Question Venogram with PAC Placement

frankal

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Can somebody please let me know with CPT codes. I am not completely sure if you can charge a venogram with port placement.

Op Note:

The patient was seen and examined in the preoperative holding
area. Consent was obtained and signed. All risks and benefits of procedure were explained
to the patient in detail, all questions answered. She expressed understanding. She was then
taken back to the operative suite and placed on the operating table in supine position. She
was anesthetized by the Anesthesia team and placed under MAC anesthesia. She was prepped and
draped in standard sterile fashion after a time-out was performed identifying the correct
patient and procedure.
Ultrasound was then used to identify the right internal jugular vein. I then took an
introducer needle and inserted it into the right internal jugular vein on the first attempt
after locally anesthetizing the skin with 1% lidocaine with epinephrine. Once the introducer
needle was in the right internal jugular vein, dark nonpulsatile blood was noted on return.
A guidewire was then threaded through the introducer needle using the Seldinger technique.
The introducer needle was subsequently removed. I confirmed placement of the wire in the
internal jugular vein with ultrasound and then I brought fluoroscopy in to confirm placement.
At that time, I noted that the wire was curling just superior to the heart and I attempted
several different maneuvers to try to get the wire to go down into the SVC, but I was unable.
After several attempts at this, I decided to perform a venogram. I then removed the wire and
then performed a second stick of the right internal jugular vein with ultrasound guidance.
This was done on the first attempt. Dark nonpulsatile blood was found through the introducer
needle. I then shot 50:50 of saline and contrast through the introducer needle to perform a
venogram. At that time, it was noted that there was some abnormal anatomy and I was going to
be unable to thread the catheter through the right internal jugular vein. Therefore, at that
time, I decided to perform a right subclavian stick. After I shot the venogram, I threaded
the needle over the guidewire in a modified Seldinger technique and removed the introducer
needle. I left that wire in place until I was able to get subclavian access. I then used
the introducer needle to stick the right subclavian vein on the first attempt. Dark
nonpulsatile blood was noted on return. Placement was confirmed with ultrasound and
fluoroscopy was then brought in to confirm that the wire was going into the SVC, which it
was. At that time, I then removed the introducer needle and I then locally anesthetized this
area with 1% lidocaine with epinephrine. An incision was made from the wire laterally to
create the pocket for the port. I then threaded the introducer sheath over the wire and
subsequently removed the wire and the dilator, leaving the sheath in place. I measured the
port tubing to be appropriate length with the use of fluoroscopy. I then threaded the port
tubing through the sheath until it was completely in the vein. I subsequently peeled away
the sheath and sutured the port into place at 3 different places using Prolene suture.
Access with heparinized saline of the port was gained and the port and tubing was flushed
with heparinized saline. This was done twice, noting dark nonpulsatile blood on return. I
then performed a final flush with heparin through the port. A final fluoroscopic shot was​
obtained. The tubing was not kinked and was in good position.
 
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