Wiki Coil emboliz/laser ablation-venous access/venogram

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Hy Guys,
Would someone give me their opinion re procedure below.
I know I can't bill for the Endovenous Ablation, as it is in the same operative field as the Coil Embolization. But I was wonder the correct billing re....venogram and venous access. So, it's 37241 and 36011 X3?..what about the Venogram done..it is a separate site....
Your input would be most appreciated.

Indications:
Diagnosis:Venous malformation [747.60 (ICD-9-CM)]
Reason:Endovascular Laser of Right Leg

CLINICAL HISTORY: 6-year-old boy with history of KT syndrome
right leg,
which is painful and not responding to conservative treatment.
Very dilated lateral vein in the upright position with extension
into the lesser saphenous vein.

COMPARISON: MRI 2/7/14

PROCEDURE: Endovenous laser ablation of of a large lateral vein
extending
along the lateral aspect of the of the calf from the lesser
saphenous vein and entering the common femoral vein and sciatic
vein to iliac veins via numerous upper thigh/buttock draining
veins.

MEDICATIONS: Tumescent anesthesia with 0.1% lidocaine - 127mls
saline (5mg/kg max)

PROCEDURE IN DETAILS: Limited ultrasound examination demonstrated

a large slow flow lateral vein along the posterior aspect of the
right calf and thigh from the lesser saphenous vein and entering
the common femoral vein and sciatic vein to common femoral vein
via numerous upper thigh/buttock draining veins.
The right lower extremity was draped and prepped in usual sterile
manner. A superficial vein along the posterior aspect of the
calf, slightly above the ankle joint, was accessed using a
21-gauge micropuncture needle and ultrasound guidance. Contrast
was injected and limited venogram was obtained again demonstrated

a large lateral vein extending along the lateral aspect of the of
the calf from the lesser saphenous vein and entering the common
femoral vein and sciatic vein to iliac veins via numerous upper
thigh/buttock draining veins.The decision was made to do
endovenous laser ablation for this vein with outflow occlusion of
some larger more superior channels.

COIL EMBOLIZATION:
Three outflow veins in the right upper thigh, two to the sciatic
vein and ultimately the common femoral vein were accessed with a
Penumbra high flow microcatheter and 0.016 Fathom wire and each
vein was injected with contrast confirming the central vein
connection.
Upper lateral vein 1 - 10mm, 35cm and 6mm 20cm Penumbra
detachable coils
Upper lateral vein 2 - 8mm, 25cm detachable coil
Upper lateral vein 3 - 8mm, 45cm detachable coil

ENDOVENOUS LASER ABLATION:
A guide wire was advanced with real-time ultrasound guidance
through this vein to the junction with greater saphenous vein. A
5 French calibrated sheath was placed. Next, tumescent anesthesia
was performed along the entire lateral vein from the upper
lateral thigh to the site of access just above the ankle. After
confirming
optimal tumescent anesthesia along the entire course of the
venous segment to be treated, endovenous laser ablation was
performed with the AngioDynamics VenaCure device. 7 Watts of
continuous laser energy was administered along each 1 cm segment
of vein over 10 seconds for a total of 27cm, for treatment time
of 264.7 seconds and a cumulative energy of 1765.95 Joules. This
corresponded to a mean energy of 70 Joules/cm. The sheath was
removed and local pressure applied
until hemostasis was assured. A sterile dressing was applied.

Whole right leg ACE and Coban wrap was applied with moderate
compression. There were no complications, and the patient left
the IR suite in stable condition.was present for the
entire
procedure.

FINDINGS:
1. KT Syndrome with dilated vein form lesser saphenous vein to
common femoral vein via a number of outflow veins in upper
lateral thigh.
2. Coil outflow occlusion of three larger outflow veins.
3. Following tumescent anesthesia, good apposition of the vein
wall
with the sheath housing the laser fiber was seen along the entire

course of the vein to be treated.
4.Confirmation of laser tip position in upper lateral thigh
distal to the coils with multiple views prior to the initiation
of laser energy.

IMPRESSION
IMPRESSION
1.Successful endovenous laser ablation of a large lateral vein
with ablation segment extending 27cm from the upper lateral thigh
to juts above the ankle including the lesser saphenous vein
segment, 7 watt setting for 70 joules/cm.
2. Successful coil outflow occlusion of three draining veins from
the lateral thigh and gluteal region To the common femoral vein.

PLAN:
Follow up US in 72 hours in US to assess for DVT in US and with
Dr in IR for physical assessment.
Compression wrap for 72 hours
NSAID therapy 8 hourly for inflammation for 72 hours.
Oxycodone PO for pain
 
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