Endovascular aneurysmal repairs (EVARs) are becoming more for the repair of abdominal aortic aneurysms. Previously, the safest way to perform this surgery was through an open approach— requiring a large ventral incision and prolonged hospitalization. Due to this abdominal incision, there was a higher incidence of ventral herniation post-operatively. There are more than 20,000 EVARs performed every year, resulting in a much less invasive procedure, lower cost than a traditional open approach, and this approach is associated with a much lower mortality.
Aneurysms are classified by site: cerebral, thoracic, and abdominal— with the most common being the abdominal type. True aneurysms involve all three layers of the vessel wall, which are the: tunica intima, tunica media, and tunica adventitia. It is important to know the difference between true aneurysms and pseudoaneurysms. A pseudoaneurysm is defined as injury to a blood vessel, which may cause leaking but is not weakened or bulging. As with many vascular pathologies, the prevalence of abdominal aortic aneurysms increases with age. The average age for diagnosis or treatment is 65-70 years old.
Another classification for abdominal aneurysms is shape and size. Risk of rupture increases once the aneurysm reaches 5cm or more. Fusiform aneurysms tend to be long with minimal bulging and carry less rupture prevalence. Saccular aneurysms tend to be short, round, and are at a higher risk for rupture due to more stress on a smaller segment of the vessel wall. It is not uncommon to see the aneurysm encompass vessels coming off the aorta, such as the renal arteries.
Along with the advancement of EVARs as a primary mechanism for abdominal aneurysm repairs, an additional procedure has been added with success called an aortic cuff. An aortic cuff is an extension device used to achieve a complete seal at the proximal aortic neck in the case of marginally favorable anatomy, or in the event of a suboptimal seal of the original graft. Previously, there was strict criteria set forth by the American College of Cardiology and American Heart Association to determine the most optimal patients for aneurysmal repair. Unfortunately, many were excluded due to their aortic anatomy. However, with the use of an aortic cuff, even those not meeting favorable anatomic criteria can now be candidates for EVARs.
When coding inpatient EVAR’s, it is important to carefully review the operative report to determine the location of the graft and the type of graft. Intraluminal devices go on the inside of the vessel. Fenestrated grafts have “arms” that extend into visceral arteries and are designated as intraluminal devices— branched or fenestrated (with further clarification for fenestrations for 1-2 arteries or 3 or more arteries). A non-fenestrated (standard) graft is a straight tube, with no arms or fenestrations. In the ICD-10-PCS code table 04V, this would be considered an intraluminal device.
In most cases, the physician will insert the original graft and check for seal and patency after placement. If a leak is detected, or the graft does not cover the defect completely, an aortic cuff may be deployed. Referring to the AHA Coding Clinic for ICD-10-CM and ICD-10-PCS 3Q 2016 page 39, graft extensions/aortic cuffs are not separately coded or reported.
Endovascular procedures have evolved in previous years and will continue to change as medical advancements are made. It is important for coders to do their research and keep up on these changes to select the most accurate codes.
Example of standard (A) and fenestrated (B) stent grafts
Robyn McCoart | Managing Auditor