mhaney
Contributor
My physician attempted to do a radiofrequency ablation on a patients leg but the vein went into spasm and collapsed on its own and he was not able to use radiofrequency catheter. So he was successful in achieving collapse of the diseased vein but not able to use radiofrequency. Since he did not turn on the RFA device, would still be appropriate to use 36475 code? Maybe with a modifier? I appreciate the help!
Op note:
[Local anesthesia was given in the inner aspect of the right lower extremity in the right mid-calf area, then using micropuncture technique and US guidance venous access was obtained, and a 7 Fr venous sheath was inserted in the right accessory GSV as on scan today appeared to be severely dilated with reflux. It appeared to be a bridging vein from right GSV in calf to the GSV in low thigh at knee level. After placing the sheet in right accessory vein, vein went into spasm and got thrombosed and I was not able to introduce the 7F Covidien ClosureFast™ catheter. Then I did a second attempt to insert get access in proximal GSV closer to the junction of right accessory vein to right GSV. After getting access and placing the sheet the same situation happened. Again right GSV went into spasm and caused thrombosis and I was not able to introduce the closure fast catheter. The sheath and the Closurefast catheter were then removed, and hemostasis was achieved using manual pressure.A pressure ACE bandage was done on the right lower extremity.]
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The right common femoral vein was fully compressible after the procedure with no evidence of DVT.
Op note:
[Local anesthesia was given in the inner aspect of the right lower extremity in the right mid-calf area, then using micropuncture technique and US guidance venous access was obtained, and a 7 Fr venous sheath was inserted in the right accessory GSV as on scan today appeared to be severely dilated with reflux. It appeared to be a bridging vein from right GSV in calf to the GSV in low thigh at knee level. After placing the sheet in right accessory vein, vein went into spasm and got thrombosed and I was not able to introduce the 7F Covidien ClosureFast™ catheter. Then I did a second attempt to insert get access in proximal GSV closer to the junction of right accessory vein to right GSV. After getting access and placing the sheet the same situation happened. Again right GSV went into spasm and caused thrombosis and I was not able to introduce the closure fast catheter. The sheath and the Closurefast catheter were then removed, and hemostasis was achieved using manual pressure.A pressure ACE bandage was done on the right lower extremity.]
*
The right common femoral vein was fully compressible after the procedure with no evidence of DVT.