Ask Dr. Z

I have read and re-read your information so far on the new AV fistula codes as well as CPT and CPT assistant and am going to take a stab at this (no pun intended, ha ha), but would really appreciate hearing your thoughts on the best way to code, given the information so far available on the application of these new codes. PREOP DX: Chronic renal failure, failing left thigh arteriovenous fistula. POSTOP DX: Chronic renal failure, failing left thigh arteriovenous fistula, stenosis of the arteriovenous fistula, long segment, approx 12cm. OPERATION: Right groin puncture, sonographic guidance into the right common femoral artery, aortic and left lower extremity angiogram, non-selective, sonographic-guided puncture of the left thigh arteriovenous fistula, fistulogram, and angioplasty of the arteriovenous fistula and the arteriovenous anastomosis. The patient has an AV fistula of the left greater saphenous vein in the left thigh. We have dilated about three weeks before and again the fistula was failing. We thought that there was some arterial component. We decided to do an angiogram first and then possible angioplasty of the AV fistula. DESCRIPTION OF THE PROCEDURE: Both groins and left thigh were prepped and draped. We then infiltrated lidocaine in the right groin and under sonographic guidance we did a direct puncture into the right common femoral artery. We then placed a wire and a 4-French sheath over the wire. We went in with a diagnostic Omni flush catheter into L1 and then proceeded to move the catheter down to the bifurcation and do a different injection. Findings were as follows. Abdominal Aorta: The abdominal aorta was patent with no evidence of stenosis. Both renal arteries were patent with no evidence of stenosis. The SMA was patent with no evidence of stenosis. The bifurcation was patent with no evidence of stenosis. The common iliac arteries bilaterally were patent with no evidence of stenosis. The left superficial femoral artery was patent with no evidence of stenosis. We then visualized the anastomosis. It was patent with a severe stenosis of the AV fistula right at the anastomosis, and beyond that a segment of approx 12cm. At this point, then we infiltrated lidocaine in the AV fistula. Under sonographic guidance, did a direct puncture into the fistula, and proceeded to do a fistulogram directly and then passed a wire through the stenosis. After that, we placed a 5X6 angioplasty balloon and inflated right at the anastomosis and beyond that, for a long area that was stenotic. After this was done, then we proceeded to do a completion fistulogram, and it showed that there was a complete patency of the AV fistula. There was no evidence of extravasation, and the fistula at this point was patent. There was a complete resolution of the stenosis. There was no residual stenosis. We then proceeded to pull on the sheath and the patient received 2000 units of heparin. We pulled first the puncture in the AV fistula. There was no evidence of any bleeding or hematoma at this point, patient was stable. Here are my questions: My initial thought was to code 75791 for the first puncture to the right common femoral artery. However, there is no description of any venous imaging/outflow on either the initial angiogram from the right femoral access, nor of the direct puncture of the AV fistula so would either 75791 or 36147 be appropriate? I know I can't use both of these codes together, but it really seems like this would be the answer if the lack of venous outflow imaging isn't an issue. 36147 would indicate the initial access to the fistula, and although 36148 refers to access for intervention, that seems to be for an additional access into the fistula and there was only one direct access. If I think about the reference to access for intervention I could choose 36148 but then I can't use that without using 36147 first. Should this be coded as an abdominal arteriogram 36200-75625, then 36147? I'm not clear on whether this is an angioplasty in the arterial side or the venous side and the whether the 12cm segment is within the graft? So it would be either 35474/75962 or 35476/75978? And if 36147 is supposed to include all catheter placements does that wipe out the 36200 if I go that route? The direct puncture came second but does that matter if it includes all catheter placements? I am really stumped. I realize I may just have to take my best shot and wait to see as info develops for these codes, but I'm really not sure what my best shot should be! Thanks, I'm sure you will want to edit as this is long winded, but you did ask for thought process!! I am not coding the sono guidance as I have no documentation or images captured for that. I also was hesitant to code an extremity angiogram as all he described of the left leg was the SFA and profunda femoral were patent. Thanks again!!!