| | |potential exposure to family and others), initial education of patient and family about the pretreatment |

| | |imaging and treatment, and initial instructions for dosimetric measurement and for therapy. |

| | |The physician includes review of any interim studies and change in clinical condition since initial |

| | |consultation and pretreatment imaging; review of dosimetric measurements; review of the therapy procedure with |

| | |patient and family, and reinforcement of education about potential exposure of family and friends and public, |

| | |and potential for murine antibody reaction; review of the preparation of the labeled monoclonal antibody; |

| | |intravenous infusion of the labeled monoclonal antibody, with concurrent observation for an immune reaction; |

| | |review of post therapy exposure measurements, if any; discharge of the patient with instructions; completion of|

| | |any written documentation including report of therapy; review and supervision of post-therapy measurements of |

| | |injection room and disposal of injection apparatus in compliance with regulatory rules. |

|[pic] |

|79445 |  |Clinical Example (79445) |

| | |A 56-year-old male with colorectal cancer developed multiple, liver metastases. Because of the number of liver |

| | |metastases, local therapy (eg, surgical resection, radiofrequency ablation) was not an option, and he had |

| | |failed systemic chemotherapy. The patient had no evidence of metastasis elsewhere. He was referred for possible|

| | |intra-arterial radiotherapy. |

| | |Description of Procedure (79445) |

| | |An appropriate dose of radiopharmaceutical is prescribed. The qualified physician supervises a certified |

| | |technologist who assays the dose of the radiopharmaceutical. Coordination with physicians obtaining appropriate|

| | |intra-arterial access is obtained, the prerequisite arterial access, selective vascular selection(s), |

| | |angiogram(s), and intervention(s) are performed and are separately coded by the relevant providing |

| | |physician(s). In coordination with the operating interventionalist, the physician supervises the administration|

| | |of the radiopharmaceutical. Post injection scintigraphic images are acquired and interpreted to assess the |

| | |final distribution of the intra-arterial injection. The physician reviews post therapy, exposure measurements |

| | |and imaging data. The physician discharges the patient with instructions. |

|[pic] |

|80100 |  |Clinical Example (80100) |

| | |An 18-year-old man comes to the emergency department (ED) in a coma. The treating physician orders a drug |

| | |screen without necessarily identifying any specific drug class to be tested. The laboratory performs a multiple|

| | |drug class screen using thin layer chromatography with a single mobile and stationary phase. |

|[pic] |

|80101 |  |Clinical Example #1 (80101) |

| | |A 30-year-old woman, with a history of anxiety and depression treated with prescription medications, comes to |

| | |the ED in a coma. The treating physician orders a drug screen for alcohol, barbiturates, benzodiazepines, |

| | |phenothiazines, and tricyclic antidepressants. The laboratory performs single drug class screening for each |

| | |analyte using immunoassay or enzyme assay methods in a random access analyzer. |

| | |Clinical Example #2 (80101) |

| | |A 25-year-old man with a history of illegal drug use comes to the ED in a coma. The treating physician orders a|

| | |drug screen for amphetamines, barbiturates, benzodiazepines, cocaine and metabolites, opiates, phencyclidine, |

| | |and tetrahydrocannabinoids. The laboratory performs single drug class screening for each analyte using a |

| | |multiple analyte rapid test immunoassay kit. |

|[pic] |

|80102 |  |Clinical Example (80102) |

| | |A 20-year-old woman with a history of illegal drug use comes to the ED in a coma. The treating physician orders|

| | |a drug screen necessarily without identifying any specific drug class to be tested. The laboratory performs a |

| | |multiple drug class screen and reports back positive, consistent with opiates. The treating physician orders a |

| | |confirmatory test, which the laboratory runs to confirm opiates using high performance liquid chromatography |

| | |(not quantitative). |

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|80156 |  |Clinical Example (80156) |

| | |A 4-year-old patient with epilepsy is placed on Carbamazepine for treatment. Due to the potential of toxicity, |

| | |close clinical observation including testing is recommended for monitoring Carbamazepine blood levels. This |

| | |test is performed using high performance liquid chromatography (HPLC) and fluorescent polarization immunoassay |

| | |(FPIA). |

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|80173 |  |Clinical Example (80173) |

| | |A 32-year-old patient diagnosed of Tourette's syndrome is placed on haloperidol for treatment. Therapeutic |

| | |monitoring is necessary to assess and optimize dosing regimens and maintenance therapy. The test is performed |

| | |using high performance liquid chromatography (HPLC) or gas chromatography (GC). |

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|80195 |  |Clinical Example |

| | |The service provided is to measure the concentration of sirolimus in the patient’s blood following sirolimus |

| | |immunosuppressive therapy. The sirolimus measurements must be made on a regular basis to monitor blood levels |

| | |of the drug for as long as the patient is being administered the drug. This is done to adjust and optimize the |

| | |dosage of the drug for each individual and to minimize toxic side effects. |

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|82042 |  |Clinical Example |

| | |A 50-year-old man with a history of ethanol abuse and hepatitis C infection is admitted with a history of |

| | |painless, slowly increasing abdominal girth. Physical examination reveals a fluid wave and shifting dullness. |

| | |Diagnostic paracentesis is performed and the ascitic fluid is sent for analysis. |

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|82045 |  |Clinical Example (82045) |

| | |A patient presents at the emergency room or outpatient setting with chest pain and other symptoms of possible |

| | |cardiovascular ischemia. |

| | |A routine venipuncture is performed to obtain a venous blood specimen. The specimen is tested in the hospital |

| | |laboratory using the Albumin Cobalt Binding test to assess if biochemical features of ischemia are present. |

| | |Positive results are indicative of a true cardiovascular event and result in further workup and probable |

| | |admission. Negative results suggest that symptoms are non-ischemic in nature. |

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|82107 |  |Clinical Example (82107) |

| | |A 60-year-old male presents with a history of hepatitis C and laboratory and ultrasound evidence of cirrhosis. |

| | |He is being followed according to the current oncology practice guidelines to assess the risk for |

| | |hepatocellular carcinoma (HCC), which includes performing a total alpha-fetoprotein (AFP) test . Because of |

| | |evidence of improved sensitivity and specificity as an indicator for the development of HCC when total and L3 |

| | |fractions of AFP are determined, the attending physician requests AFP with the L3 fraction (the AFP-L3/AFP |

| | |ratio), in addition to the existing practice guidelines. A serum sample is collected according to established |

| | |blood collection practices. |

| | |Description of Procedure (82107) |

| | |The laboratory analysis involves sophisticated technology including exposure of the sample to AFP-L3specific |

| | |lectin, immunoassay procedures with three kinds of anti-AFP antibodies with different kinds of fluorescent |

| | |labeling of the AFP fractions, and separation of the different AFP glycoforms by ion exchange chromatography. |

| | |This process utilizes two distinct and separate mobile phases for the separate and distinct detection and |

| | |quantitation of total AFP and its L3 fraction. Fluorescent spectroscopy is used to make the final determination|

| | |of the concentrations of total AFP and of AFP-L3. The results are reported as total AFP and as the total |

| | |AFP/AFP-L3 ratio (AFP-L3%). The assay is aided by sophisticated software and instrumentation support. |

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|82120 |  |A 28-year-old woman complains of a fishy-smelling vaginal discharge for the past 3 weeks. She has one sexual |

| | |partner, no history of sexually transmitted diseases, no complaints of genital itching, and increased vaginal |

| | |discharge or a yellow vaginal discharge. |

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|82270 |  |Clinical Example |

| | |A 72-year-old patient is seen for a follow-up visit for her hypertension and diabetes. During the visit, the |

| | |physician discusses the importance of colorectal cancer screening with the patient, including all recommended |

| | |screening options. The patient agrees that screening for colorectal cancer with a set of three fecal occult |

| | |blood cards is appropriate, and the physician supplies the kit and instructions. |

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|82272 |  |Clinical Example |

| | |A 57-year-old female is seen for fatigue and mentions that she has had dark stools. During the visit, the |

| | |physician performs a digital rectal exam and obtains a fecal specimen for guaiac-based occult blood test. |

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|82373 |  |Clinical Example (82373) |

| | |The patient is a 45-year-old man, a foreman who is a smoker and alcohol user. His reason for encounter is |

| | |headache, depression and sleep disorders. |

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|82595 |  |Clinical Example (82595) |

| | |Patient presents to a physician with symptoms of skin color changes when exposed to the cold. The skin color |

| | |changes may be due to impaired circulation in the small blood vessels. Physician orders a cryoglobulin, |

| | |qualitative test to determine the presence of cryoglobulins in the blood. |

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|82656 |  |Clinical Example (82656) |

| | |A 58-year-old white male presented to his primary care physician with a history of chronic diarrhea for the |

| | |past 2 and one half months. His symptoms include nocturnal diarrhea and recent weight loss (4 pounds). His |

| | |clinical signs included some steatorrhea and very malodorous and pale stools. |

| | |Results from initial investigations, including CBC, ESR, CRP, routine electrolytes, nitrogen, creatinine, LFTs,|

| | |serum calcium, B12 levels, folate, Fe status, thyroid function, and celiac serology, were all negative. Results|

| | |from stool culture and microscopy for parasites and yeast were also normal. Because the patient's symptoms |

| | |indicated possible malabsorption, he was referred to a gastroenterologist. Colonoscopy was done to assess the |

| | |stool quality and biopsies of the colon were done to rule out other causes of bowel pathology. These |

| | |investigations yielded negative findings. |

| | |The gastroenterologist then needed to assess malabsorption and pancreatic function. The following tests were |

| | |initially considered: secretin-pancreozymin test; 72-hour fecal fat; acid steatocrit; or chymotrypsin assays. |

| | |Of these, only the secretin-pancreozymin test demonstrates diagnostic specificity for pancreatic insufficiency;|

| | |however, it is quite expensive and inconvenient to perform. The human-specific test for pancreatic dysfunction |

| | |was chosen-fecal pancreatic elastase-1 (PE1). PE1 is currently the preferred noninvasive test for exocrine |

| | |pancreatic dysfunction. The patient took home the specimen collection kit, collected the stool specimen, and |

| | |sent the sample to the laboratory for analysis. The sample was sent overnight in a neat vial specimen container|

| | |at room temperature for processing. The patient was discovered to have PE1 levels below the established |

| | |reference range ( ................
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