Wiki Dialysis Cath insertion and exchange of Femoral cath to PICC

Sarahcox182

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I am scrubbing an OP note and want to make sure I am interpreting and coding correctly. The patient has a history of surgeries w/i the global period so I know they will need to be coded with 79 modifier. My questions is do the CPTs look correct? I checked with the NCCI edits as well and see nothing that indicates wrong edits etc

Description of Procedure: The patient was taken to the procedure room. She was placed in the supine position on NX flat table. Proper Identification of patient and site of surgery was done, and under sedation and using the ultrasound, lidocaine 1% was used to infiltrate under the right clavicle. Under direct ultrasound guidance, using a micropuncture kit, the needle accessed the Subclavian vein and we proceeded to advance an 0.018 guidewire into the Superior Vena Cava. The needle was exchanged. We proceeded to introduce a 4-French catheter that would go easily into the right Subclavian vein. We then proceeded to exchange the 0.018 guidewire for the 0.035 guidewire the kit. After introducing an 0.035 guidewire into the 4-French catheter, we then proceeded to mark the different access points for the tunneling of the catheter. After this was done, we then proceeded to under direct fluoroscopic guidance use the dilators over the wire, starting with the smaller dialtor first, followed by the larger dilator and subsequently, we proceeded to advance the split sheath over the dilator. This was done under direct fluoroscopic guidance going into the Superior Vena Cava. After this was completed, we then proceeded to tunnel the catheter from a counter incision lower down in the chest towards the incision of the access point. The catheter was then positioned in the desired location. We then proceeded to remove the introducer and the wire. the sheath was left in place, which was then used to introduce the hemodialysis catheter and once this was into the Superior Vena Cava and holding direct pressure over it, the sheath was split slowly and gradually. The catheter was pushed farther in until the catheter was in the Right Atrium. We then tested the backflow and inflow with excellent backflow and inflow without any issues. The catheters were flushed with saline and once again rechecked with fluoroscopy to be in the right position. We then proceeded to introduce 2.5cc of heparinized saline 1000 units per port to avoid clotting and the ports were then locked in palce and the hubs were placed at the end. After this was done, we then proceeded to attach the catheter to the skin both at the entrance point and at the level of the Y bifurcation as well. The small incision at the entrance to the subclavian was closed with 4-0 Vicryl suture and Steri-Strips. After the catheter was well secured and access points were covered with 2x2s and Tegaderm, we then proceeded to go down to the groin area. Because the patient had no IV access that could be found preoperatively, the right femoral catheter was used during the procedure; however, to have access during recovery room, the right femoral catheter was exchanged over the wirse for a single-lumen CVP line, which would be removed later before discharge. Pressure was applied at the entrance point after the CVP line was changed and secured in place to the skin with 4-0 Prolene suture. After this was completed, the patient was taken in good condition to the recovery room.

It is important to note that an attempt was made to have the patient admitted to the hospitalist service for in hospital dialysis; however, the hospitalist stated that no longer hemodialysis is done on the floor during weekends; therefore, the plan is to then remove the CVP line at the femoral level and discharge the patient home. I did speak directly to the hemodialysis unit and the patient has a good chance to having hemodialysis on Monday via the new catheter.

Tunneled Subclavian Catheter--36558
Insertion of PICC line--36569
PICC Removal--36589

Thank you for any guidance!!
 
No ma'am so this case we don't use any of those because subcutaneous ports were placed, so we code this as
36566, (+)76937 (ultrasound guidance)
(+)77001 Fluoroscopic guidan e for Venous procedures.
So you were close on the Tunneled central venous access, however this catheter was done with subcutaneous ports.
And I'm a bit iffy as in some parts of seems as though it was 1 Tunneled central venous cath placed with 1 port and other parts of the documentation lead me to suspect this was placement of 2 Tunneled CVA and two subcutaneous ports.
Either way we would NOT code the femoral catheter removal or placement as it is inherent to and bundled into either procedure.
I would clarify whether or not two central venous catheters with 2 ports was placed which I believe is what we're looking at which we code as 36566.
If only one Tunneled CVA with 1 port we code 36561.
 
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