jtuominen
Guru
Hi there-- Looking for a quick second opinion on the coding of this case. Is there are case to code 36005/75820 in addition to 76937/36558/77001 for this case? My instincts are leaning towards no.
TUNNEL CATH PLACEMENT > 5 YEARS RIGHT
HISTORY: Patient has a left upper arm fistula which has rethrombosed
for the third time in the past month. The patient and her family
requests dialysis catheter placement.
FINDINGS: The procedure and risks were explained to the patient in
detail. Upon review of prior images, the patient has stents placed
throughout the course of the left subclavian and innominate veins to
the level of the origin of the superior vena cava on the left.
Therefore catheter placement was planned for the right. Ultrasound was
used to document the status of the right internal jugular vein. A
permanent image was obtained for the patient's record. Ultrasound
documented no identifiable internal jugular or external jugular veins.
There are multiple small collateral veins within the right neck. Under
sterile ultrasound guidance the largest of these collaterals was
accessed with a needle and a wire was advanced into a more central
collateral vein. A venogram was then performed to evaluate for any
usable right upper extremity access vein. The collaterals did fill the
subclavian vein retrogradely which appeared to fill a narrowed
innominate vein. The superior vena cava was shown to be patent. Therefore under fluoroscopic guidance and roadmapping technique, a
puncture made into the lateral aspect of the right subclavian vein and
a wire was placed. A 5 French dilator was advanced over a wire into
the right atrium across the narrowed innominate vein segment.
Subcutaneous tunnel was created along the right anterior chest wall
and a palindrome 14.5 French 19 cm tip-to-cuff dialysis catheter was
placed through the tunnel. The dialysis catheter stiffeners were
utilized and advanced over a wire into the caval atrial junction. Both
ports of the catheter were then aspirated and flushed demonstrating
good function and were subsequently heparin-locked. A permanent
fluoroscopic image was obtained demonstrating the tip of the dialysis
catheter at the SVC/right atrial junction. The catheter was sutured in
place with 2-0 Prolene. The JB-I angiographic catheter was then
removed from the collateral vein and manual compression was placed at
the venotomy site until hemostasis was obtained. There were no
immediate complications.
Fluoro time 7.8 minutes
Contrast 35 mL Hexabrix
Local anesthetic 20 mL 1% lidocaine
Medication 2 mg IV Versed, 125 mcg IV fentanyl, 1 gram IV Ancef
Sedation time 35 minutes
The patient was monitored by radiology nursing staff under my
supervision and remained stable throughout the study.
IMPRESSION:
1. The left upper arm fistula was not revascularized at the family's
request. Instead a tunnel dialysis catheter was placed.
2. The patient has an occluded right internal and external jugular
vein with collateral formation in the right upper chest and a narrowed
right brachiocephalic vein segment.
3. A tunnel dialysis catheter was placed via the right subclavian vein
into the SVC/right atrial junction as described above.
TUNNEL CATH PLACEMENT > 5 YEARS RIGHT
HISTORY: Patient has a left upper arm fistula which has rethrombosed
for the third time in the past month. The patient and her family
requests dialysis catheter placement.
FINDINGS: The procedure and risks were explained to the patient in
detail. Upon review of prior images, the patient has stents placed
throughout the course of the left subclavian and innominate veins to
the level of the origin of the superior vena cava on the left.
Therefore catheter placement was planned for the right. Ultrasound was
used to document the status of the right internal jugular vein. A
permanent image was obtained for the patient's record. Ultrasound
documented no identifiable internal jugular or external jugular veins.
There are multiple small collateral veins within the right neck. Under
sterile ultrasound guidance the largest of these collaterals was
accessed with a needle and a wire was advanced into a more central
collateral vein. A venogram was then performed to evaluate for any
usable right upper extremity access vein. The collaterals did fill the
subclavian vein retrogradely which appeared to fill a narrowed
innominate vein. The superior vena cava was shown to be patent. Therefore under fluoroscopic guidance and roadmapping technique, a
puncture made into the lateral aspect of the right subclavian vein and
a wire was placed. A 5 French dilator was advanced over a wire into
the right atrium across the narrowed innominate vein segment.
Subcutaneous tunnel was created along the right anterior chest wall
and a palindrome 14.5 French 19 cm tip-to-cuff dialysis catheter was
placed through the tunnel. The dialysis catheter stiffeners were
utilized and advanced over a wire into the caval atrial junction. Both
ports of the catheter were then aspirated and flushed demonstrating
good function and were subsequently heparin-locked. A permanent
fluoroscopic image was obtained demonstrating the tip of the dialysis
catheter at the SVC/right atrial junction. The catheter was sutured in
place with 2-0 Prolene. The JB-I angiographic catheter was then
removed from the collateral vein and manual compression was placed at
the venotomy site until hemostasis was obtained. There were no
immediate complications.
Fluoro time 7.8 minutes
Contrast 35 mL Hexabrix
Local anesthetic 20 mL 1% lidocaine
Medication 2 mg IV Versed, 125 mcg IV fentanyl, 1 gram IV Ancef
Sedation time 35 minutes
The patient was monitored by radiology nursing staff under my
supervision and remained stable throughout the study.
IMPRESSION:
1. The left upper arm fistula was not revascularized at the family's
request. Instead a tunnel dialysis catheter was placed.
2. The patient has an occluded right internal and external jugular
vein with collateral formation in the right upper chest and a narrowed
right brachiocephalic vein segment.
3. A tunnel dialysis catheter was placed via the right subclavian vein
into the SVC/right atrial junction as described above.
