Is the placement of a stent in the venous outflow of a graft considered a revision

smerriweather1

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Good morning, I have been having a professional discussion with one of my vascular doctors regarding how this operative note was coded and I would appreciate some other thoughts please.
Provider codes: 36147--he states the fistulogram was done via a separate incision so it should be reportable.
36831
37230

This case was coded and billed with a 36883,GC-- as a revision with thrombectomy

I did not code this case and I personally am thinking the following codes should apply:
37230, GC
36883,59,GC
I believe even with the separate incision the purpose of the 36147 was to check the outflow of the thrombectomy, 36883, and therefore is inclusive to the procedure. The decision to do the stenting (37230) is the treatment to the stenosis and the completion fistulogram done at the end of that portion of the procedure remains inclusive to the 36883 still.

Here is the Operative Note:
DATE OF SURGERY: 09/06/2016

SURGEON: Bugs Bunny, MD

ASSISTANT: Donald Duck, MD-Resident

SECOND ASSISTANT: Mickey Mouse, PA-C (no qualified surgical resident available to assist).

PREOPERATIVE DIAGNOSIS: Occluded basilic vein transposition of left upper extremity.

POSTOPERATIVE DIAGNOSIS: Reopening of the fistula.

PROCEDURES:
1. Open thrombectomy of basilic vein transposition fistula.
2. Fistulogram.
3. Stenting of the outflow with 8 x 100 Viabahn stent graft.
4. Balloon angioplasty of basilic vein with 10 x 40 angioplasty balloon catheter.

COMPLICATIONS: None apparent.

INDICATIONS FOR PROCEDURE: Mr. X is a patient of ABC Hospital, he has been dialyzed through the left basilic vein transposition fistula, developed thrombosis of the fistula and recommendations were for thrombectomy. I had a long discussion with the patient about the risks and benefits of the procedure, risks of infection, ischemic complications, and limb loss. The patient understood the risks and benefits of the procedure and consented to the procedure.

DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed on surgical table in supine position. Sedation was provided by anesthesia team. Local anesthetic was used on the table. A surgical time-out was initiated and antibiotics were administered, all of it was documented in the chart electronically. Left upper extremity was prepped and draped in standard surgical manner. A longitudinal incision was made over the arterial anastomosis with a skin knife. It was carried through subcutaneous tissue using electrocautery. By using sharp and blunt dissection, basilic vein was dissected and encircled with vessel loop. The patient was given 3000 units of heparin and it was allowed to circulate systematically. Transverse arteriotomy was made with an 11 blade and extended with Potts scissors. Multiple _____ thrombus was removed from the venous outflow. A large thrombus was milked out using #4 and #5 Fogarty catheter, thrombectomy was successfully performed. Arterial thrombus was removed and the arterial bullet was passed off surgical table as a pathology specimen. Arteriotomy was made with interrupted sutures. Upon the completion of the repair, the patient had thrill throughout the entire length of the fistula. Fistula was cannulated through the separate incision and 6-French sheath was introduced and fistulogram was performed, which revealed high-grade stenosis at the confluence of the basilic and brachial veins. Decision was made to perform stenting. An 0.018 wire was introduced, parked in the right atrium and 90% stenosis was stented with 8 x 100 Viabahn stent graft. It was _____ with 8-mm balloon. In the midportion of the graft, there was still residual stenosis, which was post-balloon dilated with 10 mm balloon. During the inflation of balloon, contrast refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis of arterial anastomosis. Balloon was deflated. Completion fistulogram was performed, which revealed excellent flow through all the segments of the veins including axillary, subclavian, and brachiocephalic. Decision was made to stop the procedure. Sheath and the catheter were removed. Hemostasis achieved with figure-of-eight stitch. Incisions were inspected. Hemostasis was excellent. Incision was closed in layers by approximating subcutaneous tissues using Vicryl. Skin was closed using Monocryl. Upon the completion of the procedure, patient had excellent thrill throughout the entire length of the fistula and palpable pulse in radial artery at the wrist.
 

cpc2007

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There is no documentation to support revision of the AV fistula through an open incision (the stent is not considered a revision as defined by CPT 36833 for revision with thrombectomy). Open revision of an AV fistula can involve a variety of techniques depending on the exact complication the patient is experiencing. It may include taking down and re-creating the A/V anastomosis, ligating collateral branches feeding into the fistula, or inserting an interposition graft into the AV shunt. The stent is a separately reportable intervention though performed through a percutaneous technique, so it does not qualify as an open revision and we don't want to double dip and claim it as such.

For the fistulogram, it's not really the separate puncture that determines whether or not the fistulogram is separately reportable. It depends on whether the patient had a recent fistulogram with identified complications and the physician brought him to the OR for a planned intervention or if this is a truly diagnostic study that identifies a complication with the fistula and a decision to intervene is made. I would consider the fistulogram that occurs after the thrombectomy diagnostic because he identifies the area of 90% stenosis and decides to place a stent based on these findings.

My codes in this case would be 37238 (stent in a vein of the upper extremity), 36831 and 36147.
 

smerriweather1

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Thank you for your response, and I am sorry for my delay in replying. I am surprised anyone did, I usually pose questions and have many who look, but few or no responses.
Its hard to find other cardiovascular coders to bounce questions off of.
 
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