Ask Dr. Z

Pocket Revision for an ICD

Is there a code that can be utilized to report a pocket revision for an ICD? Patient was having pain, so the physician enlarged the pocket and anchored the generator lower in the pocket. This is the only procedure done.

Pocket revision

We had a plastic surgeon come to the Lab to perform a subfascial/submammary pocket. The ICD was explanted from one area and moved to this new pocket. I am thinking this is more than a pocket revision code...? 15734,but not sure. What do you think?

Scab Removal off the AV Fistula

"Patient has a scab over the AV fistula, and the physician is concerned the patient might start bleeding. An eliptical incision was made over the area of the scab and carried down through the skin and subcutaneous layers. The scab was lifted off the fistula; the underlying fistula, however, was intact and did not need any intervention. He then simply freshened up the edges of the fistula. He went ahead and undermined both the medial and lateral flaps of skin and then began closing the wound using layers. Deep layer was closed using 3-0 vicryl; skin was closed using a 4-0 monocryl." I'm not sure of the proceudure and diagnosis coding. In his pre- and post-op dx, the physician mentioned arteriovenous fistula malfunction. I'm not sure if this is considered a fistula malfunction. Please advise.

Evaluation of AV Fistula/Graft

Access left radial artery with micropuncture, left arm AV fistulogram with interpretation. This is a radiocephalic fistula. Can code 36120 be used for direct radial artery puncture for evaluation of the fistula, or is that code only for the brachial artery (36120, 75791)? When a doctor uses the word "micropuncture", does this always mean percutaneous? First example: "Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath." Second example: "We then accessed the graft with a micropuncture sheath near the arterial limb towards the venous outflow."

Excision of AVF

We have a patient who had an ulcerated left AVF. We ligated the fistula, and she had further issues with the wound healing after the ligation surgery. She came in for her new access in the right arm and had foul smelling drainage from the open wound in the left arm. Decision was made to debride the wound and excise the portion of the AVF that contained the infected hematoma and to create the new AVF in the right arm. We did the AVF creation in the right upper extremity. My concern is how to code the excision/debridement. This was an AVF, not graft, so I don’t feel as though code 35903 would be accurate. I also don’t feel as though a debridement code or 10180 would cover the amount of work actually done. I don’t think I like a revision code either, because they don’t intend on using the AVF. I would appreciate your input!

NCCI edit for 93990

If there is an NCCI edit for 93990, and we have to remove the 93990... can we report code 93931 instead? "Reason for Study: Left arm radial-cephalic vein fistula. Interpretation Summary: The left radiocephalic AVF is patent with only mild stenosis at a valve cusp in the proximal forearm. Volume flow is excellent. Procedure: A fistula duplex exam was performed on the left. Left arm radial-cephalic vein fistula. Left Arm: Left radial artery Doppler waveform shows low resistance. The fistula is patent. There is a mild (422ed263cm/sec) stenosis proximal forearm cephalic vein cusp. The volume flow is1224cc/min."

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

93990

Without specific documentation, like "color Doppler", does the below documentation of the measurements meet duplex criteria for CPT 93990? "LT ARM AVF  ** FINDINGS **: Inflow Artery: 1.66 M/s Anastomosis: 2.26 M/s Prox Fistula: Depth/Diameter: 4.7/5.6 Mm Velocity: 3.70 M/s Mid Fistula: Depth/Diameter: 8.3/6.6mm Velocity: 221 Distal Fistula: Depth/Diameter: 10.0/5.9 Mm Velocity: 1.95 M/s Anastomosis: not a graft outflow Vein: 1.65 M/s  ** IMPRESSION **: Upper Extremity Hemodialysis fistula imaged for Vascular Surgeon.   Patent LEFT upper extremity first stage brachiobasilic AV fistula without stenosis."

Device Pocket Revision

How would a pacemaker pocket revision be coded when the pocket is not relocated? Since code 33222 is now only for relocation of the pocket, I am not sure how this should be coded. "The patient had a pocket revision due to painful movement of the pacemaker within the pocket. The device was removed from the capsule, and the capsule was enlarged laterally and superiorly. A Parsonnet pouch was placed over the device and excess leads. The device within the pouch was placed back in the pocket and fixed at 5 points to the underlying pectoral muscle a few centimeters lateral and superior to the original position."

G0365

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

Brachial artery access into Dialysis Fistula

I'm not sure how to code this fistula study since the brachial artery was used to access the fistula. "Retrograde access of the fistula was performed and imaging completed. Multiple attempts were made to traverse the critical proximal stenosis of the fistula w/o success. Subsequently access of the brachial artery near the antecubital fossa in an antegrade fashion to access the outflow venous fistula from an ante grade direction. A sheath was placed into the brachial artery. After placement of the brachial artery sheath a glidewire was manipulated down the forearm artery across the arterial anastomosis into the fistula. Using Roadmap technique, the proximal stenosis was successfully traversed and ultimately antiplastied." Would the coding be 36120 and 36902?

Synechiae/Disobliteration/Endophlebectomy

Per the Journal of Vascular Surgery, May 2004, "Partial obstruction of post-thrombotic veins caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen of a vein." We did a venous disobliteration and PTA of the iliofemoral segment of vein, with a CorMatrix patch angioplasty of the left common femoral vein, followed by construction of a left femoral vein to left common femoral artery arteriovenous fistula. This fistula was to preserve blood flow, not a dialysis fistula. How would you code this?

DRIL of lower extremity

We have a patient who has a lower extremity arteriovenous graft (popliteal artery to common femoral vein) that is used for dialysis, as patient has no viable options left on upper extremity. The patient developed severe extremity pain suggesting of steal syndrome, therefore a DRIL procedure was done on the lower extremity. As code 36838 specifies upper extremity, would the coding be 36832 (a revision to AV fistula), or would this be reported with an unlisted code?

Open Thrombectomy

Patient was in for open thrombectomy of AV fistula followed by angioplasty and stent insertion. Is there an additional code for the stent placement if it was done via open approach? Would code 36903 in addition to 36831 be appropriate? If not, what code do we report, if any? “An incision was made in the medial side of the arm where the patient had an arterial revision in the last week, and then a graftotomy was made in this position and a #4 Fogarty was used to thrombectomize both the arterial and venous limbs. Once this was done, a 7 French introducer sheath was placed into the graft in the venous limb, and a fistulogram was performed. There was a very tight stenosis at the AV graft AV fistula anastomosis and at the venous anastomosis. So, an 8 x 5 cm Viabahn stent was then deployed at both locations. Then, an 8 x 4 balloon was placed over the wire in this position and angioplastied several times to 26 atmospheres."

Dr Z, what is the appropriate CPT code for mobilization or superficilization of an AV fistula for dialysis. The surgeon brings the pt to the OR and elevates or brings the fistula closer to the skin surface for better access. They do not do anything to the fistula itself. I've been using 37799. Thank you JM

Select angios w/o narrative

What is compliant to code on selective angios w/o narrative dictated, i.e. "selective" indicates the vessel catheterized?

Dict:

Procedures Performed - Aortic arch angiogram. Selective brachiocephalic and subclavian angiogram

RCFA access

Findings: Heavily calcified aortic arch with severe atherosclerosis and a 30% aortic narrowing

Heavily calcified occlusion of the left subclavian artery with retrograde filling via the vertebral to the axillary artery

Moderate heavily calcified ostial brachiocephalic stenosis

Patent left carotid artery

36225, 75710-LT, 36215-XS?

Excision of AV Fistula

"Our patient had an infected chronic thrombus and aneurysm in her left upper extremity AV fistula. She was taken to the OR for excision. A duplex Doppler was used to measure the brachial artery flow and to check the outflow vein to decide on the area of disconnection and division. Images were retained. The fistula was excised by disconnecting it from the brachial artery, followed by anastomosis and repair of the brachial artery. The aneurysm, chronic thrombus, and overlying skin were excised in the needle access segment of the fistula. The cut end of the outflow vein was repaired at the level of the shoulder. The 6 x 4 cm skin defect was closed with flaps." Can any imaging be billed? How do we code for the excision of the fistula?

Could you help me? Would this be coded 36247,35475 and 75962 or 36247,35475, 75978(angioplasty for the arterial side of the fistula)AND 36247 59,7507859 (angioplasty of the brachial artery)? The radiologist refuses to say native brachial artery. He also does not say how far above the anastomosis. I was audited a few weeks ago and now I am second guessing myself(I work for the hospital).I have your coding book and love it. Thank you. Frances () AVS(FISTULOGRAM) PROCEDURE - INDICATIONS: Poor blood flow at dialysis and pulling clots. RESULT: ARTERIAL VENOUS FISTULA: Technique: Informed consent was obtained from the patient. Access was gained into both the arterial venous side of the patient's arterial venous fistula. Contrast was then injected. This was then followed by angioplasty at the arterial side of the fistula with a 5 mm. balloon. The brachial artery was also angioplastied with a 5 mm. balloon. The catheters and sutures were then removed. Hemostasis was obtained. Complications: No immediate complications were encountered. Medications: 1% local Lidocaine to the skin, Versed and Fentanyl for conscious sedation. Approach: Fluoroscopy. Physical status: ASA-4 Findings: The patient demonstrates a brachiobasilic fistula. There is narrowing involving the arterial side of the fistula in the range of 80% to 90% with some mild aneurysmal formation. This was successfully treated with angioplasty with improved patency. There was an area of irregularity involving the brachial artery above the anastomosis which was angioplastied. This resolved after this. There is an indwelling stent involving the outflow venous structure. Just some minimal narrowing in this was identified but this was not treated because this was in the range of 20% to 30%. There is also an indwelling stent within the right brachiocephalic vein into the superior vena cava. This appears patent. IMPRESSION: Successful arterial venous fistulogram with arterial side angioplasty and brachial artery angioplasty for abnormalities.
 

36147

Does code 36147 include selective venography of a collateral vein to assess for surgical turndown option? Or should I use codes 75791, 36011? "Patient has left upper brachial artery to cephalic vein fistula. Lower fistula is punctured and contrast injected, demonstrating decent flow through the fistula which is well-dilated peripherally. There is one focal area of mild narrowing in the mid fistula which is not felt to be flow limiting. There is diffuse stenosis of the cephalic arch with collateral vessels draining to the axillosubclavian veins. Left-sided central veins are widely patent, as is SVC. Next a glidewire is advanced centrally and a sheath placed. A glide catheter was used to selectively catheterize the left arm basilic vein. Diagnostic venogram was performed at the same time that the fistula imaging was performed to assess the feasibility of surgical turndown option. This showed the basilic vein to be a large caliber vessel comparable in diameter to the fistula. It was widely patent through its transition to the axillosubclavian vein."

Poor Maturing Fistula

I need a little guidance. Patient underwent fistulogram a week ago, and the MD recanalized and angioplastied the cephalic vein. Vein was not matured, and patient returns for repeat fistulogram and balloon maturation of fistula. "Procedure: Left renal cephalic fistula accessed, and micropuncture needle placed into fistula. Fistulogram was performed (36147). Cephalic vein measured 5 mm. It was patent and much improved from previous procedure. The physician angioplastied antecubital fossa to wrist to 7 mm (35476, 75978-26)." Is this correct, and does catheter placement always get coded with the venoplasty?

37211 and 37212 in AV fistula

"Patient with thrombosed AV fistula was taken to Interventional Radiology. Ultrasound revealed a 5 cm segment of thrombus extending centrally from the arterial anastomosis. Venous limb of fistula is patent. Access was obtained directed towards arterial anastomosis, and infusion catheter was advanced to arterial anastomosis. tPA was pulsed into fistula under fluoro guidance, and tPA drip was started. Patient to return in one day for follow-up fistulogram. Impression: Successful initiation of thrombolysis therapy left upper extremity dialysis fistula." The department charged codes 37211 and 37212. Should this actually be reported with code 37211 only? In other cases by this radiologist he uses two infusion catheters in opposite directions, but in this case he uses only one. In an AV fistula, is it even appropriate to charge both codes 37211 and 37212 if two infusion catheters are used, one directed to the vein side and one to the arterial side?

Fistulagram with Retrograde Access via Left IJ

How would an AV fistula case be coded with initial fistulogram (36147) performed from fistula? But to treat the arterial stenosis access was obtained via the left IJ, catheter advanced to left subclavian, and then glidewire was used to access the fistula retrograde and catheter brought across the arterial anastomosis. The arterial anastomosis and juxta arterial outflow were treated with angioplasty along with the remainder of the venous outflow. The graft is only described as a left UE bovine graft. I am stumped on coding for the retrograde access from the IJ approach and would appreciate your guidance. 

AV Fistula/Graft

Where is the "inflow" segment of the AV fistula? When treated with PTA, is it venous or arterial? Also, where is the "access" segment of AV fistula?

Hi Dr. Z, I've gotten better at coding the peripherals since you were here in January. This is the first AV fistula procedure that's been done in our cath lab and with the G codes being deleted, I'm hoping you can help me. Here's what the doctor documented: The patient is a 34 year old male with the following indications: abnormal fistula duplex, failure to mature AV fistula . The patient has the following Comorbidities/Risk Factors: Hypertension, On Dialysis, Renal Failure Prior to PCI. DIAGNOSTIC PERIPHERAL VASCULAR PROCEDURE Under ultrasound and fluoroscopic guidance, the left AV fistula was locally anesthetized and accessed with a micro puncture needle using the standard percutaneous technique. After injection and visualization of the brachial AV fistula anastomosis, the microsheath was exchanged over a wire a short 6F Brite-tip was placed in the AV fistula. With occlusive pressure of the distal fistula, angiography was performed in mulitple views. PERIPHERAL ANGIOGRAPHIC FINDINGS Subclavian: There was severe stenoses at proximal anastomosis and inflow segment of fistula. There was normal flow through the mid and distal portions of the AV fistula. The brachial artery was normal in size and did not have any significant stenosis. The primary indication for PVI was abnormal duplex of stenosis fistula. Additional indications include: abnormal fistula duplex, failure to mature AV fistula. INTERVENTIONAL PERIPHERAL VASCULAR PROCEDURE PVI of the left AV fistula artery was indicated for failure to mature graft due to proximal stenosis. A 6F sheath was chosen for the intervention. This sheath gave good support in the left AV fistula. A heparin bolus was given. The lesion in the left AV fistula stenosis was crossed successfully with an 0.035 inch stiff angled Glide wire and a 4F multipurpose catheter. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery two times. The maximal inflation pressure was 3 and 6 atm. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon in the residual vein in the proximal left AV fistula artery three times. The maximal inflation pressure was 3,4 and 8 atm each time. We then inflated a 4.0mm diameter of 20mm length Ultrathin SDS balloon at the anastomsis of left AV fistula and brachial artery. The maximal inflation pressure was 8 atm. We then inflated a 6.0mm diameter of 40mm length Dorado balloon in the proximal left AV fistula three times. The maximal inflation pressure was 6, 10 and 9 atm each time. Repeat angiography revealed improved flow in the fistula with mild residual stenosis and no evidence of compromise of the left brachial artery. I appreciate any guidance you can give me. Kathy

Infusion of tPA in AV Fistula

Using the glide catheter to deliver 4 mg of tPA, the entire AV fistula outflow tract was laced with tPA, and we subsequently introduced a 6 x 20 cm angioplasty balloon and macerated the thrombus in the AV fistula, performing a balloon dialtion of the entire AV fistula outflow tract. The question is, what code should I use to report the tPA? Code 37212 (venous) or 37211 (arterial)?

AVM, Dural Fistula

How many times can an extrancranial embolization be captured for dural AV fistula and AVM for both left and right?

Resection of AV Fistula Aneurysm, Revision with graft, PTA cephalic arch

"Patient has 2 aneurysms in the prox aspect of his AV fistula. He had multiple venograms by an outside interventionalist & review of notes indicates a moderate stenosis just distal to aneurysm that has been ballooned multiple times...aneurysms were excluded using Ioban. A small transverse counter incision was made over the prox aspect of the arterialized cephalic vein & circumferentially dissected. Having achieved proximal control, we created another counter incision just approx 2cm distal to the distal fistula. This is to exclude both fistulae & area of stenosis. We then tunneled an Accuseal graft & created an end-to-end anastomosis with the graft & the prox arterialized cephalic vein. We then made an end-to-end anastomosis between the graft & the distal cephalic vein. Central venogram was performed with PTA of cephalic arch for 50% stenosis) We then turned to aneurysms. 2 elliptical incisions over the apices of the aneurysms are created & the aneurysms are circumferentially dissected & ligated at both ends & removed." What should I charge for this case?

76937 with AV fistula intervention

I need clarification regarding when we can charge code 76937 with AV fistula intervention. In question is the term "failing". Would any intervention on the fistula imply that it is failing, or do we need documentation that states the fistula is "failing"?

TIPS revision

Is this considered TIPS revision? "Due to clinical concern for TIPS shunt physiology effect on cardiac status, along with no appreciable improvement from it with regard to the patient's ascites and hydrothorax, the TIPS was embolized with a 14 mm Amplatzer Plug Version 2, after which it didn't appear near occluded and is anticipated to go on to completely occlude. This should be confirmed with a Doppler ultrasound in a few days."

Brachial to Brachial Bypass and Ligation of Fistula

"MD previously did brachiocephalic fistula and failed, then MD did DRIL procedure and bypass failed. NOW, incision was made in skin down to subcutaneous tissue. Cephalic vein was identified. Dissected circumferentially and encircled with vessel loop. Old brachial-brachial bypass was thrombosed. It was dissected down to its end-end anastomosis to brachial artery distal. Artery also dissected distally to allow for control. Patient anticoagulated with heparin. Proximal brachial artery was controlled and cephalic vein distal to it transected beyond the arteriovenous anastomosis by about 2 cm. Distal cephalic vein overswen with 7-0 prolene suture. Old brachial-brachial bypass transected from brachial artery which was spatulated. Stump of cephalic vein was swung and anastomosed end-to-end to the brachial artery using 7-0 prolene suture. Flushing performed and flow established. Palpable pulse in brachial artery and triphasic Doppler signal in radial artery. Subcutaneous tissue approximated; patient had palpable pulse." Should we report 37607 (fistula ligation) and 35525 (brach-brach bypass surgery)?

Aborted ICD RV lead revision

I am stumped as what I should use for coding this attempt. Can you please advise? Patient has RV lead impedance, so they planned to do an ICD RV lead revision. Doesn't seem like he did enough to charge 33244-53, 33216-53.

"Using general anesthesia with endotrachael intubation, a right infraclavicular incision was made and the old generator was explanted. The right subclavian vein appears occluded. It was decided to leave the original system in because three years of battery is left. Finally, the subcutaneous pocket was sutured using 2-0 Vicryl and the skin was closed using 4-0 Vicryl. The patient tolerated the procedure well and no complications were encountered during this implantation."

Attempted Left Arm AV Fistula

I am not sure if this unsuccessful AV fistula placement should be reported with 36821-53 x 2 or some other code. What are your thoughts? 

left: 30px;">A longitudinal incision was made to wrist between the cephalic vein and the radial artery. The cephalic vein was exposed proximally and distally along the incision, and after inspecting the vein, it appeared to be less than 2 mm and appeared inadequate for fistula placement. Because of that, this incision was closed with 2 layers of absorbable suture. A second incision was made in the upper arm, above the elbow crease, over the cephalic vein. Again, the vein was then inspected for adequacy and the vein was sclerotic and again not adequate for fistula placement. This incision was then closed in 2 layers. After discussion with the nephrologist, it was felt not to place an AV graft at this point.

In the 2010 Vascular and endovascular book page 313, you recommend coding a venoplasty inside the AV graft with an open thrombectomy but not with an open revision and thrombectomy. Can you explain the rationale for allowing it with an open thrombectomy but not with an open revision/thrombectomy. Thanks

36223-50 or 36225

Our IR dept reported 36223-50 and 36225, and insurance denied based on incorrect modifier. Should an add-on CPT code be reported? 

Left PCA aneurysm, SP coil embolization.

"Fluoro identified right femoral head introduced a 5 x 10 sheath into the right femoral artery using US, micropuncture and Seldinger technique. Angiography demonstrated adequate placement. Then introduced a 5-French catheter over an 0.035 Glidewire. Patient had very tortuous origins of her great vessels. I selectively catheterized the right brachiocephalic artery after attempting to catheterize the right common carotid artery. I evaluated the brachiocephalic artery for visualization of the vertebral artery and carotid artery. I then selectively catheterized the left common carotid artery and left subclavian artery to image the left vertebral artery. Each vessel was evaluated using multiple projections including the angiogram. I removed the catheter and sealed the arteriotomy."

Second Stage Brachial Vein Transposition, 36832 vs. 37799

A question has come up regarding the correct CPT code to use for a second stage brachial vein transposition for dialysis access. Based on the CC for HCPCS directive it appears that code 36832 may be appropriate, but others are suggesting an unlisted code (37799). Could you give your thoughts? Here is the operative report (edited for space): "Procedure: Right brachial vein second stage transposition fistula...Indications: ...Right brachial vein second stage transposition fistula...Procedure in Detail: ...We divided the vein from the previous anastomosis at the antecubital region and tunneled that through the superficial tunnel in the brachial artery that was dissected free. The venogram was then performed demonstrating no evidence of kinking or twisting of the brachial vein, patent axillary vein, subclavian vein, brachiocephalic vein, and superior vena cava. An anastomosis was then performed to the brachial artery with running Prolene suture in an end-to-side fashion."

Angioplasty in the Venous Outflow with Revision

Can you clarify the definition of "within the graft" as it relates to open surgical revision of an AV fistula/graft with balloon angioplasty in the venous outflow? Is the entire peripheral segment considered "within the graft" or just the anastomoses, graft material between the anastomoses, and the immediately adjacent areas? For example, a physician creates a surgical incision over the venous anastomosis of an AV graft. He opens the graft and retrieves thrombus using a Fogarty and places a patch angioplasty at the venous anastomosis to treat an area of stenosis there. He then performs a balloon angioplasty of an area of stenosis in the venous outflow in the cephalic vein through the same surgical incision (the stenosis is proximal to the venous anastomosis and not immediately contiguous with the anastomosis). Would you agree with 36833, 35460, and 75978 here? Or can I only report the angioplasty and radiology S&I (either 35460/75978 or 35476/75978) if these additional procedures are performed in the central segment?

Staged embolization infratentorial torcula dural AV fistula

Our physician on one day embolized (with glue) the left MMA and the left occipital artery for an "infratentorial torcula AV fistula".  He noted that there was "persistent feeding from the right MMA and occipital arteries". Then, two days later, he went back in and embolized the right posterior branch of the distal MMA. Would I use 61624/75894 (75898 if done) and catheter placements the first day and then on day 3 for the second embolization use a -76 modifier on all my other codes since he repeated it? Or since it was "staged" do I use a different modifier? Or do I use no modifiers at all? Since he actually embolized a different artery (but for same fistula) would it even be considered a repeat embolization?

Pocket Revision for erosion prevention

Physician performed a pocket revision for device erosion prevention and placed an Aigis antibiotic pouch. For this, would 33222/33223 be applicable depending on the device used?

Code 20500

Id really appreciate your help with codes for this procedure. Patient with a postoperative gastric fistula. Contrast study of the fistulous tract showed gastric fistula at the ampula. The drainage catheter was removed and a short Berenstein catheter was advanced is positioned at the gastric fistula. A microcatheter was then advanced to the fistula. Transcatheter embolization was then performed using 2cc on nBCA adhesive along the length of the fistulous tract as the catheters were withdrawn. I'll assign 20501 and 76080 for the study, but I can't find a code for the embolization of the fistula tract? Thank you!

AV Fistula/Graft Interventions Open vs. Percutaneous

When dealing with an AV fistula/graft, what constitutes open vs. percutaneous as it relates to the various interventions? Does the graft/fistula need to be incised for it to be considered open? In a recent case an incision was made to ligate a collateral, then access through the collateral with a micropuncture needle was obtained into the AV fistula where angioplasty and stent placement occurred.

36832 37799 15878

My Physician coded this as 15878? but i am unsure of the correct code for this procedure. Unlisted? Thank you PREOPERATIVE DIAGNOSIS: Left brachiocephalic fistula that is too deep. OPERATION: Removal of fat over the vein with liposuction. OPERATIVE FINDINGS DETAILS: The vein was positioned at about 6 mm from the skin at the completion. PROCEDURE IN DETAIL: The patient was taken to the operating room and placed in the supine position. Following smooth induction of general anesthesia, the left arm, hand and upper arm were prepped with Chloraprep solution and draped with sterile linens. A transverse incision was made just above the elbow and another just proximal to the shoulder over the vein. A subcutaneous tunnel was then made over the top of the vein being directed by ultrasound. A suction catheter was vigorously passed over the top, and using finger manipulation, the fat was squeezed from the top of the vein. There was a moderate amount of reaction from multiple previous needle sticks. The vein was verified to be about half as deep at the end of the procedure.

Fistula stenosis, proximal and sublcavian, with balloon rupture

"Patient comes in for a fistulogram. Stenosis is found in both the proximal fistula and the subclavian innominate junction. The proximal fistula stenosis is angioplastied and has excellent results. The subclavian stenosis is angioplastied and the balloon bursts. The physician is unable to retrieve the balloon without doing an open cutdown. He then makes an incision, ligates the fistula, removes the balloon, and ligates the fistula in the mid arm as well. The patient will now have to come back and get a PermCath placed." Do we only report code 37607, or would the angioplasties be billable as well (36902, 36907)?

Revision of Lower Extremity Bypass

Patient has a previous fem-anterior tib bypass with vein. He is taken back to the OR for stenosis of bypass at outflow. Physician did an interposition jump graft from distal bypass to new location of distal anterior tib. Would this be a revision of bypass or a new bypass code like 35571?

Excision of Aneurysm of Nonusable AV Fistula

Patient with an aneurysm of non-functioning fistula that hasn't been used since 2018 due to clotting. Procedure was coded as 37799, but insurance is denying. Is this the correct coding, and if so, is there any suggested information that can be sent to help fight this claim?

"Longitudinal elliptical incision around the existing aneurysm down to the level of the elbow was made. I identified the brachial artery in the AV fistula aneurysmal anastomosis. I clamped just above the anastomosis on the fistula after dissecting around it to get complete control. After complete proximal control I extended the elliptical incision around the entire aneurysmal portion of the fistula. Using electrocautery I dissected the entire aneurysmal dilated fistula out all the way to the occluded area in the mid upper arm. I ligated this off with a silk tie and then excised the aneurysm in its entirety. I tied off the fistula just above the anastomosis with a 5-0 Prolene suture in a running horizontal mattress fashion followed by running locking outer layer."

LAD coronary artery to pulmonary artery fistula

If an LAD artery/pulmonary fistula is embolized without a heart cath, is there a catheter placement we can show with the 37242? The fistula was accessed through the LAD.

Permacath exchange with venous angioplasty of fibrin sheath

I'm trying to determine whether I should use 36595 and 75901 or 37187 for the angioplasty of the fibrin sheath. I prefer 36595 and 75901 due to them indicating it is due to the device and not just the vein but but Coding Clinic for HCPCS - Second Quarter 2012 Page: 5-6 indicates to use 37187. Can I get your take on this? Thank you! "The skin surrounding the indwelling left jugular permacath as well as the external portions of the catheter were prepped and draped using maximal sterile barrier techniques. Lidocaine 1% was infiltrated for local anesthesia. The catheter was freed from the subcutaneous tissues using gentle traction. The catheter was removed over two stiff glidewires. A 10 mm x 4 cm balloon was advanced the brachiocephalic vein for SVC venogram. Balloon dilatation was performed throughout the left brachiocephalic vein and superior vena cava. A 28 cm BioFlow DuraMax permacath was placed to the right atrial/SVC junction. The catheter easily aspirated and flushed."

TIPS Revision

A patient was in IR for the TIPS revision. Splenic vein was catheterized to evaluate for venous obstruction as a cause of liver dysfunction. Findings: There is no webbing, stenosis, or occlusion to suggest venous obstruction as a cause of liver dysfunction. There is a large tortuous splenorenal shunt with drainage of contrast into the IVC. Can 36011 be coded?

Coil Embolization

Procedures: 1) Coil embolization of left forearm AV cephalic vein. 2) Balloon-assisted maturation of left forearm Cimino AV fistula with cephalic vein. 3) Completion of left forearm AV fistula. What are the codes? Please help; I'm new to vascular coding. 

Catheter Code with 75791

If the AV fistula was accessed through a cutdown, and the provider performed imaging (without the catheter really getting all the way to the cava or any branches or any artery), would you also report code 36005 with 75791? The provided performed a cutdown of the brachiocephalic AV, did the imaging, followed by venoplasty of the cephalic and then thrombectomy. I was thinking of using codes 36832, 35460, 75978, and 75791, but I am not sure if I should add 36005 for the cath portion. Or would code 75791 include non-selective cath access already? Please advise.

tPA

Micropuncture needle was used to cannulate arterial stump of fistula, and then arteriogram was performed of left forearm. The patient had previous arteriogram earlier that day. I injected dye into the arm with the fistula clamped, but to my dismay got a similar picture as radiology. The dye was sluggishly passed through forearm vessels with the ulnar artery being dominant. The radial and ulnar arteries were carefully dissected out and controlled with vessel loops. The brachial artery was then controlled with a vessel loop. Transverse incision was made in the brachial artery, and a Fogarty catheter was advanced into the radial artery and ulnar artery. Unfortunately I could not pass catheter or extract clot. I injected tPA into ulnar artery, opened radial artery, let tPA out, and then completed arteriotomy closure. The fistula was clamped during this whole time." I'm not sure what code to use since the tPA was not injected in the actual fistula and was not left overnight: 37211 vs. 36904?