Ask Dr. Z

 Dr. Z, I hope you can help us resolve this coding issue. HIM and I are coming up with different codes. I read the following as an open procedure of an AV graft including angioplasty, thrombectomy, and thrombolysis. PROCEDURE: The patient was taken to the operating room and placed on the operating room table in supine position. General anesthesia was given. The right upper extremity was washed circumferentially and prepped and draped in traditional sterile fashion. A small transverse incision was made right over the graft above the bicipital fossa. Through that incision, the graft was identified and was encircled with umbilical tape. A small graftotomy was performed and then using a 5 French and then a 4 French Fogarty embolectomy catheter, thrombectomy of the venous limb was carried out. After removal of well organized clots, we noticed that the patient will develop new fresh clots right at the same time undergoing the thrombectomy. The patient was then given 5,000 units of heparin. Then thrombectomy of the arterial limb was carried out with return of brisk pulsatile flow. The graft was clamped proximally and a 6 French sheath was inserted, directed toward the venous anastomosis, and a fistulogram was obtained. It showed a slight narrowing at the venous anastomosis and then a patent right subclavian axillary system, high-grade stenosis at the level of the right innominate vein with flow being diverted to large collaterals. Superior vena cava was patent without significant stenosis demonstrated there. A 0.035 inch Glidewire was advanced through the 6 French sheath and then sequential balloon angioplasty of right innominate vein was performed, first using a 10 x 40 mm conquest balloon and then a 12 x 40 mm conquest balloon. Then using a 6 mm Fox balloon, we gently inflated the balloon at the venous anastomosis. A repeat injection of contrast was satisfactory with no residual stenosis demonstrated. Then the sheath was removed and the angioplasty of the right innominate vein was performed through a 8 French sheath and then the 8 French was removed. The graft was clamped toward the venous anastomosis. The 6 French sheath was inserted, directed to the arterial anastomosis. An injection of contrast demonstrated a patent anastomosis, however, there was thrombus present into the radial artery and the distal brachial artery. A .035 inch Glidewire was advanced through the brachial, then the radial artery, down to the level of the wrist, and then a Fogarty embolectomy catheter was used, and embolectomy was performed of the radial artery and the distal brachial artery using a 4 French Fogarty embolectomy catheter. A repeat injection of contrast showed a persistent defect into the proximal right radial artery. Unclear whether it was a plaque. It persisted after a repeat embolectomy. Then it was angioplastied using a 4 x 40 mm balloon. A repeat injection of contrast after angioplasty showed some improvement. Intraoperative infusion of thrombolytic therapy was used. Approximately 3 mg of TPA was administered. Then a repeat injection of contrast was satisfactory with no further defects demonstrated to be present and good flow going down the radial artery into the end. We then had a palpable radial pulse present. The sheath was removed. The small opening in the graft was closed using interrupted sutures of CV-6 Gore-Tex suture. The wound was closed in two layers using 3-0 Vicryl in the subcutaneous tissue and the skin was closed using subcuticular suture of 4-0 Monocryl. Dermabond was applied and a small sterile dressing. SUPERVISION AND INTERPRETATION: Following a surgical thrombectomy of the right arm arteriovenous graft, a fistulogram was obtained and the findings are as outlined above. Balloon angioplasty was performed, first of the right innominate vein using up to a 12 x 40 mm balloon and then at the venous anastomosis using a 6 x 40 mm Fox balloon. Subsequently, injection of contrast demonstrated there was interruption of flow and thrombus into the distal brachial artery and the proximal radial artery and was it treated with thromboembolectomy and intraoperative infusion of thrombolytic therapy and also balloon angioplasty of the proximal right radial artery where there was narrowing and what appears to be a plaque present. A repeat completion angiogram was satisfactory with good flow demonstrated to the brachial artery, the radial artery to the hand. Here are the codes that I think should be assigned: 36381, 75790, 75798-59, 35460, 75798-59, G0393, 34101, 34111, 75962, 35458, 75986, 37201. I should add that this was done during 2009. We need all the education and help we can get. Thanks,