JulieAnne1970
New
Looking for guidance on AV Fistulas: Patient had a 36821 6 months prior. The provider wants to charge 36832 and 36819. There is a bundling NCCI edit with modifier allowed to unbundle but, to me, the op note supports a revision. Just second guessing myself and need confirmation from some experts.
PROCEDURE: Transposition brachiobasilic vein AV fistula Left arm
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room placed in supine position by the operating table. After an adequate level of general anesthesia had been administered the Left arm was prepped and draped in usual manner. A timeout was held. The patient had previously undergone a left brachiobasilic vein AV fistula creation. The vein was mature and patient comes in today for transposition of the fistula. A skin incision was made over the basilic vein just proximal to the arterial anastomosis and taken down through the underlying subcutaneous tissue down to the vein. The vein was then dissected free of surrounding tissue and surrounded with a Penrose drain. We then continued to extend the incision the entire length of the arm up to the left axilla mobilizing the vein as we went. Any side branches were divided between 2 and 3-0 silk ties and hemoclips. After completely mobilizing the vein we transected the vein just central to the arterial anastomosis. We then pulled the vein from underneath the crossing nerve structures. Next a 10 French red rubber catheter passed through the vein and flushed well. There was a short segment stricture about 5cm central to the anastomosis. The stricture was serially dilated with a 2, 2.5, 3, 3.5, and 4mm bates coronary dilators. Any small areas of leakage were oversewed with interrupted sutures of 6-0 Prolene. Following this we made a tunnel through the subcutaneous tissue between the proximal and distal parts of the incision lateral to the incision. The vein was then tunneled between the 2 incisions with care being taken not to kink the vein. Once again we placed a 10 French red rubber catheter its entire length through the vein and it passed freely and flushed freely. I then performed a end to end anastomosis between the arterialized vein segment to the non-arterialized vein with a running suture of 6-0 Prolene. The vascular clamps were removed. Immediately the vein distended up nicely and had excellent thrill. Hemostasis was ensured using Floseal and Surgicel snow. A preliminary needle sponge and tape count was reported be correct. The superficial fascia was approximated with interrupted sutures of 3-0 Vicryl. The skin was then approximated with running sutures of nylon and dressed with Xeroform gauze 4 x 4's and tape. The patient tolerated the procedure well and was returned to the recovery room in stable condition.
Thanks
Julie
PROCEDURE: Transposition brachiobasilic vein AV fistula Left arm
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room placed in supine position by the operating table. After an adequate level of general anesthesia had been administered the Left arm was prepped and draped in usual manner. A timeout was held. The patient had previously undergone a left brachiobasilic vein AV fistula creation. The vein was mature and patient comes in today for transposition of the fistula. A skin incision was made over the basilic vein just proximal to the arterial anastomosis and taken down through the underlying subcutaneous tissue down to the vein. The vein was then dissected free of surrounding tissue and surrounded with a Penrose drain. We then continued to extend the incision the entire length of the arm up to the left axilla mobilizing the vein as we went. Any side branches were divided between 2 and 3-0 silk ties and hemoclips. After completely mobilizing the vein we transected the vein just central to the arterial anastomosis. We then pulled the vein from underneath the crossing nerve structures. Next a 10 French red rubber catheter passed through the vein and flushed well. There was a short segment stricture about 5cm central to the anastomosis. The stricture was serially dilated with a 2, 2.5, 3, 3.5, and 4mm bates coronary dilators. Any small areas of leakage were oversewed with interrupted sutures of 6-0 Prolene. Following this we made a tunnel through the subcutaneous tissue between the proximal and distal parts of the incision lateral to the incision. The vein was then tunneled between the 2 incisions with care being taken not to kink the vein. Once again we placed a 10 French red rubber catheter its entire length through the vein and it passed freely and flushed freely. I then performed a end to end anastomosis between the arterialized vein segment to the non-arterialized vein with a running suture of 6-0 Prolene. The vascular clamps were removed. Immediately the vein distended up nicely and had excellent thrill. Hemostasis was ensured using Floseal and Surgicel snow. A preliminary needle sponge and tape count was reported be correct. The superficial fascia was approximated with interrupted sutures of 3-0 Vicryl. The skin was then approximated with running sutures of nylon and dressed with Xeroform gauze 4 x 4's and tape. The patient tolerated the procedure well and was returned to the recovery room in stable condition.
Thanks
Julie