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Tunnel Cath Placement

  1. #1
    Default Tunnel Cath Placement
    Exam Training Packages
    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.

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by jtuominen View Post
    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.
    Your instincts are correct in this case. There are exceptions but this is not one of them. You should not code 36005/75820 in addition to the other codes.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Default
    Thanks Danny! Have a good day!

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