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Venography with PICC placement

  1. #1
    Default Venography with PICC placement
    Medical Coding Books
    I've got another one I'm stuck on. I'm not sure whether it's appropriate to code for the venous catheterizations on this case, and if so, which code(s) to use. I did not code for the venography of the SVC or brachiocephalic veins as it seems those were done only to lay out anatomy for the intervention. Currently my codes are 36010-59-LT, 36005-59-RT, 76937, 37205/75960-LT, 37206/75960-59-RT, 36569, 77001. If you have a moment, I'd love to hear your opinions. Thank you again for all of your assistance!

    PROCEDURE: SUP VENA CAVA ANGIO
    INDICATION: Patient with large mediastinal tumor significantly
    encroaching upon the superior vena cava and bilateral brachiocephalic
    veins. Patient presents with bilateral upper arm and facial swelling.
    PROCEDURES PERFORMED
    1. Ultrasound-guided puncture of the left basilic vein.
    2. Catheterization of the superior vena cava.
    3. Ultrasound-guided puncture of the right brachial vein.
    4. Catheterization of the superior vena cava from the right arm
    puncture.
    5. Central venous angiogram.
    6. Stenting of the superior vena cava and bilateral brachiocephalic
    veins with post stent deployment angioplasty.
    7. Repeat central venogram.
    8. IV conscious sedation.
    9. Fluoroscopic placement of a dual-lumen 5-French PICC line catheter
    with tip in the cavoatrial junction.
    Preprocedure evaluation confirmed that the patient was an appropriate
    candidate for conscious sedation.
    Vital signs, pulse oximetry, and response to verbal commands were
    monitored and recorded by the nurse throughout the procedure and the
    recovery period. All medications for conscious sedation including the
    doses administered were placed in the medical record. The patient
    returned to baseline neurologic and physiologic status prior to
    leaving the department. No immediate sedation-related complications
    were noted.
    Informed and written consent was obtained from the patient after
    discussion of the risks, benefits, and alternatives for this
    procedure. The patient expressed full understanding and agreed to
    proceed forward.
    The patient placed supine on the angiography table. The bilateral
    arms were prepped and draped in normal sterile fashion.
    Ultrasound evaluation was performed of the left upper extremity. The
    basilic vein is prominent in size without internal echoes or
    thrombus. This vessel is compressible. A generous amount of 1%
    buffered lidocaine was infused in the skin and subcutaneous soft
    tissues. Under direct ultrasound guidance, a 21-gauge micropuncture
    needle was advanced into the center of the left basilic vein. A
    0.018-wire was inserted and serial dilatation was performed at the
    site. Following, a 0.035 was negotiated through the left
    brachiocephalic vein and advanced into the superior vena cava. A
    7-French Raabe sheath was then inserted into the left subclavian
    vein.
    Next, ultrasound evaluation was performed of the upper extremity
    venous structures of the right arm. The parabrachial veins were
    identified. One of the paired brachial veins was noted to be most
    prominent in size, without internal echoes or thrombus and was
    readily compressible with the transducer. As on the left, a generous
    amount of 1% buffered lidocaine was infused into the skin and
    subcutaneous soft tissues, and a 21-gauge micropuncture needle was
    advanced into the center of the right brachial vein. A 0.018-wire was
    advanced and serial dilatation was performed at the venotomy site. A
    0.035-wire was then inserted into the superior vena cava. A 6-French
    sheath was then inserted into the subclavian vein.
    Injection of contrast was performed through the left access sheath
    (tip within the subclavian vein) demonstrating high-grade stenosis of
    the central aspect of the left brachiocephalic vein with marked
    stenosis of the inferior vena cava. Venous chest wall collaterals are
    noted to opacify with contrast injection.
    Following, primary stenting was performed of the superior vena cava
    using a 14-4 SMART stent. A 7-80 stent was then extended from the
    cranial most aspect of the superior vena cava stent into the left
    brachiocephalic vein.
    Attention was then turned to the right arm. Injection of contrast was
    performed through the right arm sheath (tip in the subclavian vein)
    demonstrating high-grade stenosis of the cranial most aspect of the
    brachiocephalic vein. Primary stenting was performed using a 7-60
    stent. The distal aspect of the stent parallels the distal aspect of
    the left brachiocephalic stent. Balloon molding was performed
    throughout the bilateral stents with a 6-4 balloon. Both 6 mm
    balloons were inflated inside of the 14 mm stent to achieve improved
    luminal diameter post stent placement.
    Repeat injection of contrast was then performed through the bilateral
    upper arm sheaths. Injection of contrast demonstrates fast forward
    flow through the stented brachiocephalic vein as well as the superior
    vena cava. The previously seen chest wall collaterals are not noted
    to opacify. Given the patient's difficult access, a 5-French slip
    catheter was then inserted over the right 0.035-wire and a 0.018-wire
    was placed. Over this wire a 5-French dual-lumen PICC line catheter
    was then placed with tip terminating in the cavoatrial junction,
    caudal to the inferior most aspect of the superior vena cava stent.
    The PICC line was then secured to the arm using 2-0 Prolene suture. A
    sterile dressing was placed. The line flushes and aspirates
    appropriately. Fluoroscopy confirmed the line to be intact without
    disconnect or kink. On the left, the 7-French sheath was removed and
    hemostasis was obtained with manual compression.
    The patient tolerated the procedure well. There were no immediate
    complications.
    Stacy Gregory, CPC, CCC, RCC

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by stgregor View Post
    I've got another one I'm stuck on. I'm not sure whether it's appropriate to code for the venous catheterizations on this case, and if so, which code(s) to use. I did not code for the venography of the SVC or brachiocephalic veins as it seems those were done only to lay out anatomy for the intervention. Currently my codes are 36010-59-LT, 36005-59-RT, 76937, 37205/75960-LT, 37206/75960-59-RT, 36569, 77001. If you have a moment, I'd love to hear your opinions. Thank you again for all of your assistance!

    PROCEDURE: SUP VENA CAVA ANGIO
    INDICATION: Patient with large mediastinal tumor significantly
    encroaching upon the superior vena cava and bilateral brachiocephalic
    veins. Patient presents with bilateral upper arm and facial swelling.
    PROCEDURES PERFORMED
    1. Ultrasound-guided puncture of the left basilic vein.
    2. Catheterization of the superior vena cava.
    3. Ultrasound-guided puncture of the right brachial vein.
    4. Catheterization of the superior vena cava from the right arm
    puncture.
    5. Central venous angiogram.
    6. Stenting of the superior vena cava and bilateral brachiocephalic
    veins with post stent deployment angioplasty.
    7. Repeat central venogram.
    8. IV conscious sedation.
    9. Fluoroscopic placement of a dual-lumen 5-French PICC line catheter
    with tip in the cavoatrial junction.
    Preprocedure evaluation confirmed that the patient was an appropriate
    candidate for conscious sedation.
    Vital signs, pulse oximetry, and response to verbal commands were
    monitored and recorded by the nurse throughout the procedure and the
    recovery period. All medications for conscious sedation including the
    doses administered were placed in the medical record. The patient
    returned to baseline neurologic and physiologic status prior to
    leaving the department. No immediate sedation-related complications
    were noted.
    Informed and written consent was obtained from the patient after
    discussion of the risks, benefits, and alternatives for this
    procedure. The patient expressed full understanding and agreed to
    proceed forward.
    The patient placed supine on the angiography table. The bilateral
    arms were prepped and draped in normal sterile fashion.
    Ultrasound evaluation was performed of the left upper extremity. The
    basilic vein is prominent in size without internal echoes or
    thrombus. This vessel is compressible. A generous amount of 1%
    buffered lidocaine was infused in the skin and subcutaneous soft
    tissues. Under direct ultrasound guidance, a 21-gauge micropuncture
    needle was advanced into the center of the left basilic vein. A
    0.018-wire was inserted and serial dilatation was performed at the
    site. Following, a 0.035 was negotiated through the left
    brachiocephalic vein and advanced into the superior vena cava. A
    7-French Raabe sheath was then inserted into the left subclavian
    vein.
    Next, ultrasound evaluation was performed of the upper extremity
    venous structures of the right arm. The parabrachial veins were
    identified. One of the paired brachial veins was noted to be most
    prominent in size, without internal echoes or thrombus and was
    readily compressible with the transducer. As on the left, a generous
    amount of 1% buffered lidocaine was infused into the skin and
    subcutaneous soft tissues, and a 21-gauge micropuncture needle was
    advanced into the center of the right brachial vein. A 0.018-wire was
    advanced and serial dilatation was performed at the venotomy site. A
    0.035-wire was then inserted into the superior vena cava. A 6-French
    sheath was then inserted into the subclavian vein.
    Injection of contrast was performed through the left access sheath
    (tip within the subclavian vein) demonstrating high-grade stenosis of
    the central aspect of the left brachiocephalic vein with marked
    stenosis of the inferior vena cava. Venous chest wall collaterals are
    noted to opacify with contrast injection.
    Following, primary stenting was performed of the superior vena cava
    using a 14-4 SMART stent. A 7-80 stent was then extended from the
    cranial most aspect of the superior vena cava stent into the left
    brachiocephalic vein.
    Attention was then turned to the right arm. Injection of contrast was
    performed through the right arm sheath (tip in the subclavian vein)
    demonstrating high-grade stenosis of the cranial most aspect of the
    brachiocephalic vein. Primary stenting was performed using a 7-60
    stent. The distal aspect of the stent parallels the distal aspect of
    the left brachiocephalic stent. Balloon molding was performed
    throughout the bilateral stents with a 6-4 balloon. Both 6 mm
    balloons were inflated inside of the 14 mm stent to achieve improved
    luminal diameter post stent placement.
    Repeat injection of contrast was then performed through the bilateral
    upper arm sheaths. Injection of contrast demonstrates fast forward
    flow through the stented brachiocephalic vein as well as the superior
    vena cava. The previously seen chest wall collaterals are not noted
    to opacify. Given the patient's difficult access, a 5-French slip
    catheter was then inserted over the right 0.035-wire and a 0.018-wire
    was placed. Over this wire a 5-French dual-lumen PICC line catheter
    was then placed with tip terminating in the cavoatrial junction,
    caudal to the inferior most aspect of the superior vena cava stent.
    The PICC line was then secured to the arm using 2-0 Prolene suture. A
    sterile dressing was placed. The line flushes and aspirates
    appropriately. Fluoroscopy confirmed the line to be intact without
    disconnect or kink. On the left, the 7-French sheath was removed and
    hemostasis was obtained with manual compression.
    The patient tolerated the procedure well. There were no immediate
    complications.
    This does not seem to be a standard PICC placement to me, more a diagnostic test, followed by stent placement and PICC placement. I would code thus:
    37205/75960(26)
    37206/75960(26)-59
    36010-59 (bundles with 36569)
    36005-59 (bundles with 36569)
    36569 (or 36568 depending on patient age)
    75827(26) (may bundle with 75960)
    75822(26)-59(probably bundles with 75960)
    76937(26)

    The cath placement and venographies will probably need a 59 to avoid bundling with the PICC. I would not additionally code for the fluoro guidance because there was plenty of imaging work performed. If you decide to code for the fluoro, there will be more bunding issues with venographies.
    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. Default
    i would code:
    75827-26,59 36010-59
    75822-26,59
    36005-59
    76937-26
    36569
    75960-26. 37205
    75960-26,59 37206 (x2)
    The physician does dictate a venogram and vena cava gram and these would definitely require 59 modifiers. Also, it reads like 3 vessels stented to me. The superior vena cava, CENTRAL portion ( I am thinking that this excludes it as a bridging lesion) of the left brachiocephalic vein, and the rt brachiocephalic vein. I would love to know the final outcome of this. We all need to stick together.
    Chris McCoy, CPC, CIRCC, RTRCV

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