05QC4ZZ
Repair Basilic Vein, Left to No Qualifier with No Device, Percutaneous Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 5 Upper Veins |
| Operation | Q Repair |
| Body Part | C Basilic Vein, Left |
| Approach | 4 Percutaneous Endoscopic |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Procedure Overview
This family covers surgical repair of the veins that drain the arms, shoulders, chest wall, and skull, including the subclavian, axillary, brachial, basilic, cephalic, hand, azygos, hemiazygos, innominate, and intracranial veins. Repair is used when a vein has been cut, torn, punctured, or has developed a leak or fistula that needs to be closed by suturing or other direct means, and no other, more specific procedure (like replacing the vein with a graft or widening it with a stent) applies. Typical scenarios include a vein injured during trauma, a laceration from a misplaced central line or dialysis catheter, or bleeding discovered during an unrelated operation.
Because these veins carry blood back toward the heart at relatively low pressure, many injuries can be managed with direct suture repair rather than a graft, which is why this family exists as a distinct, catch-all restorative option. Patients undergoing this procedure are typically being treated for an acute injury or a complication of another medical intervention rather than a planned elective condition.
Anatomy & Axis Detail
Basilic Vein, Left
The left basilic vein, a superficial channel along the medial aspect of the forearm and arm, is favored for arteriovenous fistula construction and PICC placement because of its size, straight course, and relatively deep position near the brachial vessels once it pierces the fascia proximally. Repair is performed after injury from venipuncture, trauma, or complications of fistula maturation, including aneurysmal degeneration or stenosis at a prior anastomotic or access site. Since many dialysis patients favor the nondominant left arm for access, basilic vein repair on this side often occurs in the context of preserving or salvaging an existing fistula rather than treating acute trauma.
Approach: Percutaneous Endoscopic
Percutaneous Endoscopic combines a puncture through skin or mucous membrane with insertion of an endoscope to visualize the procedure internally, as in laparoscopic cholecystectomy. It is distinguished from plain Percutaneous by the presence of scope-guided visualization, and from Via Natural or Artificial Opening Endoscopic by its route being a new puncture rather than an existing orifice or stoma.
Coding & Documentation
Repair is assigned only when documentation shows the surgeon restored the vein's own tissue to its normal structure - for example, "venorrhaphy," "suture repair of laceration," or "closure of iatrogenic venous injury" - without introducing graft material or performing a more specific root operation. The operative note should identify the exact vein involved (since Upper Veins has separate body part values for each named vessel) and describe the technique used to close the defect.
The most common coding error is defaulting to Repair whenever a vein procedure doesn't obviously fit elsewhere, when in fact a more specific root operation is required if the physician actually excised tissue, controlled bleeding through ligation, or patched the vessel with graft material. Coders also miscode the body part by using a generic "upper vein" value instead of the specific named vessel documented, or they miss that Repair is inappropriate when the vein was ligated and divided rather than reconstructed.