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Thread: AV shunt intervention

  1. #1
    Join Date
    Apr 2007
    Tacoma, WA

    Default AV shunt intervention

    AAPC: Back to School
    Based on the new, current SIR guidelines, as I understand them, only the arterial PTA should be coded when both the arterial and venous ends of the AV fistula are treated, correct? Venous is only to be coded if it's the only portion treated or if a vein outside the fistula is treated.

    Based on this, what are your thoughts on coding for the below? I get: 36147, 36148, 35475, 75962. I don't see separate access or justification for any selective caths or venography/angiography as is described in the report. 76937 is bundled.

    Any assistance you can provide is greatly appreciated! Thanks!

    INDICATION: The patient is a 63-year-old male with end-stage renal
    failure status post left upper arm dialysis fistula placement.
    Evaluation is requested because of diminished dialysis flow rates.

    1. Ultrasound-guided antegrade percutaneous access of the dialysis
    2. Fistulogram.
    3. Ultrasound-guided retrograde percutaneous access of the dialysis
    4. Selective catheterization of the brachial artery.
    5. Percutaneous transluminal angioplasty of the dialysis fistula,
    arterial end.
    6. Repeat antegrade percutaneous access of the dialysis fistula.
    7. Percutaneous transluminal angioplasty of the venous end.
    8. Post angioplasty fistulogram.
    9. Upper extremity venogram.

    After informed consent was obtained, the patient was placed supine on
    the angiography table. The left upper arm was sterilely prepped and
    draped. The skin and underlying soft tissues were locally
    anesthetized with buffered 1% lidocaine. A small skin nick was then
    made. Under ultrasound guidance, using a micropuncture needle set,
    the dialysis was percutaneously accessed antegrade at a point
    approximately 2 cm proximal to the AV anastomosis. A 0.018-inch
    guidewire was passed over which a 4-French coaxial dilator was
    passed. The guidewire and inner dilator were removed and subsequent
    injections were carried via the 4-French dilator. This, however,
    immediately showed that there was catheter occlusion with stasis of
    flow noted within the fistula. The dilator was therefore removed and
    pressure held until hemostasis was obtained.
    Subsequently, under ultrasound guidance, retrograde percutaneous
    access of the dialysis fistula was achieved followed by placement of
    a 6-French bright-tipped sheath, retrograde. A 0.035-inch guidewire
    was selectively passed across the arteriovenous anastomosis into the
    brachial artery. Over this, a 4 x 40 mm angioplasty balloon catheter
    was passed and serial balloon angioplasty of the arterial end of the
    dialysis fistula was performed. The balloon catheter was removed and
    subsequent fistulogram was obtained showing an improved appearance to
    the arterial flow.
    Repeat antegrade performed access using the micropuncture needle set
    of the dialysis fistula is performed. In an antegrade direction, a
    6-French bright-tip sheath was placed. A 0.035-inch guidewire was
    passed across the distal aspect of the fistula. Over the wire, a 7 x
    40 mm balloon catheter was passed and serial balloon angioplasty of a
    venous outflow stenosis was performed. Follow up fistulogram was
    obtained showing only minimal improvement. Subsequently, an 8 x 40 mm
    angioplasty balloon catheter was passed and repeat balloon
    angioplasty of the venous stenosis was performed. Balloon catheter
    was removed and a subsequent fistulogram was obtained. Subsequently,
    a left upper extremity venography was performed. Guidewires were
    removed. Pursestring sutures were then tied about both fistula access
    sites and the sheaths were removed. Once hemostasis was obtained,
    sutures were then removed and sterile bandages were applied. The
    patient tolerated the procedure well with no immediate complications.

    An end-to-side anastomosis is seen of the cephalic vein to the
    brachial artery immediately above the level of the level. Although
    the arteriovenous anastomosis is patent, the immediate outflow
    cephalic is diffusely small in caliber with a high-grade focal
    stenosis seen approximately 3-4 cm proximal to the AV anastomosis.
    Approximately 10-12 cm proximal to the AV anastomosis, there is a
    venous outflow stenosis of approximately 70% over a less than 1 cm
    length. The remainder of the cephalic vein and central veins appear
    unremarkable without flow limiting lesions.
    Following balloon angioplasty, there is improved appearance of both
    the arterial and venous ends of the dialysis fistula without
    significant flow limiting lesions. Brisk flow is demonstrated
    throughout. There is no extravasation seen.

    Tandem stenosis involving dialysis fistula located approximately 3-4
    and 10-12 cm proximal to the AV anastomosis. Status post percutaneous
    transluminal angioplasty at both of these lesions without significant
    residual flow limiting lesions identified.
    Stacy Gregory, CPC, CCC, RCC

  2. #2
    Join Date
    Apr 2007
    durham, nc

    Default RE: AV Shunt Intervention

    I believe you have coded this correctly. I agree that there is no justification to code for any selective caths or venography/angiography as is described in the report. These are the codes I would have selected
    A.Dimmitt, CPC, CIRCC
    Durham, North Carolina

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