Ask Dr. Z

I77.0 vs Z98.890 or a more appropriate code if any.

Patient with stage 5 chronic kidney disease who has had a left brachial fistula placed in preparation for dialysis if needed in the future. I cannot find a code that seems to be appropriate since the brachial fistula has not been used. Would maybe Z98.890 be appropriate?? I have had one coder say to use I77.0, but I don't feel this is appropriate since this was not an abnormal connection. Any help with this matter is greatly appreciated.

Attempted Port placement

I have an attempted port placement: "Right internal jugular vein was accessed with a needle under ultrasound guidance with angiography of the right internal jugular vein. Catheter was removed. Left internal jugular vein was accessed with needle under ultrasound guidance. Needle was advanced to the brachiocephalic and imaged obtained of the left jugular and brachiocephalic veins." Since the SVC could not be accessed via either of the jugular veins due to central occlusion, the port catheter placement was aborted. Are codes 36000, 36000-76, 75860, and 75860-76 appropriate?

Aborted Thrombectomy with new AV Fistula Creation

Coding for pro-fee AND facility here. My instructor said for facility we can only code for what is successful, but is the same true for pro-fee? Patient has a thrombosed AV fistula, but after performing an open thrombectomy and angioplasty they could not salvage the existing AV fistula. They "aborted plan to salvage the dorsal vein" (which had been transpositioned months back when the original radiocephalic AV fistula was not able to be salvaged due to thrombosis) and created a new one by anastomosing the basilic vein to the radial artery in an end-to-side fashion. Am I looking at coding only 36821 for facility and for pro-fee for this procedure?

Ligation branch with fistula creation via 2 different incisions

Procedures: 1) Hemodialysis access, autogenous fistula, branchiocephalic, left antercubital crease. 2) Ligation of large accessory branch via small separate incision, left extremity.

The surgeon performed creation of arteriovenous fistula. Also performed closure commenced after making a small separate stab incision, closing an obviously large and a clearly visible cutaneous tributary.

Is code 36821 (arteriovenous creation) included with ligation (37607) when both are done at the same encounter via two different incisions? Or do we code both separately?

Units for CPT 64400

With the revision to CPT code 64400 this year, can we report up to three units unilaterally if all three branches (ophthalmic, maxillary, and mandibular) are injected? Or does the revision to the code only allow for one unit per side regardless of the number of branches injected? I read the code description as the former, but we are seeing some conflicting coding guidance published about this code, and we are looking to confirm. 

Code 10121

Patient had coil placed at a prior visit for an embolization of AV fistula collateral vein.  The patient is returning now exhibiting pain and redness to the area.  Physician performs cutdown to retrieve the coil.  Does this mean I should report code 36832, as physician is performing revision with removal of coils from collateral?  Or should I report unlisted code?

Radiofrequency Wire Recanalization

"LT brachiocephalic vein catheterization and venography via RT CFV access. Next, the LUE fistula was cannulated and a catheter was then advanced to the left axillary vein and venography performed from LUE access. Venograms demonstrated total occlusion of the left subclavian vein with large and tortuous draining collateral vein. A catheter and hydrophilic wire were then used thru the RT groin sheath in an attempt to negotiate thru the occluded left subclavian vein. A gooseneck snare was advanced thru the LUE catheter in attemtp to capture the wire from above, however this was unsuccessful despite multiple attempts. It was decided to perform radiofrequency wire recanalization. Appropriate grounding pads were placed on the patient's thighs and the radiofrequency wire was advanced thru a catheter from below and recanalization performed in the subclavian/axillary vein junction. The wire was snared with a gooseneck and removed thru the LUE. Balloon catheter was used to perform venoplasty of LT subclavian vein." Are codes 35476, 36147, 36012, 75820, and 75978 correct? Are there additional codes for radiofrequency wire recanalization?

Multiple Fistula Revisions Followed by Ligation

I have a challenging AV fistula case, and I want to ensure I credit my surgeon with the work involved. The case begins with a cutdown over the fistula. He attempts thrombectomy but says it is unsuccessful (not retrieving much clot and still poor thrill). He then shoots a fistulogram, identifies a high grade stenosis in the venous outflow, and angioplasties. He then sees contrast flowing out of the vein on fluoro and decides to stent the area to try to salvage things, but that doesn't resolve the problem. He ultimately decides he cannot salvage the fistula and ligates it completely. Are we prevented from trying to capture the stent (36903) with 37607 since this is one fistula and it is no longer patent when the case is finished? I'm leaning towards 37607 with modifier -22 plus 36901 for the imaging but it seems insufficient.

Brief Ultrasound of AVF in the Office

Physician performed a brief ultrasound of the right AVF. There is fistula flow throughout the fistula. There is an area of focal mural thrombus in the lower third of the fistula, which is not causing a functional stenosis. The proximal is extremely tortuous. The AVF anastomosis is visualized and does not appear obviously stenotic. What CPT code would we report if performed in the office and the doctor says "brief" ultrasound?

Pacemaker Pocket Revision vs. Unlisted Cardiology Procedure

I'm unsure whether to report unlisted cardiology procedure code 33999, skin tissue procedure code 17999, or pocket revision (as the doc is calling it) code 33222. He did remove the generator, place an antibiotic sleeve on it, and place it back into the pocket. "Procedure: Patient came into the pacemaker clinic with some drainage from her previously placed ICD site. After local anesthesia, the pocket was opened. The pocket was lavaged. There was no active bleeding. There was no obvious purulence. Cultures have been obtained in the clinic and were not done during this setting. The pacemaker was placed into an antibiotic sleeve and placed back into the pocket which was closed in layers. Sterile dressing was applied. Conclusions: ICD pocket revision for draining hematoma."

Pacemaker pocket revision

Dr Z, Could you take a look at the below case and advise how you would code it? I am thinking 33999 as leads were only repositioned in the pocket and pocket revision was performed. Thanks. The pocket was opened and generator removed. Pacing thresholds of both the ventricular and atrial leads were checked and found to be acceptable. The pocket was then flushed with antibiotic solution and the generator was replaced with the leads being moved on the top of the generator instead of the bottom. Pocket was closed.

AV fistula 35476

Please do NOT include any actual patient medical records with your question. Dr. Z, patient has brachial basillic arteriovenous fistula came for fistulogram and PTA. Fistulogram confirmed presence of stenosis in the proximal aspect of the arteriovenous fistula. Is this 35476 or 35475? Thanks

Endarterectomy of radial artery w vein patch angioplasty

"This is in a prior AV fistula that has developed stenosis just above the previously ligated fistula. Patient now has ischemic right hand pain with mild radial artery stenosis. Arteriotomy was made in the radial artery and endarterectomy was performed with removal of plaque from the primary area of stenosis and from the site of the previous arterial venous fistula. The remainder of the plaque was left intact as to not create and end point that would be difficult to manage, because the arterial wall was rather thin." Would you code this with 36832?

LA-LV fistula suture repair with AVR

Can LA-LV fistula suture repair be reported when done in conjunction with AVR? If so, what code could be used for that procedure? I've looked at 33305 and 33315, but neither seem quite right because those codes are associated with trauma; also considered unlisted code but with the fistula repair having been completed during the AVR and no significant extra time or effort documented I'm not sure it qualifies for an additional CPT and payment.

"The old aortotomy site was reopened. This provided good exposure with findings as described. The valve was removed. All pledgets were removed and everything sent for cultures. The annulus was debrided further. Using a right angle clamp, we were able to find the fistula between the ventricle and the atrium. This was closed with a pericardial pledgeted 4-0 Prolene suture."

Endograft revision and thrombectomy

"Access into the endograft was established. Occlusion of the left graft limb within the aortic bifurcation. An aortogram was performed, demonstrating widely patent right side occluded left. Intravascular ultrasound was then undertaken to evaluate the CIA and EIA on the left side and aorta. This demonstrated compression of the graft with adjunctive presence of thrombus. Decision to proceed with intervention was made. Penumbra CATx catheter was used to undertake mechanical thrombectomy of the graft within the aorta and in the iliac artery. This significant amount of thrombus was removed. Revision of the endograft repair here was undertaken with VBX stent with deployment from the aortic bifurcation and reaching just close to the end of the graft. The contralateral limb was protected with a 10 mm balloon inflated opposing leg."

Provider wants to bill codes 37220, 34710, 37184, and 37185. Could you advise on correct coding for this scenario? I'm not sure about 37220 and 34710 together.

AV Fistula Ligation/Repair of Brachial Artery for immature AV Fistula

Percutaneous access via outflow vein close to the antecubital fossa with fistulogram + central venogram.Angioplasty along entire length of the peripheral outflow vein, however, vein was still clearly somewhat diseased.Separate percutaneous access via outflow vein closer to the shoulder with fistulogram and angioplasty of the anastomosis. Repeat fistulogram showed extravasation. Balloon was reinflated, no change on repeat fistulogram which told me that the rupture was at the anastomosis directly. Longitudinal incision was made overlying the AV anastomosis w/blunt dissection of brachial artery. No backbleeding from the outflow vein. Brachial artery was fully mobilized w/creation of end-to-end anastomosis resulting in excellent pulse in the brachial artery. I then ligated the open end of the outflow vein using medium clips. There was a seroma at the basilic vein harvest site with was drained w/needle (100ml). Provider wants to bill 36902,35206,37607. Would this be a revision, 36832-22 (for conversion to open)? Your guidance is apprecicated. Thank you.

“Cephalo-subclavian junction” stenosis

Is code 36907 reportable for “cephalo-subclavian junction” stenosis? "AVF aneurysm: The left arm was isolated as a sterile field. After Marcaine Xylocaine infiltration the arterial side of the fistula was incised to dissect out the aneurysm and overlying thin skin with appropriate in flow and outflow vessel. There was enough redundancy in the fistula that the aneurysm could be resected with end to end closure of the inflow and outflow vein. 5000 units of heparin was given and the fistula was clamped proximally and distally. The aneurysm was resected. The marks needle was inserted into the cut venous side of the fistula. A central venogram was obtained. Outflow veins were followed into the atrium and there was evidence of 70% narrowing of the lumen at the level of the proximal stent of the cephalo-subclavian junction. A 7 french introducer was placed and a 10 mm 4 cm charger balloon dilatation catheter was passed and the lesion was dilated to profile. The two ends were sutured end to end with 4-0 prolene. When clamps were released there was a good thrill in the fistula and a hemostatic anastomosis."

thrombectomy at time of AVF creation

"A patient underwent creation of a brachiocephalic AVF. After construction, thrill in the fistula was noted to be weak. The anastomosis was taken down and fresh thrombus was seen at the anastomotic site. This was removed and flushed away with heparinized saline. Then thrombectomy of the brachial artery was performed with a Fogarty catheter. The artery was flushed. A Fogarty catheter was passed into the cephalic vein and a small amount of thrombus was extracted. The vein was flushed. The anastomosis was redone." How would this procedure be coded? Would the thrombectomy be considered part of the AVF creation, or is it separately reportable?

Extensive Resection of AV Fistula and repair of brachial artery

The physician removed a massive 5 cm wide fistula that was not infected. He also repaired the brachial artery. Code 35903 is for removal of an infected fistula. Is there a more appropriate code for this? We are trying to avoid using an unlisted code.

Venography through plasmapheresis fistula

Patient has a created upper extremity AV fistula for plasmapheresis (not dialysis). They are performing venography through the fistula. Do we use dialysis circuit code 36901 or stay with 36005/75820? You answered a similar question in 2011 instructing to use the non-dialysis codes, but with new CPT codes, have there been any changes in how to view this?

AV shunt intervention 35475 35476 36148

I haven't had an AV fistulagram w/3 accesses in a long time. Would you please review the codes and let me know if I'm close? "Using US guidance access was gained in the left brachiocephalic vein fistula & directed up the arm centrally for a cephalic venogram, central venogram, & fistulagram (36147) followed by US guided access of the cephalic vein directed down the arm through which a sheath was placed & the catheter placed into the brachial artery for a brachial angiogram & fistulagram followed by angioplasty of the cephalic vein in several locations due to severe stenoses as well as angioplasty of the severe stenosis of the arterial anastamosis (36148, 34575, 75962) followed by a brachial angiogram & fistulagram followed by access of the cephalic vein directed up the arm for venoplasty of the cephalic vein subclavian vein junction followed by a fistulagram (36148-59, 35476-59,75978-59).

Bypass Graft attached to AV Graft

Patient has a LUE brachiocephalic AV fistula but due to repeated issues with subclavian vein stenosis a bypass graft was inserted that went from the cephalic vein to the internal jugular vein. Since the subclavian vein is completely occluded, would the peripheral portion of the dialysis graft be from the brachial artery anastomosis to the internal jugular anastomosis with the central portion being the left internal jugular vein through the superior vena cava? Reason being they performed an angioplasty and stenting of the left innominate vein from the AV graft access (36908) and internal jugular angioplasty via the femoral vein access (37248). I know the CPT Codebook 2021 page 309 states if angioplasty or stenosis is performed via a non-AV graft access it is coded with normal CPT, but what if both the stenting of the innominate and angioplasty of the internal jugular were performed via the AV graft micropuncture? Would it be just 36907? Or would it be treated as a regular bypass graft with 37248?

36831 vs. 36833

Procedure performed: open AV graft thrombectomy with angioplasty of the AV graft (peripheral dialysis segment). Would this be coded with 36831 (open thrombectomy) or 36833 (revision/thrombectomy)? Would angioplasty and/or stenting be considered a "revision"?

36832

I'm stuck on this one, any info. on your end would be greatly appreciated.

this pt. had 36819 (Arteriovenous anastomosis, open; by upper arm basilic vein transposition) done in November.
I'm not sure what this is exactly…36832-58??

PREOPERATIVE DIAGNOSES:
1.  End-stage renal disease.
2.  First-stage right brachiobasilic fistula.

POSTOPERATIVE DIAGNOSES:
1.  End-stage renal disease.
2.  First-stage right brachiobasilic fistula.

OPERATION PERFORMED:  Second-stage superficialization of right brachiobasilic fistula.

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Less than 10 mL.

COMPLICATIONS:  None apparent.

INDICATIONS:  This 64-year-old male had failed autogenous access in the left upper extremity and had underwent a primary first-staged right brachiobasilic fistula in November 2011.  He presents now for creation of a second-stage brachiobasilic fistula on the right to superficialize the fistula.

SPECIMEN:  None.

FINDINGS:  Patent right brachiobasilic fistula.

OPERATION:  The patient was brought to the operating room and placed in a supine position.  After a time-out was performed, the right upper extremity was prepped and draped in a sterile fashion.  The brachiobasilic fistula was palpable with a thrill from the antecubital fossa up to the axilla.  This was marked and an incision sharply created over the arteriovenous fistula.  Any small additional side branches were divided between 3-0 and 2-0 silk ties.  The fistula was then mobilized and brought more anteromedial in a superficial position.  The subcutaneous tissues were then closed with running 3-0 Vicryl suture followed by 4-0 Monocryl and Dermabond.  The patient remained with a palpable radial pulse and an excellent thrill in the superficialized fistula.  I was present for the entire portion of procedure.  The patient was extubated and transferred to the recovery area in stable condition.

Attempted fistula

The patient came in for removal of a malfunctioning peritoneal dialysis catheter and creation of a fistula. The catheter was removed. Then creation of a fistula was attempted. From the op report: "We made a transverse incision over the antecubital fossa and dissected down. The cephalic vein was dissected free and ligated at the perforators. Attempts to flush the vein noted is to be under high pressure. I passed a vessel dilator without success and attempted to pass a 4 mm balloon which caused injury to the vein requiring ligation. We attempted to dilate the vein towards the wrist without success. At this point there was no possibility of fistula and the wound was closed with a 3-0 and then 4-0 Monocryl. We will need to reassess his venous system and possibly perform an upper arm graft. I need to discuss this with the patient prior to proceeding." How should the attempted fistula be coded?

Cerebral Angio with Intercostals

Indication for case was an abnormal CTA. Right femoral access used. We have the following CPTs charged. Are they correct? "Procedure Summary: Spinal dural arteriovenous fistula with venous hypertension. Fistula appears to be present at T12/L1 levels: internal carotid left and right (36224 x 2), vertebral left and right (36226 x 2), external carotid left and right (36227 x 2), subclavian bilateral (75716), right thyrocervical trunk (36218, 75774), left thyrocervical trunk (36217, 75774), left supreme intercostal (36218, 75705), intercostals bilaterally T4-T12 (36215 x 18, 75705 x 18), lumbars bilaterally L1-L4 (36245 x 8, 75705 x 8)." Are we close?

AV shunt intervention

Please do NOT include any actual patient medical records with your question. Dr Z, two questions regarding av fistula coding I haven’t seen addressed yet. First, how would we code under the most current guidelines, for angioplasty of the arterial inflow (arterial anastomosis is patent) with additional angioplasties within the fistula and outflow vein. Would we consider the inflow part of the fistula and code this as one venous angioplasty or would it be considered arterial and override the venous code? (Don’t think I have enough documentation to consider it a separate stenosis considerably away from the fistula.) Second, I have a case where the fistula is accessed and a fistulagram was performed (36147). Then from a direct access into a collateral an embolization was performed (37204/75894). How should the collateral access be coded? Thanks so much for your help.

Excision of Left Upper Arm Arteriovenous Fistula

I would appreciate some coding assistance. "Indication: Patient is a 61-year-old male with a successful kidney transplant who wants his AV fistula removed because of persistent pain. The area of the fistula was infiltrated with local anesthetic, and the skin was incised sharply. The dissection was carried down using electrocautery and sharp dissection until the level of the graft. The graft was dissected freely from the surrounding tissues from the level of the arterial anastomosis in the antecubital fossa to the level of the connection between the vein and the axillary vein at the level of the shoulder. The graft was then transected, and the proximal portion was tied with a silk suture. The distal portion was oversewn with a 5-0 prolene. It was removed and handed off the operation field. After hemostasis was achieved, the wounds were irrigated and then closed." How would you code this? I'm thinking it's got to be unlisted. The physician verified this was a large AV fistula that was excised, not a graft.

35475/75962 AV shunt

Dr. Z, I feel like I'm always having trouble determinig the right CPT code when it comes to angioplasty of fistula. Please see the example of Op note that I need help on. Thanks! The patient's left arm and right groin were prepped and draped in the usual sterile fashion. Initially 1% plain Xylocaine was infiltrated over the course of the left arm fistula just above the AV anastomosis. This area of the fistula was accessed percutaneously using a micropuncture set and a 6-French short sheath placed. A left arm fistulography was then performed from the level of the antecubital fossa to the right atrium and revealed a moderate stenosis of the cephalic vein at the level of the humeral head which was then balloon dilated using an 8-mm x 40-mm Conquest balloon with good result. At this time, the sheath was removed from the left upper arm and we tried to redirect our puncture toward the antecubital fossa but were not able to get into the fistula at this point despite trying multiple attempts. At this point, the percutaneous right femoral artery access was obtained and a 5 F short sheath placed. A retrograde right iliofemoral sheath angiography was performed and revealed a good caliber right common femoral artery at site of puncture. The patient was then given 4000 units of Heparin IV. An angled Glidewire was then passed through the 6-French sheath placed in the groin and passed to the level of the aortic arch and exchanged for a vertebral catheter, which was used to selectively cannulate the left subclavian artery followed by cannulation of the left brachial artery. Left brachial angiography was performed and revealed a severe stenosis of the fistula at the AV anastomosis. The vertebral catheter was exchanged for a 90-cm Shuttle sheath through which wire crossing of the area of stenosis of the fistula in the antecubital fossa was done followed by balloon angioplasty using 8-mm and 10 mm balloons with good result. There was still a residual stenosis noted to be present of about 20% just above the AV anastomosis.

Replace old DC PM, new PM insert and Removal, insert of 2nd new PM.

The physician removed the old DC ERI PM with difficulty from scar tissue and heavy calcification and replaced it with a new DC PM, which was then removed due to thick, heavy calcification of the atrial lead and the pocket. A smaller second new DC PM was then implanted. A pocket revision was done after old generator was removed and moved from an anterior posterior position in the pocket to superior lateral position, same pocket. How would you code this procedure, and can we bill for pocket revision?

TYRX Antibotic pocket- is pocket revision billable with new lead

The V lead only is being replaced. Old lead is capped; new lead is placed. The generator is placed in a TYRX antibiotic pocket. The pocket is made a bit bigger down below and above to accommodate the TYRX device. Would pocket revision - 33222 be billable with the new lead - 33216 in this situation? Code correct shows 33222 is bundled but a modifier is allowed.

Lead removal and placement

Please do NOT include any actual patient medical records with your question. Have cardiologist that wants to charge 33216(lead replacement,33233(PM removal), 33234(lead removal) and 33222(pocket revision) on patient that required replacement of chronic RA lead due none capture. Per patient's report generator removed, leads tested (noise defect reproduced with pressure on part of lead entering cephalic vein), Chronic RA lead removed, new lead placed, connected to generator, pocket washed with gentamycin saline and pocket closed. Per report no new generator placed and no revision of pocket. My understanding is that 33216 bundles the chronic PM removal and replacement. And documentation not adequate for charge of revision of pocket.Do you have avialable clear instructions on what is included in lead repair/replacement procedures. Thank you for your help. Rick

AV Fistula Creation and Ligation

We have a case where the patient had a synthetic AV graft. "Dr. X removed the graft and performed thrombectomy and angioplasty of stenosis to re-establish flow, but due to poor pulsation they harvested the basilic vein and performed an interposition graft. They then created a new direct AV graft, but due to the fact that they found it had poor flow, they tied off the fistula in order to divert all blood flow to the upper extremity." All this was performed during the same operative session. We're looking at code 35236 for the repair and code 37607 for tying off of the newly created AV fistula, but it seems like we're missing something. Since the AV fistula was created and left in (albeit ligated) at the end of the procedure, can we report those codes? And the thrombectomy and angioplasty performed prior to the interposition graft, do we lose those codes because it wasn't successful and therefore the doctor decided to perform the interposition graft and created a new AV graft at a different location instead of replacing the AV graft that was there?

Gastrostomy placed through existing fistula

"Patient's previous PEG tube was removed due to fistula drainage. After gastric drainage, patient returned for new gastrostomy tube placement via the fistula. Patient was placed on the gastrostomy table, and fluoroscopy was used during the procedure. The skin around the G-tube site was prepped and draped. Using fluoroscopy, the track was recannulated, and a new 20 French gastrostomy tube was advanced into the stomach via the fistula access. A balloon was inflated, and contrast and air were injected through the tube to confirm final position. Tube was secure and bandaged." Would this be considered a new PEG tube with 49440 since fluoroscopy was used, or would this be 49450 just for the replacement of PEG tube since they aren't generating a new access?

AV Graft Revision w/ compromised skin & soft tissue removal

Are we able to bill for skin/soft tissue removal during aneurysmal repair of AV fistula? "Separate longitudinal incisions were made over these aneurysmal segments. Cephalic vein was identified and secured with silastic loops. The aneurysmal portions revealed thin vessel wall with compromised overlying soft tissue. Circumferential control was obtained. 5000 units of heparin were administered and allowed 3 minutes to circulate. The cephalic vein was clamped proximally and distally to the aneurysmal segments. A longitudinal venotomy was made over the compromised sites. Redundant compromised vessel wall was excised until a 2 cm residual diameter vein remained. Aneurysmorrhaphy was performed as the vein was then re-approximated using double layer 5-0 proline suture. Vascular clamps were removed. A thrill remained throughout the fistula. Compromised skin overlying the aneurysm was resected with a 15 blade. The amputated skin measured approximately 4 cm x 8cm. Deep dermis was approximated with interrupted 3-0 polysorb suture."

CORONARY AV FISTULA CLOSURE

How would I code the below scenario? Please help!! "Initially, we had trouble negotiating the right coronary artery into the fistula due to the 180-degree turn; however, once we were able to accomplish the AV loop, we were able to take the Neuro catheter all the way into the mid segment of the fistula. Once we had accomplished this, we removed the AV loop and then advanced the 9 mm microvascular plug. We then deployed the 9 mm microvascular plug successfully and performed an additional angiography conforming that the microvascular plug was in position prior to its release."

Arterial angiography during dialysis fistula/graft evaluation

Is this one where you would use 75791 and a selective cath. Code?  36215?
Thanks!

TECHNIQUE: The risks, benefits and goals of dialysis fistula/graft evaluation with possible stent placement and possible angioplasty under conscious sedation were discussed with the patient prior to the procedure. The patient desired to proceed and signed informed consent. The patient was placed supine on the angiography table. The left upper extremity was prepared and draped in the usual sterile fashion. 2% lidocaine with epinephrine was used as a local anesthetic. Access to the fistula was obtained using US guidance and micropuncture technique directed toward the arterial inflow. Evaluation of the fistula outflow was performed with digital subtraction venography to the level of the right atrium. Reflux imaging of the arterial anastomosis was also performed. An angled glidewire was inserted and passed into the radial artery above the anastomosis, under direct fluoroscopic observation. A Kumpe catheter was inserted, and digital subtraction angiography of the radial artery was performed.The catheters and wires were withdrawn. Hemostasis was obtained with manual compression. During the process of obtaining hemostasis, a hematoma formed around the fistula, and extended along a portion of the fistula causing compression of the outflow. This resulted in a decreased thrill and increased fistula pulsatility. Additional pressure was held. The hematoma was massaged to soften it. Repeated US evaluation of the fistula was performed, demonstrating decreasing mass effect on the fistula. There was also an improvement in the exam, with increased thrill along the fistula. The patient tolerated the procedure well and exited the angiography suite in stable condition.

FINDINGS: There is brisk flow through the brachial artery-basilic vein fistula. The outflow is widely patent. The arteriovenous anastomosis is widely patent. There is sluggish distal flow in the brachial artery distal to the anastomosis, consistent with a steal phenomenon. US evaluation of the fistula after removal of access demonstrates a hematoma along the fistula, with mass effect on the fistula. The radial pulse remains strong.

IMPRESSION: 1.  Widely patent left upper arm brachial artery-basilic vein fistula. Difficulty accessing the fistula may be related to its depth.
2.  Finding consistent with a steal phenomenon. This corresponds with patient's complaint of poor circulation to his left hand, which is more pronounced during dialysis.
3.  Post-procedure peri-fistula hematoma as described above.

35881 Lt fem tib revision w lt arm vein & angiography lt lower extremity

35881 for revision w seg vein interposition (portion not shown). What code would be used for the angiography (prior noninvasive testing done)? Access was achieved by a longitudinal incision over the palpable graft pulse at the level of the knee. Sharp dissection was used to expose roughly 2 cm of the bypass graft, which at this level appeared to be of good caliber and quality and had a strong pulse. It was encircled with a vessel loop. The graft was then accessed antegrade with a 21-gauge butterfly and angiography confirmed patency of the distal graft with a focal area of critical stenosis in the graft several centimeters below the knee, but several centimeters proximal to the anastomosis. The area of diseased vein was roughly 4 to 5 cm, but the distal anastomosis appeared patent and the posterior tibial artery ran off uninterrupted into the foot. With the area of graft revision now marked after angiography. 75710-26-59?

Embolization of Gastrocutaneous Fistula Plug

What is your code recommendation of this case? "Upper abdomen was prepped and draped in usual sterile fashion. Contrast was injected into patient's indwelling percutaneous pigtail type gastrostomy tube, confirming intragastric location. Catheter hub was cut, and the catheter was removed over Amplatz superstiff wire. A 12 French sheath was advanced into the stomach in order to facilitate fistula brushing, which was performed with 3 mm bristle Cellebrity Cytology Brush over Amplatz wire as sheath was retracted from fistula. Next, Cook enterocutaneous fistula plug was deployed through 24 French sheath within the fistula. Inner disc was in appropriate position along gastric staple line, as confirmed with fluoroscopy and radiography in multiple obliquities. External portion of the plug was secured to abdominal wall with Molnar disc and trimmed. There were no immediate complications."

36147

Dr Z. I have a question reqarding attempted recanalization of occluded fistula. The patients left upper cephalic vein was punctured just beyond the AV fistula and peripheral to a large thrombosed aneurysm. Multiple attempts were made in an effort to advance out of the thrombosed aneurysm into the outflow cephalic vein in previously stented segment but this was not possible. Ultrasound demonstrates that the aneurysm is thrombosed and that the cephalic vein is thrombosed to the central cehpalic vein. The previously placed stent is thrombosed. In light of the very large aneurysm and the inability to cross out of it, it was felt that the fitula is not salvageable. I'm questioning whether this can be consider a actual fistulagram since the aneurysm prevented him from entering the fistula. Can you help with coding this? Your comments would be greatly appreciated. d :)

Percutaneous Transluminal Balloon Angioplasty and Stenting of the Left ICA

My provider submitted codes 37215, 35475, 75898, and 75962 for percutaneous transluminal balloon angioplasty and stenting of the left ICA. This does not seem correct to me, as they bundle, and also the description of code 35475 says "brachiocephalic or branches" (and this is the left ICA). Can you help me with this scenario please?

Balloon Tamponade Hemorrhagic Carotid Artery

Balloon was used to tamponade the hemorrhage. Is there a code for the tamponade, or do we just get codes 37615 and 36215 for ligation? "We then placed a 6 French 70 cm sheath into the proximal brachiocephalic artery. We utilized contrast injections from the brachiocephalic artery sheath to visualize the area of bleeding. Once this was performed, I then utilized a 6 mm x 6 cm balloon and carefully inflated this to a nominal pressure within the right common carotid artery. Once this was performed we had adequate hemostasis. The vascular surgery team then went ahead and performed the right carotid artery ligation. At this point in time, neurosurgery was available and performed cerebral angiography, which they will dictate in a separate note."

AV Fistula with Thrombolysis

Patient has a native fistula that is clotted off. The fistula is accessed and imaging is performed, showing the venous end is thrombosed. Thrombectomy is performed, but there is residual clot. A 10 cm infusion catheter is placed, and overnight thrombolysis is started. Patient returns the next day for a follow-up angiogram. Can we report codes 36147, 37187, 37212, and 37214? Our coding staff is having a difficult time knowing when it is appropriate to code thrombolysis for AV fistulae. What is the anatomical landmark you would suggest?

Dialysis Fistula

I am new to IR coding. I have an operative note for a fistula to the radiocephalic for dialysis. It looks like they did an anastomosis. Please help with the correct CPT and ICD-9 procedure codes.

37184 vs. 36904

"Patient with AV fistula presents with steal symptoms (numbness, cramping), and ultrasound demonstrates thrombus in native brachial artery. Fogarty device is used to pull and macerate the thrombus seen into the fistula." Although the physician describes the thrombus as being in the native artery, does the fact that the clot burden was able to be pulled into the fistula signify that this should be coded as 36904 (no fistula conduit thrombus noted or treated)? Or, because it is into the native artery, can it be coded as 37184? (The physician states, "Thrombus will need to be removed, based on ultrasound findings, and no peripheral intervention.") Thank you for clarifying when 37184/36904 should be used!

Non-Maturing AV Fistula

I was hoping you would help to clarify some global surgery modifier usage for me on the following: "Patient is brought in for AV fistula creation for dialysis access. Weeks later it is found that the AV fistula is not maturing, so the provider decides to bring the patient back electively for balloon-assisted AV fistula maturation." In a few cases I've seen, the patient is brought back for this same procedure multiple times during the post-operative period. I feel like the first balloon-assisted AV fistula maturation procedure should be coded with a -78 modifier due to a non-maturing AV fistula. In his operative report for the first procedure he indicates that the patient will be brought back again in 2-3 weeks for another balloon-assisted maturation procedure. Do you think the first procedure should be billed with a -78 modifier and then all subsequent procedures with a -58 modifier since the provider is indicating in his previous operative report that the patient will be brought back again?

Revision/re-do fem-pop bypass

"The patient had a previous fem-pop bypass using an in situ vein. He has now developed a tight stenosis in the segment of the vein from the knee down into the anastomosis and has had two catheter interventions, so that part is pretty much stented all the way into the native artery. Decision is made to revise this with a new bypass from the old bypass down onto the native posterior tibial artery. Cephalic vein is harvested for the bypass." We are unsure how to code the new bypass that is attached to the old (fem-pop) bypass down onto the native posterior tibial. Revision or new bypass? Can you please help with the codes?

Aneurysm in Fistula

Can code 35045 be billed with 36901 for an aneurysm repair in the radiocephalic fistula? The fistulogram was done first.

AVF, lligation followed by AVG same session

"Patient had a left brachiocephalic AVF created. After completion there were multiple leaks at the suture line. The anastomosis had to be taken down, and attempts to redo the suture line led to disintegration of the vein making it unusable. The cephalic vein was ligated with silk tie. Then a left brachial-axillary AVG was created." Can both the AVF and AVG be coded? How about the ligation?

Atherectomy of Left Arm

Could you please clarify the uses of code 0234T. The CPT description states "transluminal peripheral atherectomy". Since there is a separate code for the brachiocephalic trunk and branches (0237T) on the right side of the body, does this mean that code 0234T may be used for atherectomies in the left arm, as well as renal atherectomies?