margaret fahy
Guru
Hi, Guys,
Can someone help me with this one?
Not sure if I'm to code for both the venous and arterial angioplasties.
I have....36147,36148...and would it be 35475, 35476,59...with their rs&i codes...75962 and 75978?
Thanks so much.
HISTORY: End-stage renal disease with right upper arm fistula
(brachial artery to transposed basilic vein fistula) with
suboptimal dialysis flow via this access. Flows <300mls.
PROCEDURE: Ultrasound evaluation with Doppler was performed to
find a suitable sites for accessing the fistula (of venous
outflow to direct towards the central veins as well as basilic
vein near the axilla to direct access towards arterial
anastomosis.
The skin of the right upper arm was prepped and draped in usual
sterile manner. Under real-time ultrasound guidance access to the
fistula was achieved directed towards the central veins. A
vascular sheath (initially a 6 French subsequently changed to a 7
French) was placed and diagnostic patient either be from the
arterial inflow to the right atrium was performed. Given the
redemonstration of multifocal hemodynamically significant venous
stenoses (>50%) within the mid venous segment of the fistula,
angioplasty was performed with a 7 mm balloon. Involving the more
peripheral of significant venous stenoses, there was difficulty
with resolving continued waist involving this stenosis despite
repeated angioplasty. An additional Bentson wire was placed into
the fistula and passed centrally, and then the site was
reangioplastied with a 7 mm, which successfully resolved waist
around this stenosis. Multiple attempts were also made to
angioplasty the inflow/peripheral venous stenosis with the same 7
mm balloon, however given the landing zone of the sheath which
was erected towards the central veins it was difficult to get a
successful resolution of the stenosis. Completion fistulography
was performed. This vascular sheath was removed and hemostasis
was achieved with woggle technique. Next attention was directed
towards vascular access of the venous outflow near the axilla but
directed towards arterial anastomosis. Using real-time ultrasound
guidance, the venous outflow directed towards the arterial
anastomosis was achieved. A vascular sheath (7 French) was placed
and diagnostic fistulography was performed once the wire and
catheter were used to advance into the brachial artery. This
fistulogram demonstrated hemodynamically significant stenoses
involving the perianastomotic area as well as the peripheral
aspect of the venous inflow of the fistula. Angioplasty of the
peripheral aspect of the venous inflow was performed with a 7 mm
balloon and a perianastomotic arterial stenosis was performed
with a 4 mm mustang balloon. Completion fistulography including
reflux evaluations from this vascular access demonstrated brisk
flow through the fistula without significant stenoses. The
vascular sheath directed towards arterial anastomosis was being
removed, at which time there was transection of the vascular
sheath near the hub resulting in a significant portion of the
catheter to remain behind. This portion of the upper arm was
evaluated with fluoroscopic and ultrasound guidance which
confirmed the remnant catheter was within the soft tissues of the
right upper arm. Using fluoroscopic and ultrasound guidance, the
residual portion of the catheter was grasped and removed from the
soft tissues successfully. Two woggles were placed along with
manual compression to achieve hemostasis.
As a result of manual compression and time spent achieving the
foreign body from remnant catheter, it was then noted that the
fistula no longer demonstrated a good thrill, therefore this site
was evaluated with ultrasound. This demonstrated acute thrombus
within the fistula, however over time it was noted that thrombus
was improving but given the vulnerability of the access for this
patient, it was determined the thrombus within the fistula should
be addressed immediately.
Real-time ultrasound guidance was used to access the fistula
directed towards the central veins and a vascular sheath was
placed. A diagnostic fistulography was performed which
demonstrated mild or stenosis within the venous outflow which was
recently angioplastied probably a result of a elastic
recoil/residual stenosis in addition to thrombus within the
inflow portion of the fistula. The fistula from the level of the
axilla towards the arterial anastomosis was reangioplastied with
a 7 mm balloon. Post angioplasty/completion facial atrophy
demonstrated resolution of the stenosis and thrombus within the
fistula. The vascular sheath was removed and hemostasis was
achieved with woggle.
Dr. was present for the entire procedure. The patient will
be immediately observed in the radiology recovery suite and then
will be admitted to for observation.
FINDINGS:
Initial ultrasound of the fistula demonstrated patent, and echoic
and compressible vessel with areas of stenoses that correspond to
the recent fistulogram. Redemonstrated two regions of
hemodynamically significant venous stenoses >70% within the mid
venous segment of the fistula. Compression reflux fistulography
demonstrated approximately a 50% stenosis at arterial anastomotic
site as demonstrated on prior examination. The brachial
artery/arterial inflow appears satisfactory. No hemodynamically
significant stenoses are seen within the central veins. Post
angioplasty/completion angiography demonstrates no residual
hemodynamically significant stenoses or thrombus.
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
IMPRESSION
IMPRESSION
1. Two areas of >70% stenosis of the basilic outflow vein of the
fistula successfully dilated with high pressure 6 and 7mm
Conquest balloons to supra maximal pressure of 35mmHg.
2. Arterial anastomosis stenosis of approximately 50% dilated
with a 4mm balloon.
3. Significantly improved thrill throughout the whole right upper
arm noted , no pulsatility remaining.
Results
Can someone help me with this one?
Not sure if I'm to code for both the venous and arterial angioplasties.
I have....36147,36148...and would it be 35475, 35476,59...with their rs&i codes...75962 and 75978?
Thanks so much.
HISTORY: End-stage renal disease with right upper arm fistula
(brachial artery to transposed basilic vein fistula) with
suboptimal dialysis flow via this access. Flows <300mls.
PROCEDURE: Ultrasound evaluation with Doppler was performed to
find a suitable sites for accessing the fistula (of venous
outflow to direct towards the central veins as well as basilic
vein near the axilla to direct access towards arterial
anastomosis.
The skin of the right upper arm was prepped and draped in usual
sterile manner. Under real-time ultrasound guidance access to the
fistula was achieved directed towards the central veins. A
vascular sheath (initially a 6 French subsequently changed to a 7
French) was placed and diagnostic patient either be from the
arterial inflow to the right atrium was performed. Given the
redemonstration of multifocal hemodynamically significant venous
stenoses (>50%) within the mid venous segment of the fistula,
angioplasty was performed with a 7 mm balloon. Involving the more
peripheral of significant venous stenoses, there was difficulty
with resolving continued waist involving this stenosis despite
repeated angioplasty. An additional Bentson wire was placed into
the fistula and passed centrally, and then the site was
reangioplastied with a 7 mm, which successfully resolved waist
around this stenosis. Multiple attempts were also made to
angioplasty the inflow/peripheral venous stenosis with the same 7
mm balloon, however given the landing zone of the sheath which
was erected towards the central veins it was difficult to get a
successful resolution of the stenosis. Completion fistulography
was performed. This vascular sheath was removed and hemostasis
was achieved with woggle technique. Next attention was directed
towards vascular access of the venous outflow near the axilla but
directed towards arterial anastomosis. Using real-time ultrasound
guidance, the venous outflow directed towards the arterial
anastomosis was achieved. A vascular sheath (7 French) was placed
and diagnostic fistulography was performed once the wire and
catheter were used to advance into the brachial artery. This
fistulogram demonstrated hemodynamically significant stenoses
involving the perianastomotic area as well as the peripheral
aspect of the venous inflow of the fistula. Angioplasty of the
peripheral aspect of the venous inflow was performed with a 7 mm
balloon and a perianastomotic arterial stenosis was performed
with a 4 mm mustang balloon. Completion fistulography including
reflux evaluations from this vascular access demonstrated brisk
flow through the fistula without significant stenoses. The
vascular sheath directed towards arterial anastomosis was being
removed, at which time there was transection of the vascular
sheath near the hub resulting in a significant portion of the
catheter to remain behind. This portion of the upper arm was
evaluated with fluoroscopic and ultrasound guidance which
confirmed the remnant catheter was within the soft tissues of the
right upper arm. Using fluoroscopic and ultrasound guidance, the
residual portion of the catheter was grasped and removed from the
soft tissues successfully. Two woggles were placed along with
manual compression to achieve hemostasis.
As a result of manual compression and time spent achieving the
foreign body from remnant catheter, it was then noted that the
fistula no longer demonstrated a good thrill, therefore this site
was evaluated with ultrasound. This demonstrated acute thrombus
within the fistula, however over time it was noted that thrombus
was improving but given the vulnerability of the access for this
patient, it was determined the thrombus within the fistula should
be addressed immediately.
Real-time ultrasound guidance was used to access the fistula
directed towards the central veins and a vascular sheath was
placed. A diagnostic fistulography was performed which
demonstrated mild or stenosis within the venous outflow which was
recently angioplastied probably a result of a elastic
recoil/residual stenosis in addition to thrombus within the
inflow portion of the fistula. The fistula from the level of the
axilla towards the arterial anastomosis was reangioplastied with
a 7 mm balloon. Post angioplasty/completion facial atrophy
demonstrated resolution of the stenosis and thrombus within the
fistula. The vascular sheath was removed and hemostasis was
achieved with woggle.
Dr. was present for the entire procedure. The patient will
be immediately observed in the radiology recovery suite and then
will be admitted to for observation.
FINDINGS:
Initial ultrasound of the fistula demonstrated patent, and echoic
and compressible vessel with areas of stenoses that correspond to
the recent fistulogram. Redemonstrated two regions of
hemodynamically significant venous stenoses >70% within the mid
venous segment of the fistula. Compression reflux fistulography
demonstrated approximately a 50% stenosis at arterial anastomotic
site as demonstrated on prior examination. The brachial
artery/arterial inflow appears satisfactory. No hemodynamically
significant stenoses are seen within the central veins. Post
angioplasty/completion angiography demonstrates no residual
hemodynamically significant stenoses or thrombus.
Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.
IMPRESSION
IMPRESSION
1. Two areas of >70% stenosis of the basilic outflow vein of the
fistula successfully dilated with high pressure 6 and 7mm
Conquest balloons to supra maximal pressure of 35mmHg.
2. Arterial anastomosis stenosis of approximately 50% dilated
with a 4mm balloon.
3. Significantly improved thrill throughout the whole right upper
arm noted , no pulsatility remaining.
Results
