Ask Dr. Z

Angioplasty in Unsuccessful Endo AV Fistula Creation

During an attempt to create an endovascular AV fistula, the physician performed a balloon angioplasty of a lateral branch of the cephalic vein to try to disrupt the valve in order to allow the deep system to fill the superficial system, allowing him to proceed with the endo AV fistula creation; however, it was unsuccessful. Would it be appropriate to code for the balloon angioplasty in this setting?

embolization of AV fistula collateral

Dr, Z, Patient has AV fistula with a complication for dialysis. With two AV graft punctures and intervetion was performed using both accesses. Additonally a large accessory vein was seen arising from the venous outflow from the arteriovenous anastomosis. Using a catheter the accessory vein was selectively cathterized and was subsequently embolized using multiple coils. My question is can we assign 36217 36148 and 36299 for the accssory vein access? I understand we can't use more than two punctures for the AV fistula however this was an accessory vein so not sure of this, please advice. Thanks

Excision 35903 vs. Revision 35883

Patient had a right fem-TP trunk PTFE bypass graft that was infected. Less than 30 days from the original graft, the surgeon went in and performed a partial explantation of the graft and then created a femoral to peroneal bypass using cryopreserved vein, attaching it to the end of the previous PTFE graft. Would this be coded as an excision of infected graft with a new graft creation (35903/35666), or would this be coded as a revision (35883)?

AV graft creation, angiography, angioplasty

Dr.Z, Question for AV graft creation. Hand venogram performed and peripheral veins looked fine howver central venogram demonstrated extensive collateralization around the left subclavian and innominate veins. The decision was made to proceed with a left subclavian and innominate veins prior to creation of an AV fistula. The post op diagnosis states left subclavian and innominate vein stenosis. After PTA performed creation of left upper extremity b rachiobasillic AV fistula. My question can we charge PTA separate from the creation or it is part of the creation. If we can charge PTA can we charge two or one PTA? Thanks

THROMBECTOMY SVC RT ATRIUM VEGETATIONS & CATH PLACEMENTS

Would additional catheterizations and imaging (LT innominate, RT brachiocephalic) outside of the target treatment zone be separately reportable in the case below or is this included in 0644T?

"Right common femoral vein access. Catheterized Right external iliac vein. Venography was necessary due to questionable thrombus noted on ultrasound. Additionally, the patient has a left groin dialysis catheter which can make the patient more susceptible to thrombi. There is concern that the catheter may

either induce a scar, stenosis, or thrombotic event that would be worsened by advancement of large sheath.

Findings: Widely patent external and common iliac veins as well as the inferior vena cava. No evidence of high-grade stenosis, occlusion, or thrombus formation.

Catheterized Left innominate vein. Findings: Widely patent left innominate vein. With patent superior vena cava and right atrium. Suspicion for continued fibrin sheath within the superior vena cava. No evidence of complication such as active extravasation.

Catheterized Right brachiocephalic vein.

Findings: Patent right brachiocephalic vein and superior vena cava. Small residual fibrin sheath noted. No definite complication. No obvious large pulmonary thrombus.

Mechanical or aspiration thrombectomy Venous segment treated: Right atrium and superior vena cava

Transesophageal echocardiogram findings: TEE was performed by the anesthesiology service.

This was used to successfully advance the flush catheter to the fibrin sheath with subsequent aspiration of the vegetations. Selection and aspiration was performed under real-time TEE guidance. There was visualization of the thrombectomy. No evidence of embolization material by TEE."

Hi. How would you code revision of scar of left basilic transpostion AVF. An 1 1/2 inch segment of scar was removed. There was a sinus tract there which was completely excsed. Specimen was sent to Pathology. Thank you.

Ligation of AV Communication

When my vascular physician constructs an AV fistula for dialysis (36820, for example) he will also sometimes do "exploration of right arm arteriovenous fistula at the level of the mid arm with ligation of arteriovenous communications x 2 and exploration of right arm arteriovenous fistula in the upper arm with ligation of arteriovenous communication". Is this something that is coded separately from the 36820, or is it just part of the procedure?

Fibrin Glue/Evicel Injection

Is there a code for a fibrin glue injection into a fistula? Report summary as follows: "Patient with a known fistula to the rectum. Contrast is injected through the presacral abscess drainage catheter. Given the drainage output color, I suspect the fistula continues to communicate with the rectum and therefore fibrin glue is injected."

PTA for maturation of arteriovenous fistula

In 2015 it was recommended that we use unlisted code 37799 for angioplasty to dilate a fistula when no stenosis is present. Is this still the recommendation, or are we able to use CPT code 36902 for the dilation of a small vessel?

Removal of Non-Infected AVG

I could use your input on the following scenario: The patient has a non-functional AV bovine graft in the left forearm, which our physician ligated and removed to prevent steal phenomenon in a new upper arm fistula, which he created in this same operative session. Normally, I would code for the ligation of the AV graft (37607) and the creation of the new upper arm direct type fistula (36821). Is there another code that could be used for the ligation and removal of the old forearm graft, which was not infected? The ligation was successful, but our physician was concerned that once he created the new AV upper arm fistula the patient would develop a steal phenomenon without removing the old forearm graft.

36832

Please do NOT include any actual patient medical records with your question. Patient came in status post endovascular repair of left arm AV fistula pseudoaneurysm usign a viabhan stent graft. The patient has developed an AV fistula complication consistent with stenosis. Fistula cannulated and fistulogram obtained. Stenosis noted in cephalic vein and two pseduoaneurysms noted.PTA was performed on cephalic vien. Attention was turned to the pseudoaneurysms. The pseudoaneurysm clsoer to the elbow appreared to be large. Due to the size of teh pseudoaneurysm, the decision was made to proceed with incision, the pseudoaneurysm was exposed. A pseudoaneurysm was then opened under direct vision. Approximately 20ml of old organized thrombes was evacuated. The pseudoaneurysm was then reparied primarily using prolene suture. not sure what to code for the driange of pseudoaneurysm? Please advice. Thanks

When is 35860 separately reportable?

"The patient underwent common femoral endarterectomy and left SFA to posterior tibial artery bypass graft earlier in the day. Patient now presents back in the OR later that day for lower extremity revascularization due to an acutely thrombosed bypass graft. LLE angiogram was performed. The left groin, thigh, and calf incisions were reopened and explored. Hematoma was evacuated from all three. Hemorrhage from the suture line of the proximal SFA anastomosis was controlled with Prolene suture. As it appeared there was adequate inflow in the superficial femoral artery and adequate outflow in the native posterior tibial artery. It was concluded based on imaging that the issue with the bypass was of conduit quality, and therefore a decision was made to revise the bypass by replacing the conduit."

The provider wants to report code 35860 in addition to the bypass graft revision code (for the exploration and evacuation of hematomas). Would this be considered bundled with the revision code? Or is it separately reportable with a -78 modifier?

2- IVUS and 2-Venograms

Our physicians performed two venograms and used the IVUS catheter to navigate the right internal jugular vein and the left brachiocephalic vein. I coded as 36012-50, 37253, 37252, and 75860-26 x2. Is that correct?

Venoplasty of AV fistula stenosis related to plasmapharesis, NOT dialysis

Good morning all, my question pertains to 36147, my patient has an A-V fistula for plasmapheresis for a dx of CIDP. My interventionalist does a fistula study and finds stenosis and thrombus, we are doing everything 36147, 35476 and 75978 these codes are used for except for the word dialysis. The term dialysis means separation, but all reasearch still adds the word renal to it. Would this have to be coded 36299 for the injection and can I still code 35476 and 75978 for the angioplasty? Appreciate your thoughts. Judy

Valvulotomy of AV shunt upper extremity

Can lysis of a valve be reported in addition to the code for creation of an AV fistula? Our surgeons are passing a Mill's valvulome and doing lyse of the valve in the vein to control the flow of blood thru the fistula.

Pacemaker pocket revision

Dr Z, Could you review the below procedure and advise how you would code? The patient had a pacemaker inserted two months ago and was complaining of pain at the generator site. The pocket was opened and the generator removed. Thresholds were tested and noted to be within normal range. The pocket was flushed and the generator was then reinserted but with pacemaker wires repositioned on top of the generator instead of the bottom. If I understand correctly, this would not be a lead repositioning since the leads were moved in the pocket and not at the heart so was leaning toward unlisted 33999. However, in reading the Q&A from November 22, 2011, should this be considered a pocket revision although only the leads were "revised" within the pocket? Please explain. Thanks.

Venogram of Basilic vein with Brachial artery Basilic vein avf graft

"A venotomy was made in the basilic vein, and a 0.035 Bentson wire was placed. A 6 French sheath was then placed in the left basilic vein over the wire using Seldinger's technique. A venogram for the LUE was then performed. The LUE venogram revealed: widely patent SVC, left brachiocephalic, left SCV, left axillary, and left basilic veins."

This procedure was done after dissection of artery and vein, but before arteriotomy and venotomy for PTFE graft anastomosis. Can we bill 36830 with 36005 and 75820?

Cimino shunt av fistula 35475

Could you please explain difference between Cimino and AV fistulae coding. If a physician performs angioplasty of the arterial anastomosis of the Cimino fistula what is a correct code to report? Thanks.

75710 with 36147

Patient has AV fistula, and physician documents medical rationale for advancing the fistula beyond the anastomosis (i.e., steal/embolus). I am comfortable in the concept that code 36147 includes imaging of the adjacent fistula. However, the question came up that if the physician evaluates only one other artery, is that sufficient for code 75710? Or does it have to be multiple arteries? It's a weird question, but the physician has it in his head that to qualify for 75710 beyond 36147 there should be at least three vessels visualized, but that seems to imply that there is a minimum to use the code. Thanks for any insight.

angioplasty, embolization/banding maturation px 36832

"The left radial to perforator arteriovenous fistula is patent.  There is early filling of the brachial vein. selection of the AV anastomosis and drug coated balloon angioplasty of the AV anastomosis and the perforator vein was done, Volume flows demonstrated adequate flow in the perforator vein and decreased insufficient flow in the cephalic vein.  Decision was made to coil the brachial veins-multiple Nester coils were deployed in brachial vein. Decision was to band the distal basilic vein.  0.018 wire was advanced into the basilic vein.  Over the wire, 2 mm balloon was inflated. silk suture used to band basilic vein."

Would this px be revision? 36832- angioplasty of the arteriovenous anastomosis, coiling of the brachial vein, and banding of the basilic vein were done.

Embolization Code with EverlinQ AV Fistula Creation

I know I will be using unlisted code 37799 for the AV fistula creation, but what embolization code if any would I code? Or should that be part of the unlisted code? Also do I bill separate for the catheter placements for the fistula creation or should that be part of the unlisted code? "A 5 French catheter was then introduced through the venous sheath and into the brachial vein. Transcatheter embolization of the brachial vein was performed with a single 8 mm coil in order to encourage fistula flow through the perforator vein and into the superficial access sites. Post embolization angiogram demonstrates successful embolization with diminished flow through the brachial vein."

Attempted fistulogram

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. 

Hybrid AV Graft Case

My physician performed a cutdown thrombectomy on PTFE dialysis graft arterial and venous anastomosis. Then he angioplastied the venous stenosis (severe recoil) and then placed a stent. The problem is, when he closes the graft he patch angioplastied, does this make it a revision of a dialysis graft? I know if we code this to a revision then the angioplasty and stent code are bunded. So do I code this as either: A) 36833/75791-2659, or B) 36831/75791-2659, 35460-51/75978-26, 37207-51/75960-26?

Femoral Vein access to AV Fistula with Advancement to Brachial Artery

"Access in the right brachial artery with fistulogram. Second access in the common femoral vein through the IVC, right atrium, SVC to the AV fistula and then advanced into the brachial artery with PTA of stenosis in the fistula." I would code 36120 and 36902-52 for the brachial access and PTA. Would the catheter placement code for the common femoral vein access through the fistula to the brachial artery be 36012 and 36215, or just 36012?

Chest Port Revision

I'm having trouble figuring what exactly was done here. The heading says "Right chest port revision", and then goes on to say a right internal jugular venotomy was performed, but no mention of ultrasound guidance. Then, the existing right chest port was explanted and a new double-lumen Bard port was tunneled. The catheter was inserted through the new right internal jugular access site and then connected to the double lumen port. The port was anchored to the right chest wall and flushed and aspirated appropriately. The impression says "Successful removal of a single lumen right chest port with placement of a new double-lumen port." Would this be coded 36582?

Arteriovenous Fistula intervention with IVUS only

The surgeon describes completing venoplasty in an arteriovenus fistula by direct access using IVUS as S&I. No angiogram/venogram was done. He used IVUS to diagnosis the stenosis in the AVF. Can I still use CPT code series 36901-36909?

Transnephric Venous Fistula Embolization with Gelfoam, 37241

What can we code for the following?  "A nephrostogram was performed on the left through the existing nephrostomy tube. The left nephrostomy tube was then exchanged over a stiff angle glide wire for a new nephrostomy tube and anchored in place. An antegrade nephrostogram was then performed on the right through the existing nephrostomy tube. The nephrostomy tube was exchanged over a stiff angle glide wire for a new nephrostomy tube. A follow-up nephrostogram shows fistulization from the lower pole calix of the right kidney to small branch of the right renal vein with rapid opacification of the main right renal vein and inferior vena cava. The nephrostomy tube was exchanged over stiff angle glide wire, which was passed down the right ureter. A peel-away sheath was then placed over the wire into the right renal pelvis, and a C1 gliding catheter was advanced into the lower pole calix and in the fistula to the vein. The fistula was then embolized with multiple gelfoam torpedos. A follow-up nephrostogram shows occlusion of the fistula without oppacification of the renal vein. A new nephrostomy tube then placed."

Crisscross infusion catheters placed in a fistula

How would you bill for crisscross infusion catheters placed in a fistula? Fistulogram showed thrombus within AV fistula with total occlusion. Successful crisscross placement of 5 French sheath and 10 cm infusion catheter within the venous limb directed peripherally and 6 French with 10 cm infusion catheter within the arterial limb directed centrally.

Hybrid Case Question

Revision of right BKA to an above-knee amputation for necrosis and distal left SFA exposure with retrograde crossing of chronic total occlusion, angioplasty, and stenting. I believe correct codes would be 34812-LT, 37226-LT, and 27886-LT. What are your thoughts?

Transhepatic Cholangiogram w/ Fibrin glue Embolization

Is there a code for fibrin glue embolization of biliary cutaneous fistula?

"Technique: 1% lidocaine was administered to the fistula tract site. Fistula tract in the RUQ was cannulated with a 5 French 40 cm Berenstein catheter and glidewire. The catheter was positioned near the central ducts, and a gentle injection of contrast was performed, demonstrating no flow into the CBD. The injection also demonstrated recurrent biliary cutaneous fistula. We then attached the fibrin and thrombin syringes to the catheter, and a gentle injection of fibrin glue and thrombin was performed with a total of 6cc into the fistulous tract. The catheter was withdrawn until it was outside of the skin and the injection stopped."

AV fistula angioplasty

Are the new codes for AV fistula angioplasty only for hospitals and out-patients facilities. We bill for radiologist on hospital base. Do we need to use these new codes or the oldest ones.

Code Q9967

For place of service 11 (doctors office) can we bill code Q9967 (contrast material) when we are performing a procedure such as fistula angioplasty, fistula angiogram, etc.? And, if we can, are there any Stark rules we should be aware of?

1.LU extremity fistulo. 2. Balloon angio L brachioceph anastomosis 6X40 bal

"Local anesthesia with lidocaine 1% and Bupivacaine 0.25% was infiltrated above the elbow. Percutaneous puncture of the cephalic vein was performed with a micropuncture needle. A 0.018 wire was advanced through the needle. A microsheath was advanced over the wire. A fistulogram was performed. A 0.035 inch glidewire was advanced through the microsheath. A 6 French sheath was placed. The stenosis in the brachiocephalic anastomosis was crossed with the wire. Angioplasty of the stenosis was performed using a 6 mm x 40 mm balloon. There was a good angiographic result and resolution of the stenosis. The sheath was removed, and hemostasis was achieved with 2-0 Prolene pursestring suture. Successful angioplasty of stenosis in the brachiocephalic anastomosis. Patient with large stealing branch." I reported codes 36901 and 36907. Would that be correct?

Angiography of Bypass Graft

The following vessels were selectively catheterized: left common carotid artery, left subclavian artery, left subclavian to right internal carotid artery bypass graft, left vertebral artery, and brachiocephalilc artery. Multiplanar cervical and intracranial angiograms of the above mentioned vessels were obtained and interpreted. I want to report codes 36223 (LCC), 36226 (left vertebral), and 36223-59 (brachiocephalic), but what do I code for the angiography of the bypass graft, 36225-59?

Excision/takedown/ligation of bleeding AV fistula

What is the appropriate way to code takedown of AV fistula that includes excision of aneurysmal portion in addition to ligation? The description of code 37607 only describes ligation with sutures or banding. Is it still appropriate to use 37607 for this case? We considered 36832 as well, but this is a complete takedown due to hemorrhage, skin thinning, and ulceration. Or should we use unlisted code 37799? "Course of the fistula as well as the two aneurysmal portions were marked and excised through the skin using a 15 blade. The proximal portion of the fistula was encircled with a right angle and clamped with a Cooley clamp. Fistula was divided and then oversewn at the proximal portion in a horizontal mattress followed by overhand fashion. The fistula was then excised, the diseased portion to the more distal outflow cephalic vein, and clamped at the distal aspect. The tourniquet was deflated for total tourniquet time of approximately 15 minutes. The distal most aspect of the outflow cephalic vein was similarly oversewn with 5-0 Prolene in a horizontal mattress fashion followed by overhand fashion."

radial artery angioplasty of radiocephalic fisutla

Can 37246 be coded in addition to 36902 in this case, or is it part of the fistula? "POSTOPERATIVE: Flow dysfunction in left forearm radial artery to cephalic vein arteriovenous fistula plus greater than 70% stenosis of the left radial artery. PROCEDURES PERFORMED: 1) Retrograde needle access in the left cephalic vein with placement of sheath. 2) Selective catheterization of left radial artery. 3) Selective angiogram of the left radial artery with runoffs. 4) Angioplasty of the left radial artery. 5) Angioplasty of the left cephalic vein. DESCRIPTION: A needle was placed into the left cephalic vein retrograde. A wire was passed, a sheath was placed, and then over wire technique was used to place a catheter into the left radial artery. Left radial artery selective angiogram was performed with runoff showing a greater than 70% stenosis of the left radial artery and left cephalic vein. Balloon angioplasty was then performed in the left radial and left cephalic veins. Post angioplasty angiogram showed good results. No residual stenosis and good flow."

Plication of right radiocephalic fistula: 36832 or 37607

"Patient with history of chronic aneurysmal degeneration of right radiocephalic fistula. Skin incision was made directly overlying the length of the fistula and was deepened to soft tissue taking care to protect the fistula. The fistula was circumferentially controlled and skeletonized throughout its course in the right upper arm taking care to preserve a segment in the forearm and upper arm shoulder region which could still be accessed for dialysis. The aneurysm was clamped and over a 24 French chest tube it was plicated using 5-0 Prolene in a running fashion. The chest tube was removed for completion and we flushed and backbled prior to completion. Stitches were placed as necessary. There is an excellent thrill. Skin flaps were then created. Then the fascia was tunneled on the lateral aspect of the arm. Skin closed with interrupted 2-0 nylon vertical mattress stitches. Wound was dressed with 4 x 4's Kerlix. There is excellent thrill at completion." 

Is this report coded 36832 or 37607? 

36901 and 37246 vs 36902

"Ultrasound was used to evaluate the left arm. Then, under direct ultrasound guidance, the AV fistula was punctured just distal to the arterial anastomosis. Hard copy ultrasound was saved and sent to PACs. A 4 French antegrade sheath was placed in standard fashion. Left upper extremity venograms were obtained. Then, the 4 French sheath was exchanged for a 7 French sheath over a Bentson wire. The Bentson wire and KA 2 catheter were then used to cross the venous outflow stenoses and the wire was placed centrally. Then, the venous outflow was angioplastied in two focal areas of stenosis with a 10 mm x 40 mm balloon. Final venograms were done after prolonged balloon inflation of the MultiHance focal stenoses. The final venograms demonstrate improved flow through the fistula with no significant residual stenoses. The fistula is slightly aneurysmally dilated. The images were reviewed. The sheath was then removed and hemostasis was achieved with manual compression." Would correct coding be 36901 and 37246? Or 36902?

PTA to improve poorly maturing RT upper arm cephalic vein fistula.

"Under ultrasound guidance, a 21 gauge needle was advanced into the fistula just above the arterial anastomosis. Over guidewire, a 5 French catheter was placed. Through the catheter, contrast was injected with imaging over the arm and chest. Each was made over a guidewire for a 6 French sheath. Through the sheath, a 6 and then 7 mm balloon were used to dilate the length of the body of the fistula from just above the arterial anastomosis to the upper humerus level. A completion angiogram was performed. The sheath was removed. Manual compression was applied to achieve hemostasis. Findings: Initial ultrasound examination showed a diffusely small, immature right upper arm brachial artery to cephalic vein fistula with two focal severe stenoses in the inflow and body segment. The body of the fistula measured less than 5 mm throughout. Impression: Balloon-assisted maturation of immature right upper arm cephalic vein fistula with dilatation up to severe stenoses as well as length of the cannulation segment." The physician reported codes 37799 and 76937, but shouldn't it be codes 36902 and 76937 instead? 

Revision of external iliac to popliteal dacron graft thrombectomy.

Patient has an external iliac to popliteal graft using Dacron. Procedure includes Fogarty catheter thrombectomies and multiple graftotomies. The only revision synthetic bypass graft code I'm finding is 35883 for a femoral anastomosis. This patient does not have a femoral anastomosis. Another option 35875/35876 is for arterial or venous graft, which doesn't apply to this patient. What code would I use for an iliac Dacron graft thrombectomy?

Deployment of septal occluder right pulmonary artery/pulmonary vein fistula

Deployment of septal occluder for right pulmonary artery/pulmonary vein fistula. This was performed by IR radiologist and cardiologist. I am not sure about catheter selections and what imaging studies I can charge for the IR lab. I am going to condense the actual report below. Lt. common fem venous access obtained, Grollman cath and wire utilized to gain access to rt. superior pulmonary vein cath removed for exchange length wire that was left in place. Rt. common fem venous access obtained, Grollman cath utilized to gain access to rt. pulmonary artery. Cath exchanged by sheath and the sheath positioned in rt. main pulmonary artery with AP and lat PA-grams performed. Additional angiography of rt. lower lobe pulmonary artery performed. Could not identify definitively the fistula and used wire and catheter to negotiate the fistula tract and gain access to left atrium. Lt. atrial angiography confirmed access in the lt. atrium. At this point the cardiologist entered the procedure and you have already answered my coworkers question regarding the occluder. I was thinking of using 75741, 36015, 36015, and 75774? Thank you for your help on this unusual case!

AV graft thrombectomy

I have a question about an AV graft thrombectomy converted to a systemic heparanization with follow up the next day. This was done in January 2010 so the new AV graft codes were used. The AV fistula was accessed and a fistulagram performed. The cephalic vein was thrombosed and basilic vein was small in caliber. tPA was given and the cephalic segment manually massaged. Following this, balloon angioplasty was perfomed throughout the basilic vein and the thrombosed segments of the fistula. Due to adherent thrombus in the fistula and residual clot burden, an additional 4 mg tPA was injected into the fistula. The patient was converted to systemic anticoagulation through the access sheath and will return the following day for re-eval. The patient returns the following day for a follow up fistulagram. There was re-angioplasty of the basilic vein because it was still small in caliber. A Trerotola thrombectomy basket was advanced into the distal AV fistula due to some clot still present. This was cleared. Note that a second sheath was placed within the more proximal fistula and served as a working sheath for today's procedure. Hopefully, I have included the main parts of both reports. The codes I got for the first day are 36147 for the fistulagram and 36870 for the thrombectomy. Should I code the angioplasty of the basilic vein? For the second day, should the codes be 75898, 36148, 35476 and 75978? Can a second thrombectomy be coded since this was an ongoing infusion from the day before? Thanks for any guidance on this one.

Thrombectomy and ligation on occluded fistula

Dr Z, The patient came in and had a diagnostic fistulogram performed showing severe calcification/stenosis in arterial side along with formation of thrombus. The MD performed an arterial PTA and then opened the graft and removed thrombus. A follow-up fistulogram was done but complete occlusion was noted in the cephalic vein and attempts to cannulate were unsuccessful. The MD decided that this fistula was beyond repair and performed a ligation. A temporary dialysis catheter was placed. Since the PTA was through a separate access, I was thinking 35475/75962. However, I am not sure how to capture both the thrombectomy and ligation - since the fistula is no longer functional. Any assistance would be appreciated. Thanks.

36831

Hi Dr. Z. We have a case in which we want to know if the PTA that is done after an open graft revision and thrombectomy (36833) is coded open 35460 or not reported per the information after the op note below. I am assuming the venogram is not reportable. OPERATIVE REPORT Occluded left arm arteriovenous graft. POSTOPERATIVE DIAGNOSIS: 1. Occluded left upper arm arteriovenous graft. 2. Pseudo-aneurysms times two. PROCEDURES PERFORMED: 1. Aneurysmectomy times two. 2. Thromboembolectomy and balloon angioplasty of the venous anastomosis. 3. Intraoperative venogram. ANESTHESIA: General anesthesia. BLOOD LOSS: About 100 mL BACKGROUND: The patient is a 64 year old African American male who has been undergoing dialysis for some time secondary to his end stage renal failure. He had developed two aneurysms on an arteriovenous graft; one proximally and one distally, resulting in occlusion of this graft. He was taken to the operating room at this time. DESCRIPTION OF PROCEDURE: With the patient prepped and draped in a standard fashion, incisions were established over each of the aneurysms by blunt and sharp dissection. The aneurysms were isolated from the graft, opened and then resected down to opening the graft proper. There was sufficient graft to establish a primary resection of the defected graft and complete and end-to-end anastomosis using 5-0 Prolene suture. Prior to securing the suture line, a 4 Fogarty catheter was passed proximally and distally removing both arterial and venous thrombus, resulting in both forward flow and back flow. The suture line was then secured. A venogram was then performed. This indicated a stenotic area in the venous anastomosis. Using a 7 mm x 4 cm balloon angioplasty catheter, this was inserted across the anastomosis, inflated to 12 atmospheres, and allowed to remain in position for approximately five minutes. The balloon was then deflated, withdrawn, and a second venogram performed indicating excellent resolution in the stenotic region. The catheter was then removed and the access site was closed with a single Figure 8. 5-0 Gore-Tex suture. There was excellent pulsatile flow through the graft at this point. There was no evidence of active bleeding. The wounds were irrigated with warm saline solution with 1 gram of Amikacin. The wounds were then closed in a subcutaneous fashion using 3-0 Vicryl suture. Sterile dressings were applied. COUNTS: The sponge and instrument counts were correct. The patient tolerated the procedure well and was taken to the recover. VASCULAR CODING BOOK: 8. If an open surgical declot and surgical revision of the graft or anastomosis is performed, use code 36833, and do not code for additional angioplasty/stent within the graft (anastomosis to anastomosis). If an additional angioplasty or stent is performed outside of the graft, code for the additional intervention as well. This would be codes 75978 and 35460 (open) or 35476 (percutaneous) for angioplasty. Utilize codes 75960 and 37205 (percutaneous) or 37207 (open) for stent placement if performed. Dr. Dunn Q&A: ZHealth Online Q&A 2618 Date: Tuesday, March 15, 2011 Question: 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 the 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! Answer: I would code as one revision only as you suggested. When we do thrombectomies, we often open the arterial as well as venous anastomosis with separate incisions but can only code one thrombectomy. Lastly, when we do angioplasties via an open incision like here, would use the open venoplasty code 35460 instead of 35476. Thanks, Dr. D David Dunn, MD, FACS

Open thrombectomy dialysis AV fistula with PTA & fistulogram

"The patient has outflow stenosis around the elbow with flow through the perforator vein into the brachial vein with stenosis there. The fistula was opened, and a large amount of thrombus was evacuated. A Fogarty was passed proximally and retrieved clots from there as well. After this the fistulotomy was repaired, and the fistula was then punctured with a needle wire and sheath, and fistulogram was performed. This demonstrated high-grade stenosis of the brachial vein down the perforator, which is the sole outflow of this fistula. We crossed the lesion with a wire and noted that we were in two different perforator systems and ultimately engaged each. These were treated with 6 mm balloon angioplasty. We then also treated the proximal fistula lesion with 8 mm balloon angioplasty. Repeat injection demonstrated improvement. The sheath was removed and the puncture site repaired." Can we report codes 36831, 35476, and 36147 for the same encounter/same physician? There is an NCCI edit on codes 36831 and 36147. Would it be appropriate to assign modifier -59 or-XU to 36147 in this scenario?

AV fistula

I have a question about your response #2884 dated 5/27/11. Why would you recommend 36011, first order selective venous. I have a similar encounter. "a 5 french angiographic catheter was manipulated into the large venous side branch arising from the middle of the patient's left radiocephalic fistula (i.e. forearm cephalic vein). This venous side branch was successfully occluded using six 5mm diameter embolization coils and standard embolization techniques. We coded 36012 for catheter placement. Claire Shumate Compliance Analyst

AV Fistula of Leg

When the physician has no other option to place a fistula in the arms, and he decides to do a direct in the leg from the common femoral vein to common femoral artery, should an unlisted code be used? If so, should we have the code mirrored to 36821?

Open Revision/Trombectomy vs. Percutaneous Fistulogram/venous angioplasty vs Ligation/AV Fistula Creation

I hope you can give some insight into this procedure. Basically the physician performed open revision with thrombectomy (36832), then performed fistulogram (36147), followed by percutaneous venous angioplasy (35476 and 75978-26), and then decided to ligate the entire fistula (37607) and create a whole new graft (36830).  Based on the below documentation, would you bill all those codes? Or should only the open procedure be coded as per NCCI Chapter 5, Section D, #9? Any assistance will be appreciated!

A linear incision was made in the fistula at the arterial anastomosis. I noted immediately that the thrombus was well organized and adherent to the fistula walls. It required mechanical removal. I carefully inspected the area of the arterial anastomosis, removing the fibrin plug. I passed a #3 Fogarty catheter distally in the brachial artery and retrieved no additional thrombus. I sounded the proximal brachial artery with the right angle, and there was no evidence of a stricture at the arterial anastomosis. I removed as much thrombus from the body of the fistula as allowed by the arterial cuff, which had been placed proximally. In order to control the arterial inflow and to avoid stricturing of the fistula, I acquired a bovine patch and partially closed the fistulotomy with the bovine patch and 6-0 Prolene suture. This allowed for application of an atraumatic clamp at the arterial anastomosis and removal of the proximal arterial tourniquet. I evacuated the clot from the remaining portion of the fistula body by vigorous manipulation beginning at the axilla. I removed a relatively small amount of clot. I did retrieve venous backbleeding. Heparinized saline was instilled, and an atraumatic clamp was placed on the body of the graft. The patch angioplasty was completed. There was a pulse within the graft with removal of the arterial tourniquet. This was not accompanied by a thrill though there was a continuous Doppler signal. I cannulated the patch with a 21 gauge micropuncture needle. I advanced the 0.018 guidewire under fluoroscopy. The needle was exchanged for a 5 French transitional dilator. I removed the inner stiffener and 0.018 guidewire, and through the transitional dilator, I performed a fistulogram. Although there was continuous flow in the fistula the fistula was noted to be quite sclerotic. This did not appear to be thrombus. A retrograde filling of the brachial artery revealed the arterial anastomosis to be widely patent. I attempted to pass a short 0.035 guidewire through the transitional dilator, but it would not negotiate the fistula. I acquired a 0.035 Glidewire, and with some manipulation the Glidewire traversed the fistula and was placed in the superior vena cava. I removed the 5 French dilator and advanced a 6 French short sheath. I advanced a 5 French Kumpe catheter over the Glidewire and exchanged the Glidewire for a 0.035 Rosen wire. I repeated the fistulogram documenting the fairly extensive sclerotic changes within the fistula. Again, these did not appear to be thrombus. I acquired a 5 French and subsequently a 6 French x 4 centimeter balloon catheter and proceeded to dilate the entire fistula from the end of the sheath to the basilic vein junction with the brachial vein. There was no evidence of a central stenosis. The balloons were inflated to pressures of 14 millimeters of mercury. Following the balloon angioplasty, I repeated the fistulogram. While there was some improvement in the luminal diameter of the fistula, it remained quite ratty and there was sluggish flow. I did not feel that further efforts at maintaining the fistula would be productive. I ligated the fistula just beyond the arterial anastomosis. I proceeded with an AV graft insertion. A short incision was made in the axilla, and I identified a 12 millimeter brachial vein. I carefully dissected between the nerve trunks and identified a 6-7 millimeter axillary artery. The artery lies medial and deep to the vein. A counterincision was made on the upper arm to allow for tunneling in a loop configuration. The patient was given an additional 1000 units of heparin. I carefully exposed the artery, placing no tension on the nerve trunks. An end-to-side arterial anastomosis was completed with 5-0 Prolene suture. Two of the three large nerve trunks lie medial to the graft and one lies lateral. Upon completion of the anastomosis, there was no anastomotic bleeding. The bovine graft was then withdrawn through the subcutaneous tunnel in two movements. It was allowed to lie in a gentle loop configuration. A partial occlusion clamp was placed on the axillobrachial vein, and an end-to-side anastomosis was completed between the bovine graft and the vein with a 5-0 Prolene suture. Whereas the arterial anastomosis is 5-6 millimeters in length, the venous anastomosis is 8-10 millimeters in length. Prior to completing the anastomosis, the vessels were vented and were flushed with heparinized saline. There was minimal anastomotic oozing. This was readily controlled with Fibrillar. Once hemostasis was confirmed, the three operative wounds were closed with two layers of absorbable suture.

Radiocephalic AV Fistula with Angioplasty

Creation of radiocephalic AV fistula with angioplasty of cephalic vein. Reporting code 36902 seems like it would bundle, and code 36907 is inappropriate. Any ideas?

Modified Miller Banding 36832

We understand that traditional Miller banding on a dialysis fistula is considered an open revision and coded with 36832. Is the more minimally invasive “modified Miller banding” also considered open and coded with 36832? Or would it be considered percutaneous?

"Basilic vein was marked on the skin using duplex and local anesthetic applied. A small 15 blade was used to make a skin incision and the basilic vein was identified. Basilic then encircled with a Prolene and a stiff glidewire was placed on top of the basilic vein and a modified miller banding was then performed. Incision site was then irrigated and closed with interrupted 3-0 Vicryl buried deep dermal followed by 4-0 Monocryl and skin glue."