kissing balloon angioplasty/stent

[Shirleybala]

Hi,
I am having problem in coding this report thro a same point of access 2 guidewires are inserted and did a kissing ballon angioplasty in both baraciocephalic vein and kept 2 stents if we have to code 2 cath codes
Please help me to code this.
The patient's left arm was prepped and draped in the usual sterile
manner and locally anesthetized with lidocaine. Preliminary
ultrasound evaluation was done in the arm, demonstrating patent
left basilic vein, which was documented. Under real time
ultrasound guidance the left basilic vein was accessed with a
micropuncture set, image recorded. The access site was dilated
and 7 French vascular sheath was placed. Contrast was injected
and digital subtraction angiography was performed.

Findings:

There is high grade stenosis/ virtual occlusion of essentially the
entire length of the left brachiocephalic vein and a short segment
of the superior vena cava, just below the confluence of
brachiocephalic veins. Selective injection was performed to the
right brachiocephalic vein, confirming patency.

The left groin was then prepped and draped in the usual sterile
manner and locally anesthetized with lidocaine. The left common
femoral vein was accessed with a micropuncture set, exchange made
for a second seven French vascular sheath. A Berenstein catheter
and angled glide wire was then successfully advanced into the
super vena cava, across the high grade stenosis into the right
brachiocephalic vein. An exchange was made for a Rosen guide
wire. A second Rosen guidewire was advanced from the left groin
across the stenosis, right atrium and into the inferior vena cava.

After administration of 3000U IV heparin, Kissing balloon
angioplasty was performed of the superior vena cava extending into
both brachiocephalic veins, using 8mm diameter x 8cm long
balloons. Angiography performed after balloon dilatation
demonstrates no improvement.

Subsequently 2 stents were deployed; a 14 mm x 6 cm extending
from the SVC to the right brachiocephalic vein and a 14 mm x 8 cm
long luminex stent extending from the SVC into the left
brachiocephalic vein. The stents were post dilated to 10 mm again
with kissing balloons. Completion angiography was performed
demonstrating patency of the stents. However there still was poor
flow since the left brachiocephalic vein had not been stented
peripherally enough.

The port catheter tip again had to be repositioned, the catheter
tip was successfully pushed into the left axillary vein with a
Fogarty balloon. A second luminex stent was then placed, 12 mm x
4 cm extending further into the left brachiocephalic vein, just to
the IJ vein. This was post-dilated with a 10 mm balloon. The
port catheter tip in the left axillary vein was then snared from
the groin, and pulled back into the super vena cava. Completion
angiography was performed demonstrating improved flow, and patency
of all 3 stents with contiguous flow of contrast from the left
axillary vein into the right atrium.

At the end of the procedure both vascular sheaths were removed and
hemostasis achieved with manual compression. The patient
tolerated the procedure well, left the department in stable
condition.

Thanks,
Shirley

[MLS2]

this one's a doozie! I'm thinking an upper extremity venogram (75820/36005) from the basilic vein access. From the left groin access I got a 36011 for the cath. advancement to the rt. braciocephalic vein, and a 36012 for the lt axillary cath. placement. It sounds like the SVC (75827) was angioplastied (75978/35476) and that the balloons extended into the braciocephalic veins...I think I would do that as one angioplasty. 2 stents, 75960x2, 37205, 37206. I was also thinking a 36010 for the placement in the IVC from the 2nd guidewire via the femoral artery (not 100% on that though)
let me know your thoughts on this one

[Shirleybala]

Hi,

I have coded like this but i was not yet satisfied so only i left for the clarification.

37205- one stent in rt brachiocephalic vein
37206- additional stent in lt brachiocephalic vein
35476-one angioplasty in rt brachiocephalic vein
35476-59- one angioplasty in lt brachiocephalic vein
36569- the cath thro the lt basilic vein is then changed to port catheter (snared from groin and placed in SVC) taken as PICC line .
36011-first guide wire to rt brachiocephalic vein thro left common fem vein approach
36011-59- second guide wire to lt brachiocephalic vein thro left common fem vein approach
75978-26- angioplasty S&I
75978-2659- angioplasty S&I
75960-26- Stent S&I
75960-2659- additional stent S&I
75827-2659- SVC gram thro lt basilic vein approach.
Thanks
Shirley

[MLS2]

Ok after looking at this again... I have 2 stents (75960x2, 37205, 37206) and 2 angioplasties (75978x2, 35476x2 of the braciocephalics). I have the upper extremity venogram from the basilic vein access (75820/36005) 36011x2 for bilateral braciocephalic veins from the groin access and an SVCgram (75827). What i'm thinking is that there was the arm access and the leg access and that they met at the IVC for the kissing balloon angioplasties. I don't see anything about a PICC line though.
what do you think? we're getting there

[Shirleybala]

Hi,

Basilic vein approach is not used for kissing balloon angioplasty it is used for a separate angioplasty , kissing balloon angioplasty is done by passing 2 guidewires thro the same left groin approach.

The basilic vein catheter is changed in to PICC line in the last paragraph (snared from the groin and left in SVC)

[MLS2]

your physician's wording is just different from what i'm used to reading...even the interventionalist that I work for was confused on this one
hopefully you got the answers you needed.