Wiki Venoplasty lower extremity

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dtruelson

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Hi, this one gave me a headache-any help would be greatly appreciated!!

I got 37238, 37239, 37248, 37249, 36010, 36010, 37252, 37253 X 4, 75822, 75825, 76937, 76937.

PROCEDURE:

Diagnostic venography and interventions

Procedural Personnel
Attending physician(s):
Resident physician(s):

Pre-procedure diagnosis: Recurrent sarcoma
Post-procedure diagnosis: Same
Indication: Other-left iliac vein obstruction
Additional clinical history: None

Complications: No immediate complications.

PROCEDURE SUMMARY:

- Venous access with ultrasound guidance
- Selective venography as described below
- Intravascular ultrasound as described below
- Additional procedure(s): Venous stenting as described below

PROCEDURE DETAILS:


Pre-procedure
Consent: Informed consent for the procedure including risks, benefits and alternatives was obtained and time-out was performed prior to the procedure.
Preparation: The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis.

Anesthesia/sedation
Level of anesthesia/sedation: Moderate sedation (conscious sedation)
Anesthesia/sedation administered by: Independent trained observer under attending supervision with continuous monitoring of the patient's level of consciousness and physiologic status

3 mg of Versed
250 mcg of Fentanyl
Total intra-service sedation time (minutes): 227

I was present throughout the sedation period. The patient was monitored continuously 1:1 thought-out the entire procedure by me while sedation was administered.

Access x 2
Local anesthesia was administered. The vessel was sonographically evaluated and determined to be patent. Real time ultrasound was used to visualize needle entry into the vessel and a permanent image was stored. A 9 French sheath was placed.
Vein accessed: Left and right popliteal veins.
Access technique: Micropuncture set with 21 gauge needle

Left venography/intravascular ultrasound
Indication for venography: Evaluate for stenosis, thrombosis, or occlusion
Vein catheterized: Left popliteal vein, femoral vein, iliac vein, IVC
Findings: Patent left popliteal vein, left femoral vein, and proximal most portion of the external iliac vein with extrinsic narrowing just inferior to the left inguinal ligament and narrowing of the left external and common iliac veins in the pelvis
secondary to mass effect. The IVC was patent. Intravascular ultrasound advanced over wire and was used to measure the diameter of the inferior IVC, left common and external iliac veins, and left common femoral vein for selection of stent diameter.

Right venography/intravascular ultrasound
Indication for venography: Evaluate for stenosis, thrombosis, or occlusion
Vein catheterized: Right popliteal vein, right femoral vein, right iliac veins, IVC.
Findings: Patent right popliteal vein, right femoral vein, and right iliac venous vasculature with extrinsic compression of the inguinal ligament and within the pelvis near the level of the inferior margin of the sacroiliac joint. Intravascular
ultrasound was used to measure the diameter of the inferior IVC, right common and external iliac veins, and right common femoral vein for selection of stent diameter.

Left venoplasty
Venoplasty location: Left common femoral vein, left external/common iliac veins, and IVC confluence
Venoplasty balloon: 8 x 80 mm, 10 x 40 mm,
Post-intervention venography: No significant change in venous patency.

Right venoplasty
Venoplasty location: Right common femoral vein, right external/common iliac veins, and IVC confluence
Venoplasty balloon: 8 x 80 mm, 10 x 40 mm
Post-intervention venography: No significant change in venous patency.

Left venous stent placement
Venous stent location: IVC confluence, left common iliac vein, left external iliac vein
Venous stent: Medtronic Abre, 16 x 150mm
Post-stenting venoplasty: 16 mm balloon

Venous stent location: Left external iliac vein to proximal femoral vein
Venous stent: Medtronic Abre, 16 x 100mm
Post-stenting venoplasty: 14mm balloon

Post-stenting venography: Widely patent left iliac venous vasculature without angiographic evidence of narrowing

Right venous stent placement
Venous stent location: IVC confluence, right common iliac vein, extending to proximal segment of the right external iliac vein
Venous stent: Medtronic Abre, 16 x 100mm
Post-stenting venoplasty: 16 mm balloon

Venous stent location: Right common iliac vein, extending to proximal segment of the right external iliac vein
Venous stent: Medtronic Abre, 14 x 80mm
Post-stenting venoplasty: 14 mm balloon

Venous stent location: Right external iliac vein to proximal femoral vein
Venous stent: Medtronic Abre, 14 x 10mm
Post-stenting venoplasty: 14 mm balloon

Post-stenting venography: Widely patent right iliac venous vasculature without angiographic evidence of narrowing. There is now some wall adherent and non occlusive intraluminal thrombus within the superior right femoral vein.

Mechanical or aspiration thrombectomy and venoplasty
Venous segment treated: Proximal right femoral vein
Thrombectomy device: 6 French sheath, 8 x 80 mm balloon
Post-thrombectomy venography: Small amount of wall adherent/ eccentric residual thrombus along the medial margin of the proximal right common femoral vein
 
I would code 37238-RT, 37239-LT, 36010, 36010-59, 37252, 37253 x 4, 75822-59. Angioplasty is part of stent placement so 37248,49 are not billable, 75825, the IVC findings is not described in the report and should not be coded.

HTH,
Jim Pawloski, CIRCC
 
I am so sorry I am super new to billing this out. Can someone pretty please help me. Been doing my homework for a day and I'm unsure. This is what I am working with.

Pre-op. Diagnosis:
1.Chronic embolism and thrombosis of inferior vena cava - I82.221
Post-op. Diagnosis:
1.Chronically occluded bilateral iliac veins and IVC
Operation:
1.Ultrasound-guided access into the bilateral greater saphenous veins and the right internal jugular vein with permanent recording and reporting
2.Pelvic venogram and inferior vena cavogram
3.Intravascular ultrasound of bilateral iliac veins and inferior vena cava
4.Endovascular retrieval of inferior vena cava filter
5.Stent placement within the infrarenal IVC, left common iliac vein, right common iliac vein, right external iliac vein, and right common femoral vein
Anesthesia:
Local anesthesia with 1% lidocaine was administered at the access site. Anesthesia was provided by anesthesiologist Dr. Nguyen.
Indications:
Post-thrombotic syndrome. History of 3 year old IVC filter. Known occlusion of IVC and bilateral iliac veins.
Details of Procedure:
Informed consent for the procedure including risks, benefits and alternatives was obtained and time-out was performed prior to the procedure. The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis.

Initial scout images showed a tilted Celect IVC filter.

The patient was positioned supine on the angiography table. Using ultrasound guidance, the patent bilateral greater saphenous veins were percutaneously accessed using a micropuncture needle. Permanent images were stored. 10 French sheaths were introduced at each access site. Contrast was injected and pelvic venogram performed. This revealed complete chronic occlusion of the right external and common iliac veins. The left external iliac vein was patent, without stenosis. Numerous pelvic, paravertebral, and abdominal wall collaterals were present. There was chronic occlusion of the infrarenal IVC at the level of the filter and extending caudally. The nose and hook of the filter was embedded within the right lateral caval wall. The struts extended outside of the cava. The inferior vena cava cephalad to the filter was patent.

Using ultrasound guidance, the patent right internal jugular vein was percutaneously accessed using a micropuncture needle. A permanent image was stored. Using this access, a 16 French sheath was placed. The tip of the sheath was placed at the level of the nose of the IVC filter. An endobronchial forceps device was then used to free the nose and hook of the filter from the caval wall. The nose of the filter was then grabbed with the forceps and the filter freed from the cava by advancing the sheath over the filter. The filter was then pulled out of the sheath. Examination of the filter revealed it to be intact.

Next, using a wire and catheter, the right iliac vein and IVC occlusion was crossed. Contrast injection in the IVC confirmed successful crossing. The left external iliac vein occlusion was then crossed via the left groin access with a wire and catheter. Contrast injection in the IVC confirmed successful crossing.

Parallel balloon angioplasty of the infrarenal IVC was then performed using 12 mm balloons. 12 mm balloon angioplasty of the left common iliac vein and right common iliac, external iliac, and common femoral veins was next performed.

Next, double barrel 14 mm Zilver Vena stents were deployed within the infrarenal IVC with extension across each common iliac vein. An additional 14 mm Zilver Vena stent was deployed within the right external iliac and common femoral veins. All stents were profiled with the 12 mm balloons.

Post stent reconstruction venograms showed excellent brisk flow throughout both iliac veins and within the IVC, without residual stenosis and with resolution of collateral filling.

Sheaths and wires were removed and hemostasis achieved using manual compression. Sterile dressings were applied.
Specimens:
None.
Complications:
None.
Findings:
Summary:

Chronic infrarenal IVC and bilateral iliac venous occlusions secondary to indwelling IVC filter. The IVC filter was successfully retrieved and iliocaval stent reconstruction performed, as described above.

Plan:

Start Eliquis 2.5 mg BID and aspirin 81 mg daily. Follow up in 2 weeks.
Notes:
Total fluoroscopy time: 15 minutes
Procedure Codes:
1.76937 US GUIDE, VASCULAR ACCESS. Units: 3.00. Modifiers: 26, 59
2.37193 REM ENDOVAS VENA CAVA FILTER. Modifiers: 22
3.37238 OPEN/PERQ PLACE STENT SAME, Inferior vena cava.
4.37239 OPEN/PERQ PLACE STENT EA ADD, Left common iliac vein.
5.37239 OPEN/PERQ PLACE STENT EA ADD, Right common iliac vein.
6.37239 OPEN/PERQ PLACE STENT EA ADD, Right external iliac vein.
7.37239 OPEN/PERQ PLACE STENT EA ADD, Right common femoral vein.
8.G9500 RADIATION EXPOSURE INDICES DOC.
9.36005 INJECTION EXT VENOGRAPHY.
10.75820 VEIN X-RAY, ARM/LEG.
11.37252 INTRVASC US NONCORONARY 1ST.
12.37253 INTRVASC US NONCORONARY ADDL.
 
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