Question need help coding this please

heart123

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he patient was brough to the operating room and was placed supine with arms at 90 degrees. After time out was performed the patient intubated, was given antibiotics and the upper extremity was prepped and draped in the usual sterile fashion. Attention was then turned to the antecubital fossa. A 6 cm transverse incision was then perfomed , the cephalic vein was identified and was skeletonized along its distal 5 cm in the arm, dissection being carried as distally as possible. The tendonous aponeurosis of the biceps was then incised and the brachial artery was exposed and was encircled with a vessel loop. The patient was given heparin intravenously. The cephalic vein was ligated at its most distal end and was brought into the arterial side of the operative field. Vascular clamps were used to obtain control of the brachial artery and a 6 mm longitudinal arteriotomy was then made with a 11 blade. Stay sutures were placed. The end of the vein was slightly spatulated to match the size of the arteriotomy. The arterio-venous anastomosis was then performed with 6-0 prolene, in a continuous running manner. At the completion the artery was back and forward flushed., and the sutures were tied. There was evidence of an excellent thrill in the cephalic vein in the arm; the radial artery at the wrist maintained its pulse. The wound was then closed in 2 layers, as usual.
The right neck and upper chest were prepped and draped in usual sterile fashion. IUnder ultrasound guidance, the right internal jugular vein was cannulated with an 18-gauge needle. A 0.035 inch starter wire was inserted into the superior vena cava under fluoroscopy. there si resistance on advancing the wire so a venogram was obtained through a 5 Fr sheathplaced over the wire: the above mentioned junction is stenotic. An Advantage wire is used to maneuver the stenosis , and its tip is dropped in the IVC. A skin nick was made at the puncture site with a #11 blade. The 23 cm Bard catheter was brought in from the lateral right chest wall with a sharp tunneler; a sheath was placed over the wire and the obturator was removed. The sheath was removed and the peel away sheath was placed over the wire. The obturator is removed and the catheter tip was placed within the sheath over the wire. The sheath was then peeled away, leaving the catheter tip in position. The catheter tip was pulled back such that the skin cuff was at the chest wall exit site. Both ports were flushed with heparinized saline and packed with tPA. The puncture site was reapproximated with subcuticular 4-0 Monocryl stitch. Dermabond and sterile dressings were applied. The patient tolerated the procedure well and was extubated at the conclusion of the case. He was returned to the post anesthesia care unit in satisfactory condition.
 

ernist8489

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Hi,
For the arteriovenous anastomosis have you looked at 36821? For the second procedure 36566.

Hope this helps,
I reviewed and coded this same case for them last night.
Your 100% correct on the Arteriovenous Anastomosis ( Brachial-Cephalic AV Fistula For hemodialysis access, direct anastomosis) we would code as 36821.
However let's talk about the Tunneled Central Venous Access Device placement with placement of subcutaneous port.
I was very iffy between reporting 36566 (CVC Tunneled, two catheters, two access sites, two ports) and 36561- CVC Tunneled with subcutaneous port.
I may have over thought this but I wasn't really comfortable with assigning 36566 because I didn't feel as though two separate catheters were places from two access sites and the only documentation of the ports is the closing statement from the physician when he states he flushes ports with saline and packed with TPA.
Maybe I misread it though and if I did I would love to go over this with you.
Also we would absolutely code (+)76937 For ultrasound guided jugular access and documentation of fluoroscopy enables us to report (+)77001. We typically in most cases report both Fluoro and U/S guidance with Central Cath placements when rendered.
Thanks in advance.
Erik Brown, CIRCC, CPC
 

kathrynw

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was very iffy between reporting 36566 (CVC Tunneled, two catheters, two access sites, two ports) and 36561- CVC Tunneled with subcutaneous port.
I may have over thought this but I wasn't really comfortable with assigning 36566 because I didn't feel as though two separate catheters were places from two access sites and the only documentation of the ports is the closing statement from the physician when he states he flushes ports with saline and packed with TPA.
Maybe I misread it though and if I did I would love to go over this with you.
Also we would absolutely code (+)76937 For ultrasound guided jugular access and documentation of fluoroscopy enables us to report (+)77001. We typically in most cases report both Fluoro and U/S guidance with Central Cath placements when rendered.
Erik, you are absolutely right. I would recommend querying the physician for clarification on the ports/catheters before making a determination. I also forgot to mention the ultrasound and flouroscopy codes. Thank you for replying with them!
 
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