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Management of extensive atheroma or calcification of the ascending thoracic aorta remains a challenge. Off-pump surgeons have pioneered the anaortic no-touch technique using single or bilateral ITA composite grafts ( Marni Leather Multistrap Sandals clearance wiki kWM5Bh
- 17 ) ( Figure 5 ). A popular technique involves grafting the in situ LITA to the LAD and joining the free RITA or RA as a Y graft to the LITA for distal sequential anastomoses to the branches of the circumflex and RCAs. This has been used successfully by several authors ( Lanvin Suede Embellished Pumps low cost sale online sale enjoy big discount for sale 7o5XsGe
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). There is a potential risk of failure in using a single inflow although this is believed to have adequate flow reserve. There is also the potential for a steal phenomenon as well as a reduction in patency of the distal LITA-LAD segment has been reported, which is regarded as a major concern by our group. When anaortic OPCAB is undertaken, we prefer to use bilateral in situ ITAs to graft the left circulation, with a RA as Y graft from the circumflex graft to reach around the lateral wall to the posterior descending artery. Alternatively we have used an RA graft to the PDA from the aorta using the ingenious Heartstring device (Maquet Getinge Group, San Jose, California, USA) for a clampless proximal anastomosis on the aorta. The use of three in situ arterial conduits by addition of the right gastroepiploic graft to the posterior descending coronary artery is another more technically demanding option ( eastbay for sale Aquazzura Christy Metallic Flats low price cheap online buy cheap brand new unisex mB9kg
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Figure 4 Total arterial revascularization in an 80 year-old patient. A single LITA is grafted to the LAD; bilateral RA grafts are sutured to the circumflex and RCAs
Figure 5 Off-pump anaortic total arterial reconstruction using a composite RITA Y-graft arising from the LITA graft
Figure 6 The right gastroepiploic artery is passed anterior to the stomach through a window in the diaphragm to be anastomosed to the posterior descending coronary artery

Sequential grafting ( Lanvin Tweed Platform Sandals wholesale price sale big discount fJutLG3tJw
), composite Y-grafts ( Hart Schaffner Marx AUGUSTA Le clearance best place discount clearance QgjK3amXnS
) and extension grafts ( Figure 9 ) are ancillary procedures allowing additional target artery anastomoses by the efficient use of an arterial conduit. They minimize peripheral incisions for conduit harvesting and may even allow six distal anastomoses in diffuse disease. The LITA-RITA Y-graft technique of Calafiore and Hwang allows complete revascularization based on two intra-thoracic conduits only ( 18 , Jerome C Rousseau Ponyhair Slingback Sandals free shipping 2014 new footaction online buy cheap for sale nI4YFGNub
) ( Figure 10 ).

Figure 7 Sequential grafting. A. Longitudinal in-parallel side-to-side anastomosis between the LITA and RA or segment of RITA; B. Oblique and diamond-shaped anastomoses for sequential grafting when there is a short length of conduit available
Figure 8 Composite T- or Y-grafts. These angled composite grafts are commonly used on the left system to enhance the number of distal anastomoses
Figure 9 An oblique end-to-end anastomosis to minimize stricture. This technique is employed to provide extra RITA length for distal anastomoses on the right side
Figure 10 Complete arterial revascularization based on two composite internal thoracic artery conduits in a patient with extensive aortic calcification

Current patency data confirm that ITA grafts function into the third decade with freedom from failure in over 80%. Most of the later data relates to the widely recognized outstanding results from the LITAs. Tatoulis recently published results of a series of 991 right ITA grafts from 5,766 patients. There was no significant difference between the RITA and the LITA when grafted to the LAD (96.5% vs . 94.5%) and similar patencies between RITAs and LITAs were found when grafted to the circumflex system (90.5% and 88.5% respectively). When grafted to the RCA, the in situ RITA results were less satisfactory, but arterial grafts were far superior to SVGs ( clearance get to buy Bottega Veneta Vintage Intrecciato Leather Pumps online sale buy cheap supply F05aS6w
). These data support the belief that the RITA behaves in a similar way to the LITA and that more effort should be made by surgeons to explore the potential benefits of the RITA.

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Monday Dec 04, 2017

One of the most frequent complaints I hear from physicians is about the work done before and after an office visit, whether done the same day or another day. They say it is frustrating to spend so much time on those activities and receive no payment.

The Centers for Medicare Medicaid Services (CMS) actually provided a bit of help in January although some practices may still not know about it. CMS created a set of CPT codes that allows physicians, physician assistants, and nurse practitioners to bill for non-face-to-face prolonged care of patients. Although any specialty physician can use these codes, CMS framed the change as a way to support primary care.

The codes are 99358 (Prolonged evaluation and management (E/M) service before and/or after direct patient care, first hour) and + 99359 (each additional 30 minutes; list separately in addition to code for prolonged service).

This service must be related to a face-to-face E/M code, and it could be performed on the same day as the face-to-face service or on a prior or subsequent day. The 99358 code is not an add-on code so could be billed as the only service. The 99359 code, on the other hand, is an add-on code to the first and must be billed on the same day as 99358. The code reflects time spent on care by the physician, NP, or PA, and does not cover office staff time. These codes are not used for typical pre- and post-visit work, such as reviewing your record or documentation after the visit.

The codes follow CPT time rules. The physician, NP, or PA must spend more than half of the required one hour to report the codes. So, for example, you would bill 99358 for visits of 30-74 minutes. But you would bill 99358 and +99359 for a visit of 75 minutes or more, with +99359 for each additional 30-minute increment.

These codes could be used for extensive record review or coordination of care. Make sure to document the time of the service and the work that was performed. For example, “I spent 45 minutes today reviewing Ms. Smith’s old records, prior to her visit.”

The national average reimbursement for 99358 is $113 with $55 reimbursed for each unit of 99359. That amount makes it worthwhile for most family physicians to submit claims for this service.

— Betsy Nicoletti, a Massachusetts-based coding and billing consultant

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