Question Venograms with thrombectomy and angioplasty

uneeq3

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Hello my IR friends, its been a minute but I have a case I'm not sure about. I would appreciate any help. Thank you in advance.

So I have 37187x2, 37248x2, 75822, 75825, 76937x2


Diagnostic Report - Sunrise Radiology PROCEDURE: Bilateral iliac vein/inferior vena cava venogram with extirpation of venous thrombus and balloon angioplasty.

HISTORY: Severe bilateral lower extremity pain/lower extremity edema due to subacute/chronic thrombosis of the bilateral external/common iliac veins. Status post bilateral iliac vein stenting approximately 4 weeks prior
SURGEON:

PREOPERATIVE DIAGNOSIS:
1 Bilateral severe lower extremity edema

POST OPERATIVE DIAGNOSIS: Thrombosis of the bilateral iliac stents and IVC AngioJet

PROCEDURE LIST:
1. Ultrasound guidance for venous vascular access x2 , bilateral common femoral veins.
2. Bilateral external iliac vein catheterization and venogram.
3. Selective catheterization of the inferior vena cava and inferior vena cava venogram
4. Left external iliac/common iliac vein extirpation of matter; post thrombectomy venography
5. Right external iliac/common iliac vein extirpation of matter; post thrombectomy venography
6. Bilateral external/common iliac vein and inferior vena cava balloon angioplasty.
7. Post intervention angiogram and interpretation


TECHNIQUE/FINDINGS:

General anesthesia was induced by the anesthesiology team.


INFORMED CONSENT: Informed consent was obtained from the patient with an explanation of the potential risks, benefits and alternatives. The risks include bleeding which may be minor or major resulting in need for possible transfusion, vascular injury which could necessitate surgical intervention, unexpected embolization of thrombus into adjacent arteries or veins needing additional treatment, unexpected permanent or temporary nerve injury, or rarely the loss of limb and life.

The bilateral groins were prepped and draped in sterile fashion. 10 mL of 1 Percent subcutaneous lidocaine was administered. Under direct ultrasound guidance, the bilateral common femoral veins were accessed utilizing a micropuncture needle.

Ultrasound was utilized for the evaluation of the underlying vein and for the documentation of potential access sites. It was used to document patency of the vein as well as to place the catheter into the precise desired location within the main. Concurrent real time ultrasound visualization was performed of the needle entering the vessel. Permanent copy of the ultrasound guidance was documented with an ultrasound image and placed into the patient's permanent medical records.

A 018 wire was advanced through the micropuncture needle followed by placement of a small coaxial dilator and both common femoral vein. The inner stiffener was removed. Venography was performed from the micropuncture sheath positioned within the bilateral external iliac veins which demonstrated occlusion of the bilateral external/common iliac vein stents with large pelvic collateral veins. A stiff Glidewire was then advanced through the micropuncture sheath and coiled within the external iliac veins bilaterally. The micropuncture sheath was then exchanged for a 6 French sheath. The occluded iliac stents were then across bilaterally utilizing a stiff Glidewire and Kumpe catheter. Kumpe catheters were then advanced into the inferior vena cava from each access and inferior venacavogram was performed after successful crossing bilaterally demonstrating intraluminal position within the inferior vena cava as well as severe stenosis/atresia of the infrarenal inferior vena cava. Stiff Amplatz wire then placed into the suprarenal inferior vena cava. Over the wire, a 24 French vascular sheath was then placed into the external iliac vein. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the left external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus. Post thrombectomy venogram was then performed.

A 24 French sheath was then placed into the right external iliac vein over a Amplatz wire. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the right external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus.
Post thrombectomy venogram was then performed.

Post thrombectomy bilateral external iliac venogram demonstrates in-line flow to the inferior vena cava however there is severe stenosis of the bilateral external/common iliac veins and infrarenal inferior vena cava. Sequential balloon angioplasty was then performed with thin 8 mm balloon followed by a 12 mm balloon of the bilateral common/external iliac veins as well as inferior vena cava. Post balloon angioplasty demonstrates improvement of in-line flow from the bilateral iliac vein to the inferior vena cava with persistent stenosis of the treated iliac veins and inferior vena cava. Due to requirement for inferior vena cava/iliac vein reconstruction which will necessitate a large approximately 24 mm inferior vena cava stent, which was not available, no stenting was performed at this time.


All wires and catheters removed. A pursestring suture was performed utilizing 2-0 silk with closure utilizing a suture tension device.


Kerma Area Product: 581 Gycm2.

CONTRAST: 160 cc of Visipaque

Medications: 10% 1 mL lidocaine subcutaneous injection. 7000 units intravenous heparin.

IMPRESSION:

INITIAL LATERAL PELVIC VENOGRAM DEMONSTRATES COMPLETE OCCLUSION OF THE EXTERNAL/COMMON ILIAC VEINS. SUCCESSFUL BILATERAL COMMON/EXTERNAL ILIAC VEIN MECHANICAL/SUCTION THROMBECTOMY WITH EXTIRPATION OF MATTER AS WELL AS BILATERAL ILIAC VEIN/INFERIOR VENA CAVA BALLOON ANGIOPLASTY RESULTING IN IN-LINE FLOW FROM THE BILATERAL COMMON FEMORAL VEINS TO THE INFERIOR VENA CAVA.

POST THROMBECTOMY VENOGRAM DEMONSTRATES ATRESIA/SEVERE STENOSIS OF THE INFRARENAL INFERIOR VENA CAVA AND BILATERAL ILIAC VEINS. THIS WILL REQUIRE EVENTUAL BILATERAL ILIAC VEIN/INFERIOR VENA CAVA VENOUS RECONSTRUCTION TO BE PERFORMED in approximately 2-4 weeks. PATIENT TO REMAIN ON SYSTEMIC ANTICOAGULATION UNTIL DEFINITIVE INTERVENTION.
 

mk2001

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Hello my IR friends, its been a minute but I have a case I'm not sure about. I would appreciate any help. Thank you in advance.

So I have 37187x2, 37248x2, 75822, 75825, 76937x2


Diagnostic Report - Sunrise Radiology PROCEDURE: Bilateral iliac vein/inferior vena cava venogram with extirpation of venous thrombus and balloon angioplasty.

HISTORY: Severe bilateral lower extremity pain/lower extremity edema due to subacute/chronic thrombosis of the bilateral external/common iliac veins. Status post bilateral iliac vein stenting approximately 4 weeks prior
SURGEON:

PREOPERATIVE DIAGNOSIS:
1 Bilateral severe lower extremity edema

POST OPERATIVE DIAGNOSIS: Thrombosis of the bilateral iliac stents and IVC AngioJet

PROCEDURE LIST:
1. Ultrasound guidance for venous vascular access x2 , bilateral common femoral veins.
2. Bilateral external iliac vein catheterization and venogram.
3. Selective catheterization of the inferior vena cava and inferior vena cava venogram
4. Left external iliac/common iliac vein extirpation of matter; post thrombectomy venography
5. Right external iliac/common iliac vein extirpation of matter; post thrombectomy venography
6. Bilateral external/common iliac vein and inferior vena cava balloon angioplasty.
7. Post intervention angiogram and interpretation


TECHNIQUE/FINDINGS:

General anesthesia was induced by the anesthesiology team.


INFORMED CONSENT: Informed consent was obtained from the patient with an explanation of the potential risks, benefits and alternatives. The risks include bleeding which may be minor or major resulting in need for possible transfusion, vascular injury which could necessitate surgical intervention, unexpected embolization of thrombus into adjacent arteries or veins needing additional treatment, unexpected permanent or temporary nerve injury, or rarely the loss of limb and life.

The bilateral groins were prepped and draped in sterile fashion. 10 mL of 1 Percent subcutaneous lidocaine was administered. Under direct ultrasound guidance, the bilateral common femoral veins were accessed utilizing a micropuncture needle.

Ultrasound was utilized for the evaluation of the underlying vein and for the documentation of potential access sites. It was used to document patency of the vein as well as to place the catheter into the precise desired location within the main. Concurrent real time ultrasound visualization was performed of the needle entering the vessel. Permanent copy of the ultrasound guidance was documented with an ultrasound image and placed into the patient's permanent medical records.

A 018 wire was advanced through the micropuncture needle followed by placement of a small coaxial dilator and both common femoral vein. The inner stiffener was removed. Venography was performed from the micropuncture sheath positioned within the bilateral external iliac veins which demonstrated occlusion of the bilateral external/common iliac vein stents with large pelvic collateral veins. A stiff Glidewire was then advanced through the micropuncture sheath and coiled within the external iliac veins bilaterally. The micropuncture sheath was then exchanged for a 6 French sheath. The occluded iliac stents were then across bilaterally utilizing a stiff Glidewire and Kumpe catheter. Kumpe catheters were then advanced into the inferior vena cava from each access and inferior venacavogram was performed after successful crossing bilaterally demonstrating intraluminal position within the inferior vena cava as well as severe stenosis/atresia of the infrarenal inferior vena cava. Stiff Amplatz wire then placed into the suprarenal inferior vena cava. Over the wire, a 24 French vascular sheath was then placed into the external iliac vein. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the left external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus. Post thrombectomy venogram was then performed.

A 24 French sheath was then placed into the right external iliac vein over a Amplatz wire. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the right external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus.
Post thrombectomy venogram was then performed.

Post thrombectomy bilateral external iliac venogram demonstrates in-line flow to the inferior vena cava however there is severe stenosis of the bilateral external/common iliac veins and infrarenal inferior vena cava. Sequential balloon angioplasty was then performed with thin 8 mm balloon followed by a 12 mm balloon of the bilateral common/external iliac veins as well as inferior vena cava. Post balloon angioplasty demonstrates improvement of in-line flow from the bilateral iliac vein to the inferior vena cava with persistent stenosis of the treated iliac veins and inferior vena cava. Due to requirement for inferior vena cava/iliac vein reconstruction which will necessitate a large approximately 24 mm inferior vena cava stent, which was not available, no stenting was performed at this time.


All wires and catheters removed. A pursestring suture was performed utilizing 2-0 silk with closure utilizing a suture tension device.


Kerma Area Product: 581 Gycm2.

CONTRAST: 160 cc of Visipaque

Medications: 10% 1 mL lidocaine subcutaneous injection. 7000 units intravenous heparin.

IMPRESSION:

INITIAL LATERAL PELVIC VENOGRAM DEMONSTRATES COMPLETE OCCLUSION OF THE EXTERNAL/COMMON ILIAC VEINS. SUCCESSFUL BILATERAL COMMON/EXTERNAL ILIAC VEIN MECHANICAL/SUCTION THROMBECTOMY WITH EXTIRPATION OF MATTER AS WELL AS BILATERAL ILIAC VEIN/INFERIOR VENA CAVA BALLOON ANGIOPLASTY RESULTING IN IN-LINE FLOW FROM THE BILATERAL COMMON FEMORAL VEINS TO THE INFERIOR VENA CAVA.

POST THROMBECTOMY VENOGRAM DEMONSTRATES ATRESIA/SEVERE STENOSIS OF THE INFRARENAL INFERIOR VENA CAVA AND BILATERAL ILIAC VEINS. THIS WILL REQUIRE EVENTUAL BILATERAL ILIAC VEIN/INFERIOR VENA CAVA VENOUS RECONSTRUCTION TO BE PERFORMED in approximately 2-4 weeks. PATIENT TO REMAIN ON SYSTEMIC ANTICOAGULATION UNTIL DEFINITIVE INTERVENTION.
I don't do just IR so I could be completely wrong here.
76937x2, 75822, 75825, 37187x2, 37248, 37249x2, 36010 & 36005
36005 shows as bundled but modifier allowed so I was wondering if that would be a modifier allowed due to diagnostic angiogram rule since both intervention codes state catheter placement should be coded separately.
I have 37248 & 37249x2 because the book I have states 1 angioplasty should be reported per vessel & 37249 should be used when additional separate and distinct vessels are treated, regardless of whether they are on the same side or the opposite side as the initial angioplasty.

I hope this helps!
 

uneeq3

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I don't do just IR so I could be completely wrong here.
76937x2, 75822, 75825, 37187x2, 37248, 37249x2, 36010 & 36005
36005 shows as bundled but modifier allowed so I was wondering if that would be a modifier allowed due to diagnostic angiogram rule since both intervention codes state catheter placement should be coded separately.
I have 37248 & 37249x2 because the book I have states 1 angioplasty should be reported per vessel & 37249 should be used when additional separate and distinct vessels are treated, regardless of whether they are on the same side or the opposite side as the initial angioplasty.

I hope this helps!
Hi Margaret, thank you so much for your response. So I missed the non-selective code for IVC and injection venogram code. I'm reading the report again and I see my error. So the bilateral iliac angioplasty and IVC angioplasty represents 3 angioplasties with the the first represented with 37248 and the other two 37249....correct? I value the reasoning behind your answers which helps me improve and learn IR coding. I will keep plugging away. As always I appreciate your time.
Thank you again...it really helps. :)

Lisa, COC
 

mk2001

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Hi Margaret, thank you so much for your response. So I missed the non-selective code for IVC and injection venogram code. I'm reading the report again and I see my error. So the bilateral iliac angioplasty and IVC angioplasty represents 3 angioplasties with the the first represented with 37248 and the other two 37249....correct? I value the reasoning behind your answers which helps me improve and learn IR coding. I will keep plugging away. As always I appreciate your time.
Thank you again...it really helps. :)

Lisa, COC
Correct. That's the way I was coding them.

I'm glad I could help and hope you have a great day! :)
 

christoff9

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Hello my IR friends, its been a minute but I have a case I'm not sure about. I would appreciate any help. Thank you in advance.

So I have 37187x2, 37248x2, 75822, 75825, 76937x2


Diagnostic Report - Sunrise Radiology PROCEDURE: Bilateral iliac vein/inferior vena cava venogram with extirpation of venous thrombus and balloon angioplasty.

HISTORY: Severe bilateral lower extremity pain/lower extremity edema due to subacute/chronic thrombosis of the bilateral external/common iliac veins. Status post bilateral iliac vein stenting approximately 4 weeks prior
SURGEON:

PREOPERATIVE DIAGNOSIS:
1 Bilateral severe lower extremity edema

POST OPERATIVE DIAGNOSIS: Thrombosis of the bilateral iliac stents and IVC AngioJet

PROCEDURE LIST:
1. Ultrasound guidance for venous vascular access x2 , bilateral common femoral veins.
2. Bilateral external iliac vein catheterization and venogram.
3. Selective catheterization of the inferior vena cava and inferior vena cava venogram
4. Left external iliac/common iliac vein extirpation of matter; post thrombectomy venography
5. Right external iliac/common iliac vein extirpation of matter; post thrombectomy venography
6. Bilateral external/common iliac vein and inferior vena cava balloon angioplasty.
7. Post intervention angiogram and interpretation


TECHNIQUE/FINDINGS:

General anesthesia was induced by the anesthesiology team.


INFORMED CONSENT: Informed consent was obtained from the patient with an explanation of the potential risks, benefits and alternatives. The risks include bleeding which may be minor or major resulting in need for possible transfusion, vascular injury which could necessitate surgical intervention, unexpected embolization of thrombus into adjacent arteries or veins needing additional treatment, unexpected permanent or temporary nerve injury, or rarely the loss of limb and life.

The bilateral groins were prepped and draped in sterile fashion. 10 mL of 1 Percent subcutaneous lidocaine was administered. Under direct ultrasound guidance, the bilateral common femoral veins were accessed utilizing a micropuncture needle.

Ultrasound was utilized for the evaluation of the underlying vein and for the documentation of potential access sites. It was used to document patency of the vein as well as to place the catheter into the precise desired location within the main. Concurrent real time ultrasound visualization was performed of the needle entering the vessel. Permanent copy of the ultrasound guidance was documented with an ultrasound image and placed into the patient's permanent medical records.

A 018 wire was advanced through the micropuncture needle followed by placement of a small coaxial dilator and both common femoral vein. The inner stiffener was removed. Venography was performed from the micropuncture sheath positioned within the bilateral external iliac veins which demonstrated occlusion of the bilateral external/common iliac vein stents with large pelvic collateral veins. A stiff Glidewire was then advanced through the micropuncture sheath and coiled within the external iliac veins bilaterally. The micropuncture sheath was then exchanged for a 6 French sheath. The occluded iliac stents were then across bilaterally utilizing a stiff Glidewire and Kumpe catheter. Kumpe catheters were then advanced into the inferior vena cava from each access and inferior venacavogram was performed after successful crossing bilaterally demonstrating intraluminal position within the inferior vena cava as well as severe stenosis/atresia of the infrarenal inferior vena cava. Stiff Amplatz wire then placed into the suprarenal inferior vena cava. Over the wire, a 24 French vascular sheath was then placed into the external iliac vein. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the left external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus. Post thrombectomy venogram was then performed.

A 24 French sheath was then placed into the right external iliac vein over a Amplatz wire. Utilizing a 24 French flow retriever suction thrombectomy catheter, and mechanical suction thrombectomy of the right external/common iliac vein was performed. Multiple passes were made yielding a large amount of subacute/chronic thrombus.
Post thrombectomy venogram was then performed.

Post thrombectomy bilateral external iliac venogram demonstrates in-line flow to the inferior vena cava however there is severe stenosis of the bilateral external/common iliac veins and infrarenal inferior vena cava. Sequential balloon angioplasty was then performed with thin 8 mm balloon followed by a 12 mm balloon of the bilateral common/external iliac veins as well as inferior vena cava. Post balloon angioplasty demonstrates improvement of in-line flow from the bilateral iliac vein to the inferior vena cava with persistent stenosis of the treated iliac veins and inferior vena cava. Due to requirement for inferior vena cava/iliac vein reconstruction which will necessitate a large approximately 24 mm inferior vena cava stent, which was not available, no stenting was performed at this time.


All wires and catheters removed. A pursestring suture was performed utilizing 2-0 silk with closure utilizing a suture tension device.


Kerma Area Product: 581 Gycm2.

CONTRAST: 160 cc of Visipaque

Medications: 10% 1 mL lidocaine subcutaneous injection. 7000 units intravenous heparin.

IMPRESSION:

INITIAL LATERAL PELVIC VENOGRAM DEMONSTRATES COMPLETE OCCLUSION OF THE EXTERNAL/COMMON ILIAC VEINS. SUCCESSFUL BILATERAL COMMON/EXTERNAL ILIAC VEIN MECHANICAL/SUCTION THROMBECTOMY WITH EXTIRPATION OF MATTER AS WELL AS BILATERAL ILIAC VEIN/INFERIOR VENA CAVA BALLOON ANGIOPLASTY RESULTING IN IN-LINE FLOW FROM THE BILATERAL COMMON FEMORAL VEINS TO THE INFERIOR VENA CAVA.

POST THROMBECTOMY VENOGRAM DEMONSTRATES ATRESIA/SEVERE STENOSIS OF THE INFRARENAL INFERIOR VENA CAVA AND BILATERAL ILIAC VEINS. THIS WILL REQUIRE EVENTUAL BILATERAL ILIAC VEIN/INFERIOR VENA CAVA VENOUS RECONSTRUCTION TO BE PERFORMED in approximately 2-4 weeks. PATIENT TO REMAIN ON SYSTEMIC ANTICOAGULATION UNTIL DEFINITIVE INTERVENTION.

I would code 36010 x 2 because both catheters were placed in the IVC. You get 75822 and 75825 for imaging. Good documentation of the ultrasound access so 76937 x 2. Bilateral thrombectomies, 37187 x 2. You also get 2 angioplasties because it was used to treat an underlying stenosis and not the thrombus. That is 37248 x 2. you will need bilateral modifiers on these. Looks like you coded it correctly except the cath placement.

37248 has a bilateral indicator of 1 on the Medicare Physician Schedule Data Base. That means:

1=150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

This is how I would code it. IMO
 
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