Ask Dr. Z

Greetings,

This site has been my life line. Here I go with another AV fistula creation.
Local anesthetic was infiltrated along the previous surgical scar in the antecubital fossa. The skin incision was made overlying the previous incision and cautery was used to dissect down to the aneurysmal portion of the fistula. This segment of the fistula was mobilized circumferentially and the arteriovenous anastomosis was identified and dissected free. The fistula was doubly clamped and divided. The stump of the fistula, which was still attached to the vein, was oversewn with a GoreTex suture. This allowed the very small stump to act as a vein patch angioplasty to the brachial artery. The remaining segment of the aneurysmal portion of the vein was excised. The wound was then closed in layers with interrupted Vicryl in the deep tissue and a running Vicryl suture for the skin. Is this a revision of a fistula or ligation?

Graft Thrombecomy with revision

Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!

36901, 36907, 37248?

For the following, can codes 36901, 36907, and 37248 be billed? "Left brachiocephalic AV fistula with multiple areas of high-grade stenosis in upper and mid cephalic vein, extending into a previously placed metallic stent in shoulder region. Left basilic vein fistula fistulogram and central venogram with sequential balloon angioplasty of three stenoses. Two of the cephalic veins measure greater than 95%, and in-stent stenosis measures greater than 80% with 6 mm x 2 cm cutting balloon and 8 mm x 6 cm balloon."

Revision of leg bypass by ligation of the fistula in the bypass

Patient has swelling in the leg and has a leg bypass. Found to have three fistulae in the fem distal bypass. Fistulae were not thrombosed. The procedure: "Incision was made in the proximal thigh, and the fistula was dissected out and ligated with a clip. This was done in the same fashion to the two other fistulae." I'm not sure how to code this. It seems they are revising the bypass graft and not an AV fistula. Should I reported unlisted code 37799? Code 35903 doesn't seem correct because there is no infection. I'm undecided if 37607 would be correct. 35883 but there is no aneurysm. Do you have any suggestions?

36818

Hello,

For this case I have the angioplasty and fistulagram 75791. Don't know if I should charge the cephalic transposition 36818 because 2 incisions were not done to tunnel a vein, just subcu tissue was closed underneath to raise the vein. And don't know if a ligation counts. Does there have to be a know problem with colaterals and a seperate incision done to charge a ligation? I think a revision was not done to code that because in a revision there is a new anastomosis created with or without thrombectomy. Do I just charge the fistulagram and pta, or is there anything else appropriate to charge? Thanks,
Jenny



INDICATIONS: The patient is status post left brachiocephalic AV fistula. The vein is deep and ultrasound shows a central vein stenosis.

FINDINGS: The cephalic vein in the upper arm was nicely dilated. Fistulogram showed a high-grade stenosis at the cephalic vein just prior to the junction with the subclavian vein. Following angioplasty with a 5 mm cutting balloon, there was significant residual stenosis. Following angioplasty with a high-pressure 8 mm Dorado balloon, there was good flow through the fistula and the subclavian, innominate vein and superior vena cava were widely patent. Following transposition, there was an excellent palpable thrill through the arm.

PROCEDURE: The patient was identified and brought to the operating room. She was placed in the supine position. Her left arm was prepped and draped in standard fashion. An incision was made along the cephalic vein from the elbow to the upper portion of the upper arm and extended down through subcutaneous tissue. The cephalic vein was dissected circumferentially. Through a large side branch, a 5-French sheath was placed and then a fistulogram and central venogram was performed. The patient was given heparin and a wire was advanced across the cephalic vein stenosis. A 5 mm x 2 cm VascuTrack balloon was advanced to the area and angioplasty was performed. Follow-up angiogram showed residual stenosis and therefore, an 8 mm high-pressure balloon was advanced across the anastomosis and angioplasty was performed. Following angioplasty, there was good flow to the AV fistula. Subsequently the sheath was removed and the side branch oversewed with Prolene. The remainder of the side branches were ligated and divided and the cephalic vein was circumferentially dissected. Subsequently, the subcutaneous tissue plane was closed underneath AV fistula elevating it to a more superficial position. Subcutaneous flaps were created on either side and then the top portion of the wound was closed in layers.
 

Fistulogram with AVF or AVG revision

With the new 2017 dialysis circuit codes, when a revision or thrombectomy/revision is performed, can you code an extremity arteriogram or extremity venogram with the open procedures?

Would the be coded as a revision 36832 or can i code 37607 and 36901

Would this be coded as a revision with 36832, or can I code 37607 and 36901? "Under sterile and controlled conditions, the patient was prepped and draped in the usual sterile fashion. Micropuncture needle was then placed after lidocaine was infiltrated in the proximal part of the fistula. Fistulogram was obtained. It was noticed the patient had a patent arterial inflow and venous outflow with a large branch in the arm. The branch was localized. Small incision made over the branch. The branch was ligated with silk suture. Completion of fistulogram now showed a widely patent AV fistula with no flow in the accessory branch. The sheath was removed. Pressure was applied. Wounds were closed in a double layered fashion with skin reapproximated in a subcuticular fashion. Dermabond was applied, and patient left the operating room to be monitored in PACU."

Revision, Ligation, and Miller Procedure

I am trying to code a case, and my provider and I are in disagreement over my coding. He performed the following: 1. Repair of pseudoaneurysms x 2 AV fistulae, 2. Ligations saprophytic retrograde forearm cephalic vein AV fistula, 3. Miller procedure [minimally invasive limited ligation endovascular revision (4 mm angioplasty balloon), and 4. Fistulogram including central venogram. I coded this case with 36832, thinking that the ligations (37607) and the use of the balloon are included in the revision. I also did not code for the fistulogram (36147), thinking that this was a planned procedure and not the decision to treat. My provider thinks that he should get to code for all procedures. Am I correct in my thinking, or is he?

AVF Thrombectomy/Revision with PTA/Stent of the newly created anastomosis

I have a question regarding a thrombectomy/revision of a brachiocephalic AVF followed by PTA/stenting of the newly created anastomosis. "The surgeon performed a fistulogram, revealing occlusion/thrombus of the cephalic vein. He then removes the thrombus. Further occlusion was found near the shoulder. Incision was extended to dissect out more of the cephalic vein. A second incision was made in the axilla, and the basilic vein was dissected out. The basilic vein was then anastomosed to the cephalic vein. Another fistulogram was performed, revealing stenosis in the area of the end-to-end anastomosis. The surgeon then angioplastied and stented this." Would the correct coding for this be 36833 (thrombectomy/revision) and 36147 (fistulogram) only? I do not believe that I should code for the stenting (37238) due to it being done at the anastomosis just created. I was looking at it as an inflow/outflow type issue. Am I correct in my thinking?

Can we code a 36140, when brachial artery was accessed and introduced

A guidewire and a cath were introduced to the IVC and RA to SVC and eventaully LUE. The cath and wire were guided under fluoro through the AV fistula into the brachial artery. Cath was removed. The area of stenosis within the fistula was dilated with dorado balloon. The area of stenosis in the left subclavian vein and brachiocephalic vein was then treated and angioplasted with 12 mm balloon with good results. Can we code the 36140 (brachial artery access), 36902 (angioplasty of fistula), 37246 (subclavian vein through femoral access), and 36012 (cath placement from femoral to subcalvian access)?

Ligation of Basilic Vein

My doctors have started performing percutaneous AV fistula creations with the new Ellipsys device. The patient was brought back a month later after this creation, and a percutaneous angioplasty was performed of the fistula for stenosis, but in addition to this they did ligation of the basilica vein to increase the flow. Can I bill 37606, or do you advise revision 36832 with the angioplasty 36902?

Innominate venoplasty

Hello Dr. Z, can you please advise on how you would code the following? Pt came in with left brachiocephalic fistula with a hx of cephalic arch stenosis with a stent and central innominate stenosis where previous innominate PTA was required from a femoral approach because the wire would not pass from the AVF. RFV was cannulated. Angio of SVC and RA were normal and L innominate vein was not seen due to complete occlusion. The L innominate vein was selectively catheterized from the SVC. Angio of the central veins revealed a 90-100% stenosis of the innominate vein. Central venous angioplasty was carried out with <10% residual. An attempt was then made to pass a wire into the cephalic arch from the subclavian which was unsuccessful due to the presence of occlusion at the junction of the stent in the cephalic arch with the subclavian vein. Therefore, decision was made to cannulate the AVF. Left upper brachiocephalic fistula was cannulated and an angiogram was performed that showed 90% stenosis in the stent in the cephalic arch vein extending into the subclavian. Venous angioplasty was carried out showing 10% residual stenosis. Would the following codes be correct since there are 2 separate accesses? 36011, 75827-59, 35476, 75978 36147, 35476-59, 75978-59 ...or would the 36147 need to be changed to 75791? Thanks - a little confused.

AV graft revision followed by graft relocation

Please do NOT include any actual patient medical records with your question. Dr.Z, We have a patient with upper extremity autogenous AV graft came with graft malfunction. open thrombectomy and open PTA performed then residual stenosis noted and decided the graft is not amenable to revision. So created new AV fistula in the same extremity basillic vein to brachial artery. My question since they are not using the graft can we still use 36833 and 75791 for the graft procedures along with 36821? Please advice. Thanks

Debridement of AV Fistula

"For an area of infection in midpoint of AV fistula, incision was fashioned proximally over basilic vein and of distal basilic vein. The vein was dissected free. Once dissected free it was clamped proximally and distally at the arterial limb of basilic vein, divided, and oversewn with sutures. Then ligated the venous outflow tract to prevent back bleeding. Wound irrigated and closed in layers with sutures. Attention was turned to midpoint of fistula, where obvious infection was. An elliptical incision was fashioned and deepened down to the skin and subcutaneous tissue. The anterior wall of the fistula was completely resected involving the area of obvious infection. Was irrigated and sutured." Is this enough documentation to only use code 36832 as a fistula revision, or should this be reported with codes 37607 and 37799?

Question Revision of AV Fistual with venin Superficialization vs lipectomy

Would this be just one code 36832, or would a second or unlisted code be used for lipectomy? 

"1. Revision of right AV fistula by way of side branch ligation.

2. Subcutaneous fatty tissue excision overlying cephalic vein and forearm for vein superficialization.

PROCEDURE: After team timeout and performed sterile mapping with ultrasound of the fistula, found a large side branch coursing laterally marked this position. We also marked several positions along the forearm 4 counterincisions versus lipectomy of subcutaneous fat to bring the skin closer to the fistula. After team timeout, we performed a small incision overlying the side branch and ligated this with 3-0 silk sutures x2. We then turned our attention to the lipectomy with 2 transverse incision across and performed cylindrical removal of fatty tissue overlying the vein, we also lysed the vein fascia that was keeping it in place in the forearm, superficializing this and had a nasal groove of palpable cephalic vein afterwards. We had excellent hemostasis."

Dilation with fogarty balloon for fistula creation

The patient came for possible creation of AV graft. No prior mapping was done prior to arrival in OR. A venogram was performed via direct puncture. Venogram showed several areas of stenosis within the cephalic vein; however, decision was made to proceed with PTA of cephalic vein prior to creation of brachiocephalic fistula. Dissection was carried down to the cephalic vein and vessel exposed. A Fogarty balloon catheter was used to dilate the vein. Following successul angioplasty, the fistula creation was completed. Would it be appropriate to code the open PTA (35460) and the venogram (36005/75820) separately or are these considered part of the AV creation? Thanks in advance for your assistance.

Revascularization using distal inflow(RUDI)in LT upper arm w/GSV conduit

"The proximal left radial artery was used for inflow. It was heavily and circumferentially calcified, but was patent and did serve as effective inflow. The outflow was the first 2 cm of the left cephalic vein just upstream from the AV anastomosis. The cephalic vein fistula was dilated to greater than 1 cm and had excellent flow. The great saphenous vein was of good quality for a conduit and was harvested from the distal thigh and proximal calf and dilated to beyond 3 mm in diameter. Following the bypass, there was a good flow within the fistula and there was a weakly palpable thrill, and the bypass graft itself had an easily palpable thrill. The perianastomotic brachiocephalic arteriovenous fistula was ligated, and this was done between the arteriovenous anastomosis and the bypass graft anastomosis." The GSV was used as bypass from the radial artery to cephalic vein somewhat similar to a DRIL, but how would I code this?

AV Fistula Aneurysm Excision

What code should we use for AV fistula aneurysm excision? The graft wasn't revised at the end, and the transection wasn't quite at the anastomosis, so it wasn't like they repaired the native vessel's defect (so I guess I can't code it as a vessel repair). I know I wouldn't code it as revision with 36832. The doctor is coding it as 35011, but I don't agree. Please advise.

Pacemaker/AICD Pocket Revision

We are having trouble with how to code for a pocket revision when the pocket is not relocated. It is our understanding that the revision is bundled into the placement or replacement of the pacemaker/AICD. What do we code if all that is performed is a revision of the pocket?

TIPS revision with plasty outside portal system

Questioning procedures done outside the portal and hepatic veins during a TIPS revision - going with the same logic here when doing a thrombectomy in addition to revision - can we code cath placements along with angioplasties (or stent placements) if done in the splenic vein/SMV/IMV?

Carotid Arteriogram and Intervention

"A right brachiocephalic stent was placed via a right femoral approach. A selective catheter was placed in the right brachiocephalic with images. The catheter was then advanced through the right bracheocephalic, subclavian, and axillary in the right brachial artery. Images of the right brachiocephalic were obtained. The bilateral common carotids, bilateral subclavian, bilateral vertebral, and the right axillary were all read." Are 37218, 32222-59, and 36226-59 the codes to use for this procedure?

Amputated Toe Revision with Debridement

Would revision of an amputated toe with debridement of skin, subcutaneous, muscle and bone be 28810 again for the revision along with 11043, or is the debridement bundled?

Lead Revision Same Session as Initial Implant

Patient comes in for an ICD implant. They extubate the patient, and patient becomes violent and dislodges a lead. Patient consents to immediate lead revision. Patient is then re-prepped, placed back under anesthesia, and they fix the dislodged lead. They never left the OR. Do we capture the lead revision, or is it included in the initial implant since they did not leave the OR?

AV Shunt Intervention

Right arm fistula procedure. Normal access of the fistula and imaging (36147). There was a stenosis present in the innominate branch. Multiple attempts were made to cross this lesion from the inital access site. This was unsuccessful. The decision was made to obtain groin access and address the lesion from below. This attempt was successful. Now comes the question you've been waiting for... What on earth do I charge for the groin access and the venoplasty of the brachiocephalic? I did give a good ole college try...this is what I billed: 36147,36011, 35476 and 75978. i'm hoping that I wasn't too far off.

AV shunt intervention

Please do NOT include any actual patient medical records with your question. Dr. Dunn, The patient came in with AV fistula and revision was done with new Flixene graft was sewed to the old venous limb and also open thromebctomy performed. Shuntogram was done with evidence of innominate vein stenosis. This was treated with ballon angioplasty. Can we code thsi with 36832 75790 and 35460 and 75978? Dr. Z's vascular book 2009 page # 313 instruction #9 refers PTA is included within the graft (anastomosis to anastomosis) when performed with revision/thrombectomy. Is central vein stenosis can be coded separate since stenosis is not anastomosis to anastomosis? Please clarify. Thanks

TIPS revision - 37183

A patient underwent TIPS revision. The last lines of the procedure report are: "Follow-up portogram demonstrated brisk flow through the TIPS shunt. The portal pressure was measured at 22 mmHG. The right atrial pressure was measured at 10 mmHG. An 8 French sheath was exchanged for a triple lumen catheter under fluoroscopic control. The tip was positioned in the right atrium. The catheter was sutured in place. The patient tolerated the procedure and left the department." I'm not sure I understand why a catheter was left in the atrium. Is this a normal part of a TIPS/TIPS revision? If not, how would this be coded?

Reportable as AVF Ligation or Revision?

Is this reportable as AVF ligation or revision? "Post-op complication of AVF revision (aneurysm resection and angioplasty). Post-op diagnosis: Wound hematoma, ANASTOMOTIC BREAKDOWN. Clinical Indications: Bleeding fistula wound. Description of procedure: Prevail prep was used, and the right arm was isolated as a sterile field. The previous incision was opened by removing the staples and cutting the vicryl sutures. Blood immediately exploded out of the incision, and clot and blood were evacuated from the wound and control was obtained first by arterial pressure and then rapidly both the venous and arterial sides were controlled with vascular clamps. The arterial side was doubly ligated with silk and over sewn with a 4-0 prolene. The venous side was doubly ligated with silk. The wound was irrigated with the pulse irrigator and closed with nylon and staples. Findings: Completely disrupted anastomosis."

AV fistula angioplasty and thrombus removal via two separate access sites

"We started the procedure by locating the left arm cephalic vein fistula. Access was achieved, and a 5 French was advanced without difficulty. Left brachiocephalic AV fistula angiogram and central venogram done, and a recurrent stenosis at left cephalic arch was noted and crossed with torque wire. Balloon angioplasty of cephalic arch with 8 x 40 mm Charger balloon (36902). Completion angio shows excellent flow via cephalic arch without residual stenosis. We then noticed presence of chronic clot adherent to proximal cephalic vein at aneurysmal segment without complete occlusion. Another access was done with micro puncture kit and proximal location and upsized to 8 French. We utilized an 8 French LIMA guide for suction thrombectomy and were able to remove some clot from cephalic vein. Completion angio shows some residual clot at cephalic vein without any flow compromise. Repeat duplex US shows residual clot, which was not able to be removed with suction catheter." For the thombectomy, since it is being done via a separate access site, would this be 36905-59 or 37187-59?

Thrombectomy

"Open thrombectomy/revision of AV fistula in upper arm. Femoral vein was tunneled (U loop) up from the thigh, across the abdominal wall up to the deltopectoral region, and was bridged with Gore-Tex." Would this simply be 36833?

Carotid Angiogram

I'm new to carotid angiogram and wondering which CPT code (36222 or 36223) is correct for this case. 

"Catheter advanced to the ascending aorta to right brachiocephalic then right common carotid artery engaged. Multiple views of right carotid system then catheter pulled back to brachiocephalic. A brachiocephalic angiogram performed. The catheter pulled back and engage left subclavian. The catheter used to engage the left common carotid artery with multiple views. Finding state left carotid artery is normal and bifurcates into the internal and external carotid artery. External carotid normal and internal reveals 90% focal stenosis."

36832 and Skin Excision

"I marked out the two skin ulcerations using elliptical incisions. I dissected down to subcutaneous tissue using electrocautery. I was very careful to make sure to not enter into the wall of the fistula. I dissected on both sides. Once I had adequately mobilized, I then took a sharp 15 blade and excised the skin ulceration overlying the anterior portion of the fistula. Once this was done, I irrigated thoroughly and inspected the wall of the aneurysm which appeared to be intact. It was not weak and developed. Therefore, I do not feel that an aneurysmorrhaphy or plication was necessary at this time." Will this still be considered a revision of AV graft (36832)? Perhaps with a -52 modifier showing reduced procedure?

Two access sites to reach one stenosis of fistula

Right arm brachiocephalic fistula. RT common femoral vein is accessed with US guidance, and image saved to PACS. Stenosis in mid-cephalic vein is reached and treated with angioplasty. Then, “due to delivery sheath and stent delivery system length discrepancies, unable to safely stent the lesion from the right femoral approach.” Second access is made in upper arm cephalic vein and then stent is placed across the same stenosis. My codes: 76937, 36903, and 36012-XS for the remote access. How did I do?

Cardiology - revision lead VS complete pacer replacement

I have a case where the cardiologist put in a dual chamber pacemaker (33208-KX). The following day the patient had chest pain and palpitations, so the note says the patient will have revision of pacemaker and leads. I am not sure how to code this revision. Here is the revision report: "An incision was made inferior to clavicle. Dissection was carried down to myofascial plane and then continued caudally to form a pocket for the generator. The atrial lead was placed in the atrial appendage. Ventricular lead was placed in right ventricular septum. Suture was used to secure the new leads. The leads were pushed in about another 2-3 cm to provide more slack. Thresholds and impedance were excellent. New generator was securely attached to the leads and placed in pocket." Would this be just a revision (33215), or would you code this as removal and replacement of the entire system?

Neuroplasty During Fistula Revision

I'm looking for guidance on the following procedure since we see it every so often with AV fistula cases. "...Once the vein was completely mobilized, it was it was examined and found to have good flow. The median antecubital nerve was noted to split evenly at the mid to distal aspect of the basilic vein, and, instead of dividing one of the branches, I elected to perform a neuroplasty to split the nerve fibers longitudinally all the way to the axilla. This was done painstakingly with fine scissors to split the perineurium and then the nerve fibers with gentle counter traction. After this was performed, the vein was brought up between the two branches without difficulty."

Coronary Sinus Venogram with Embolization of Fistula from LAD to Left Ventricle

A coronary sinus catheter is placed via left subclavian vein for a CS venogram to locate site of a fistula from distal LAD artery to what appeared to be CS, found to actually be the left ventricle. Catheter was placed into the distal LAD, traversing the fistula to deploy coils and close off the fistula. Verified results with final angiography. We reported codes 37204, 93454, 75894, and 75898. How would the coronary sinus venogram be coded?

36819 vs 36832

Patient has pre-existing brachiocephalic av fistula which now has aneurysms. Physician resects the cephalic vein from where it was anastomosed to the brachial artery. A subcutaneous tunnel was then made distal to the antecubital fossa

with the distal cephalic vein brought in juxtaposition to the previous brachial artery anastomosis. The anastomotic segment was cleared to allow for end-to-side anastomosis to be completed from the brachial artery to the cephalic vein. This was then completed.

due to lack of significant palpable thrill, in order to better provide outflow from this retrograde system, incision was made overlying the basilic vein in the forearm. Subcutaneous tunnel was made and the distended basilic vein was passed through. Distal basilic vein was transposed and juxtaposed to the cephalic vein. A venotomy was made within the cephalic vein and the basilic vein spatulated to accommodate an end-to-side anastomosis.

Since original anastomotic site used, is this revision (36832) or new creation (36819)?

Exc of AVF pseudoaneurysm and infected stent

Patient has a brachiocephalic AVF with a pseudoaneurysm and infected stent. The pseudoaneurysm is opened, hematoma expressed, and sac debrided. The remaining cuff of vein is ligated. Another incision is made, and cephalic vein/stent is freed up proximally and distally and removed in entirety. Would this be a revision of an AVF since it all occurs in the AVF? How would I code for the excision of the stent/cephalic vein in the AVF?

Dear Dr. Z, This is a procedure we've been unable to locate any coding advice on thus far: CLINICAL INFO: ESRD w/left upper arm fistula that is difficult to cannulate PROCEDURE: Skin overlying the Left Upper Arm fistula was prepped/draped...Ultrasound was used to mark the course of the fistula on the skin. Multiple sterile OR markers were used. Then, 22 gauge needle was used to abraid the skin through the ink. This resulted in small tattoo dots along the course of both sides of the fistula. IMPRESSION: Successful marking of he course of a left upper arm fistula. We have considered Unlisted Skin 17999 (APC 12, SI "T") with 76942 (SI "N"), but also wonder about Unlistd Vasc. 37999 and/or Unlisted Ultrasound 76999. Your opinion and advice would be much appreciated! Thank you in advance. It was great meeting you at our facility in November!

IVUS in AV Shunt

Procedure: femoral AV fistula, fistulogram, stents outside fistula, upper extremity venogram, and IVUS (several vessels including fistula). Can IVUS inside the fistula be billed?

Fluoroscopy in Surgery

How should fluoroscopy use with angiography in surgery be coded for use during open lower extremity revascularization? AAA repair? A/V fistula revision? Should angiography codes be used or 76000, 76001?

Occlusion of Enterocutaneous Fistula Track

"Under fluoroscopic guidance, access was obtained to the patient's fistula tract. The catheter was then placed within the bowel, and contrast injection confirmed position of the catheter within the bowel. Following this, flossing of the fistula tract was carried out. Following this, a bio design enterocutaneous fistula plug was introduced into the colon at the site of the fistula with the distal end of the device deployed within bowel in the plug traversing the fistula tract." Are codes 20500 and 76080 appropriate?

AV Dialysis Shunt, ICD-10-CM

I realize that, for purposes of coding CPT procedures, an AV dialysis shunt (fistula or graft) is defined as beginning at the arterial anastomosis and extending to the right atrium. Procedures performed in any of those veins are considered shunt procedures. Based upon that definition I have assumed that problems with those same veins, all the way to the right atrium, would be reported with shunt diagnosis codes in ICD-10-CM. For example: I would use the shunt diagnosis code T82.868A for thrombus of the brachiocephalic vein in one of these patients. However, my auditor would use the regular venous thrombus code I82.290. Who is right, and where does the fistula or graft end and the vein begin for ICD-10 diagnosis coding?

Diagnostic RT brachiocephalic venogram

How would you code a right vrachiocephalic venogram?

"Access is on the right vasilic vein with catheterization of the right brachiocephalic vein. Findings: Patent RT BCV and SVC stent with no evidence of stenosis."

Would I code this as 36005-RT and 75820, or 75827?

Can we code this as 36832 and 36907

Our coders are struggling to agree on how to code this procedure. We cannot come to an agreement of the best suited codes to use. "Patient has left brachiocephalic fistula that has two aneurysms that developed two ulcerations. Physician performed incisions in vertical fashion, excising the aneurysm and excessive skin on two aneurysmatic area, one above the antecubital area and the other in the distal upper arm. Incision taken down to the dilated aneurysmatic vein. Vein entered, skin and ulcer were excised in both lesions. Aneurysmatic vein wall then excised so about 1 cm of conduit on each incision. Closed venotomies on each incision. Clamp released for flow thru fistula. Then punctured access in mid upper arm, placed sheath, obtained shuntogram which showed the cephalic arch had a stent and vein was present. Superior vena cava was patent but innominate vein 80% stenosed. Angioplasty performed; sheath removed site closed."

Ligation of a Acquired AV Fistula

How would you code this? The office wants 37607 (ligation of angioaccess of AV fistula), but the description of that code says of a created AV Fistula, and on this surgery it is not surgically created. Would this be unlisted code?

DX: Acquired AV fistula, not surgically created (HCC) [I77.0]

Procedure(s):

LIGATION, AV FISTULA RIGHT WRIST - Wound Class: Clean

An incision was made over the left radial artery. We traced up and down the artery and found a connection between the radial artery and radial vein. This led to multiple branches. We went around the fistula and all the branches as well using a right angle and tied it off with a 4-0 silk. The fistula was also tied off with 2 4-0 silk sutures. We were unable to palpate the thrill and she had an excellent radial pulse. Satisfied with this we irrigated the wound and closed it in multiple layers.

Multiple Angiograms

Please help me code the following: "Reason - asymmetric arm blood pressures, abnormal stress test, leg pain, abnormal lower ext arterial Doppler. Performed: Left heart cath coronary angio selective right brachiocephalic angiogram selective left subclavian angiogram infrarenal and aortoiliac angiogram with runoff selective right external iliac angiogram selective left external iliac angiogram unsuccessful pci attempted of occluded left common iliac Accessed both left and right groins, due to left iliac total occlusion. Results: Patent subclavian and brachiocephalic Distal aortoiliac disease." Please help me code the above procedures and include what dx code could be used for the asymmetric arm blood pressures.

BI VENTRICULAR AICD POCKET REVISION

I know that there is no longer a CPT for revision, so I was wondering what would be the best way to code this procedure. "Incision made over device and device removed. Leads disconnected from device, and pocket revision performed to free the previously placed leads. Leads were then reconnected to generator, irrigation of pocket performed, and generator placed back in pocket. Pocket closed and patient sent to recovery in good condition." Would this be billed as 33215 or unlisted CPT?

Revision or Ligation and Thrombectomy

"Patient presented with massively dilated brachiocephalic AVF with discomfort. The left upper extremity of the patient was prepped. A skin incision one centimeter above the cubital fossa was made and deepened into the subcutaneous fat using electrocautery. After careful isolation of the arterial inflow to the aneurysm, the vein was encircled with vessel loop for traction. The inflow was ligated with 1-0 ethibond transfixion suture. An elliptical incision was made over the aneurysm, the outflow was also ligated with 1-0 ethibond, and aneurysmal sac was opened and partially excised. Doppler signal of the brachial artery was verified after skin closure, and radial pulses were still palpable." Should I report codes 37607 and 36831? Or 36833?

Revision Catheter

What code(s) would be appropriate for revision of peritoneal dialysis catheter, open?

Coil Embolization and Stenting of Fistula Between Carotid Artery and Internal Jugular

"A patient has a left internal jugular vein to left common carotid artery fistula. A stent was placed in the left jugular vein, spanning the insertion of the fistula into the vein (via a left common femoral vein access). Coil embolization was placed in the distal aspect of the fistula at the jugular communication via the left common carotid artery (by right common femoral access)." Will I be able to report codes 61624 (36223, 75894, and 75898) and 37238 (36011) for the above procedure?