EngageMed2
Contributor
Can you bill 36821 & 36832 if one fistula is at forearm near the hand and is taken down and then a separate one created near the AC fossa? Here is the op note.
Written informed consent was obtained from the patient. Site was marked. The patient was then taken from preop staging area to the operating room suite, placed supine on the operating room table. General endotracheal anesthesia was introduced. Antibiotics were infused. Patient was positioned supine. Left arm was prepped draped in normal sterile fashion. Time-out was called. Ioban skin protectant was used. I had marked out the arterial venous anatomy with ultrasound prior to prepping. We began with takedown of the forearm fistula. I made an incision through the previous scar at the wrist. I gained control of the fistula vein. Dissection was aided by tourniquet. The tourniquet was inflated. I divided the cephalic vein fistula and closed the vein with 6-0 Prolene. The radial artery was then repaired with a cuff of vein with a running 6-0 Prolene. The tourniquet was taken down and good flow was confirmed to the hand with Doppler. Palmar arch and ulnar arteries along with radial artery showed good signals. We irrigated with warm saline and closed with 3-0 Vicryl followed by 4 Monocryl.
I then turned my attention to creation of the upper arm fistula. A transverse incision was made a fingerbreadth below the antecubital fossa. I deepened this with cautery through subcu tissue. Sharp dissection was then used to dissect out the antecubital vein. I divided the outflow to the basilic vein between 3-0 silk ties. This gave the dominant outflow to the upper arm cephalic vein. I then marked the vein with a skin marker to prevent inadvertent twisting. I then opened the biceps fascia and dissected out the brachial artery ulnar artery and proximal radial artery. I gained control of the proximal radial artery keeping flow to the hand through the ulnar artery. Arteriotomy was then made with an 11 blade scalpel and Potts scissors. Stay stitches were placed. The vein was divided and spatulated. I then performed an end to side anastomosis with a running 7-0 Prolene suture. We released flow to the proximal radial artery and to the fistula. Care was taken to ensure hemostasis. We had a palpable thrill in the fistula with good flow documented with Doppler to the fistula to the brachial, radial, ulnar arteries. We also had continued good flow to the hand at the distal radial, ulnar and palmar arch. Satisfied we irrigated the surgical site with saline. We closed in layers with 3-0 Vicryl and 4 Monocryl. Both skin incisions were cleaned and dressed with Dermabond
Any help is appreciated.
Written informed consent was obtained from the patient. Site was marked. The patient was then taken from preop staging area to the operating room suite, placed supine on the operating room table. General endotracheal anesthesia was introduced. Antibiotics were infused. Patient was positioned supine. Left arm was prepped draped in normal sterile fashion. Time-out was called. Ioban skin protectant was used. I had marked out the arterial venous anatomy with ultrasound prior to prepping. We began with takedown of the forearm fistula. I made an incision through the previous scar at the wrist. I gained control of the fistula vein. Dissection was aided by tourniquet. The tourniquet was inflated. I divided the cephalic vein fistula and closed the vein with 6-0 Prolene. The radial artery was then repaired with a cuff of vein with a running 6-0 Prolene. The tourniquet was taken down and good flow was confirmed to the hand with Doppler. Palmar arch and ulnar arteries along with radial artery showed good signals. We irrigated with warm saline and closed with 3-0 Vicryl followed by 4 Monocryl.
I then turned my attention to creation of the upper arm fistula. A transverse incision was made a fingerbreadth below the antecubital fossa. I deepened this with cautery through subcu tissue. Sharp dissection was then used to dissect out the antecubital vein. I divided the outflow to the basilic vein between 3-0 silk ties. This gave the dominant outflow to the upper arm cephalic vein. I then marked the vein with a skin marker to prevent inadvertent twisting. I then opened the biceps fascia and dissected out the brachial artery ulnar artery and proximal radial artery. I gained control of the proximal radial artery keeping flow to the hand through the ulnar artery. Arteriotomy was then made with an 11 blade scalpel and Potts scissors. Stay stitches were placed. The vein was divided and spatulated. I then performed an end to side anastomosis with a running 7-0 Prolene suture. We released flow to the proximal radial artery and to the fistula. Care was taken to ensure hemostasis. We had a palpable thrill in the fistula with good flow documented with Doppler to the fistula to the brachial, radial, ulnar arteries. We also had continued good flow to the hand at the distal radial, ulnar and palmar arch. Satisfied we irrigated the surgical site with saline. We closed in layers with 3-0 Vicryl and 4 Monocryl. Both skin incisions were cleaned and dressed with Dermabond
Any help is appreciated.