baratii
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Hi All:
Can anyone assist me in below case:
On physical examination, the patient has a proximal right upper extremity arteriovenous fistula. There are multiple indwelling stents noted in the outflow vein. There is a moderate-sized aneurysm present at the antecubital fossa, which has pulse-like thrill. The remainder of the fistula demonstrates no palpable thrill. 1% lidocaine was used to anesthetize the skin. Using ultrasound guidance, the arterial limb where there is a moderate-sized aneurysm present was accessed towards the outflow direction and a 6-French introducer sheath was placed. Contrast was injected, which shows that the arterial limb and moderate aneurysm in this location are patent, but the remainder of the fistula is thrombosed. A 5-French Kumpe catheter was introduced over a 0.035 wire and right central venogram and right upper extremity fistulogram was performed from the superior vena cava to the access site. 3000 units of heparin were administrated intravenously. Next, a 5-French Trerotola device was introduced and used to mechanically thrombolyze the arteriovenous fistula from the axillary vein to the access site. Followup angiogram shows significant clearance of clot. There still remains a significant 90% narrowing with persistent residual clot in the arterial limb in between the indwelling stents and the patent moderate-sized aneurysm. In addition, there are multiple 40% to 75% areas of stenosis seen throughout the indwelling stents. Also, there is a diffuse 6.0 cm segment of 80% narrowing of the outflow axillary vein. All of these areas were angioplastied with an 8.0 mm x 60.0 mm balloon. Followup angiogram shows resolution of the stenosis within the indwelling stents and in the outflow axillary vein. However, despite multiple angioplasties and Trerotola passes, the residual clot and 75% narrowing spanning 3.0 cm in the arterial limb in between the aneurysm and the indwelling stents persist. This is ultimately treated by placement of an 8.0 mm x 16.0 mm Bard LifeStar Stent. This is post angioplastied with 8.0 mm x 60.0 mm
balloon. Followup angiogram shows resolution of the stenosis and restoration of brisk flow and good palpable thrill. All catheters, wires and sheaths were then removed. Hemostasis of the access site was achieved using suture closure with 3-0 absorbable Vicryl sutures with adequate hemostasis achieved. A bandage was placed. The patient tolerated the procedure without immediate complication and was transferred to postoperative recovery in good condition for observation.
Findings: Patient with proximal right upper extremity brachial artery to axillary vein arteriovenous fistula. The fistula is thrombosed. Successful mechanical thrombolysis was performed.
A 3.0-cm segment of 75% persistent narrowing and persistent clot in the arterial limb in between arterial limb aneurysm and indwelling stents in place. This stenosis/residual clot remains despite multiple angioplasty attempts. This was ultimately treated with placement of an 8.0 mm x 60.0 mm Bard LifeStar Stent with resolution of the stenosis and very good angiographic result. Long segment of multiple indwelling telescoping stents noted in the outflow vein. There are several areas of intrastent stenosis ranging from 40% to 80% stenosis. These areas of stenosis resolved after angioplasty with
8.0 mm x 60.0 mm balloon with resolution of stenosis and good angiographic result. A 6.0 cm segment of diffuse 80% narrowing of the outflow axillary vein, resolved after angioplasty with a 8.0 mm x 60.0 mm balloon. No right central venous stenosis. The right subclavian vein, brachiocephalic vein and superior vena cava are widely patent. No arterial anastomotic stenosis. There is moderate-sized aneurysm of the arterial anastomosis/arterial limb. This is at the antecubital fossa.
Impression:
1. SUCCESSFUL DECLOT OF RIGHT UPPER EXTREMITY ARTERIOVENOUS FISTULA.
2. MULTIPLE AREAS OF 40% TO 80% STENOSIS SEEN THROUGHOUT INDWELLING STENTS IN THE OUTFLOW
VEIN, RESOLVED AFTER ANGIOPLASTY WITH GOOD ANGIOGRAPHIC RESULT.
3. 6.0-CM SEGMENT OF 80% STENOSIS OF THE RIGHT AXILLARY OUTFLOW VEIN, RESOLVED AFTER
ANGIOPLASTY WITH GOOD ANGIOGRAPHIC RESULT.
4. 3.0-CM SEGMENT OF PERSISTENT 75% STENOSIS/RESIDUAL CLOT NOTED IN THE ARTERIAL LIMB. THIS
DOES NOT RESOLVE AFTER MULTIPLE ANGIOPLASTY ATTEMPTS AND THEREFORE WAS SUCCESSFULLY
TREATED WITH STENT PLACEMENT WITH GOOD ANGIOGRAPHIC RESULT AND RESOLUTION OF THE
STENOSIS.
5. MODERATE-SIZED ANEURYSM NOTED AT THE ARTERIAL LIMB/ARTERIAL ANASTOMOSIS.
6. NO RIGHT CENTRAL VENOUS STENOSIS.
7. BRISK FLOW AND VERY GOOD THRILL PRESENT AFTER THE PROCEDURE.
My Codes are :
37236
36870
35476
36147
75978
Can we code the angioplasty in vein(CPT 35476) when arterial stent(CPT 37236) is placed or When Arterial and Venous repair of an AV fistula is performed, only the arterial or highest level of intervention performed within the same zone should be coded???
Thanks.
Can anyone assist me in below case:
On physical examination, the patient has a proximal right upper extremity arteriovenous fistula. There are multiple indwelling stents noted in the outflow vein. There is a moderate-sized aneurysm present at the antecubital fossa, which has pulse-like thrill. The remainder of the fistula demonstrates no palpable thrill. 1% lidocaine was used to anesthetize the skin. Using ultrasound guidance, the arterial limb where there is a moderate-sized aneurysm present was accessed towards the outflow direction and a 6-French introducer sheath was placed. Contrast was injected, which shows that the arterial limb and moderate aneurysm in this location are patent, but the remainder of the fistula is thrombosed. A 5-French Kumpe catheter was introduced over a 0.035 wire and right central venogram and right upper extremity fistulogram was performed from the superior vena cava to the access site. 3000 units of heparin were administrated intravenously. Next, a 5-French Trerotola device was introduced and used to mechanically thrombolyze the arteriovenous fistula from the axillary vein to the access site. Followup angiogram shows significant clearance of clot. There still remains a significant 90% narrowing with persistent residual clot in the arterial limb in between the indwelling stents and the patent moderate-sized aneurysm. In addition, there are multiple 40% to 75% areas of stenosis seen throughout the indwelling stents. Also, there is a diffuse 6.0 cm segment of 80% narrowing of the outflow axillary vein. All of these areas were angioplastied with an 8.0 mm x 60.0 mm balloon. Followup angiogram shows resolution of the stenosis within the indwelling stents and in the outflow axillary vein. However, despite multiple angioplasties and Trerotola passes, the residual clot and 75% narrowing spanning 3.0 cm in the arterial limb in between the aneurysm and the indwelling stents persist. This is ultimately treated by placement of an 8.0 mm x 16.0 mm Bard LifeStar Stent. This is post angioplastied with 8.0 mm x 60.0 mm
balloon. Followup angiogram shows resolution of the stenosis and restoration of brisk flow and good palpable thrill. All catheters, wires and sheaths were then removed. Hemostasis of the access site was achieved using suture closure with 3-0 absorbable Vicryl sutures with adequate hemostasis achieved. A bandage was placed. The patient tolerated the procedure without immediate complication and was transferred to postoperative recovery in good condition for observation.
Findings: Patient with proximal right upper extremity brachial artery to axillary vein arteriovenous fistula. The fistula is thrombosed. Successful mechanical thrombolysis was performed.
A 3.0-cm segment of 75% persistent narrowing and persistent clot in the arterial limb in between arterial limb aneurysm and indwelling stents in place. This stenosis/residual clot remains despite multiple angioplasty attempts. This was ultimately treated with placement of an 8.0 mm x 60.0 mm Bard LifeStar Stent with resolution of the stenosis and very good angiographic result. Long segment of multiple indwelling telescoping stents noted in the outflow vein. There are several areas of intrastent stenosis ranging from 40% to 80% stenosis. These areas of stenosis resolved after angioplasty with
8.0 mm x 60.0 mm balloon with resolution of stenosis and good angiographic result. A 6.0 cm segment of diffuse 80% narrowing of the outflow axillary vein, resolved after angioplasty with a 8.0 mm x 60.0 mm balloon. No right central venous stenosis. The right subclavian vein, brachiocephalic vein and superior vena cava are widely patent. No arterial anastomotic stenosis. There is moderate-sized aneurysm of the arterial anastomosis/arterial limb. This is at the antecubital fossa.
Impression:
1. SUCCESSFUL DECLOT OF RIGHT UPPER EXTREMITY ARTERIOVENOUS FISTULA.
2. MULTIPLE AREAS OF 40% TO 80% STENOSIS SEEN THROUGHOUT INDWELLING STENTS IN THE OUTFLOW
VEIN, RESOLVED AFTER ANGIOPLASTY WITH GOOD ANGIOGRAPHIC RESULT.
3. 6.0-CM SEGMENT OF 80% STENOSIS OF THE RIGHT AXILLARY OUTFLOW VEIN, RESOLVED AFTER
ANGIOPLASTY WITH GOOD ANGIOGRAPHIC RESULT.
4. 3.0-CM SEGMENT OF PERSISTENT 75% STENOSIS/RESIDUAL CLOT NOTED IN THE ARTERIAL LIMB. THIS
DOES NOT RESOLVE AFTER MULTIPLE ANGIOPLASTY ATTEMPTS AND THEREFORE WAS SUCCESSFULLY
TREATED WITH STENT PLACEMENT WITH GOOD ANGIOGRAPHIC RESULT AND RESOLUTION OF THE
STENOSIS.
5. MODERATE-SIZED ANEURYSM NOTED AT THE ARTERIAL LIMB/ARTERIAL ANASTOMOSIS.
6. NO RIGHT CENTRAL VENOUS STENOSIS.
7. BRISK FLOW AND VERY GOOD THRILL PRESENT AFTER THE PROCEDURE.
My Codes are :
37236
36870
35476
36147
75978
Can we code the angioplasty in vein(CPT 35476) when arterial stent(CPT 37236) is placed or When Arterial and Venous repair of an AV fistula is performed, only the arterial or highest level of intervention performed within the same zone should be coded???
Thanks.