Ask Dr. Z

Hi Dr. Z. I have a central stenosis treatment question with access from an AV fistula. I know some rules changed this year and the CPT codes. I was on your call in May, but there were no real examples of treatment of central stenosis. We accessed with a micropuncture needle, wire, and sheath. The fistulograms were obtained up to and including the central venous circulation. The patient has a very large fistula. The outflow is fairly rapid. Visualization of the central circulation was difficult, but there was persistent retrograde filling into the internal jugular and other branches around his shoulder consistent with the clinical impression of central obstruction. I ended up placing a #7-French sheath and passing a guide wire. We meet obstruction about the level of the trachea in the innominate vein. We passed a Bern catheter and performed selective injections in this area which appear to confirm a stenosis just at about the level of the trachea and left of the trachea and central vessels there. With some difficulty with an angled wire, I eventually crossed this lesion. I selected a 10-mm balloon and performed 2 inflations to angioplasty the area with good resolution of a mild wasting in the area. I do not feel there was any real indication to aggressively dilate this further. Follow-up images appear to show improved outflow. Finally, there is clearly adequate outflow for this thing to function. My question is about the catheter coding and S&I for the central stenosis now. I know the 36147 now includes the visualization of the central vessels, so does this also then includes the cath placement to the central vessels as well? At what point now would you use the 36010 via AV Fistula access and do you have an example of the 75791? We coded the above as 36147 since the 36010 is a CCI edit and he only goes to the inomminate and not the SVC. We also coded the 35476 and 75978 for the angioplasty of the vein. Are we on target or totally missing this? Thanks Dr. Z. TN Subscriber 8.26.10.