# Help w/ VIR coding of



## camsgram (Mar 3, 2014)

1. Open catheter thrombectomy, left forearm AV graft
2. Stent placement, left AV anastomosis
3. Stent placement, left outflow basilic vein
4. Fistulogram

I came up with 36831, 37236 (covers peri-anastomotic region and outflow?), 36147

Or should it be 36831, 37236, 37238, 36147 ??  

SO confused...


----------



## churst21 (Mar 6, 2014)

I have the same senerio so I decided to bill 36831 and 37238 but the only problem is 36831 requires a 59 modifier because it's bundled in 37238. So know I'm trying to find out if the 2 should be coded together


----------



## dpeoples (Mar 6, 2014)

camsgram said:


> 1. Open catheter thrombectomy, left forearm AV graft
> 2. Stent placement, left AV anastomosis
> 3. Stent placement, left outflow basilic vein
> 4. Fistulogram
> ...



Can you provide a report?


----------



## lgrogan (Apr 21, 2014)

*open thrombectomy AV graft and stent*

Have there been any answers to the original post? I have a vascular surgeon that basically performed the same procedures described in the original question.  I have assigned 36831-59 and 37238, however the intent of the procedure was the open thrombectomy 36831 and the stent was in addition due to further stenosis at the vein anastomosis, so I question whether both should be reported.  In addition, I thought only one intervention could be reported for the graft in one treatment zone.  

Thanks in advance for any assistance.

Here is the op note:

PREOPERATIVE DIAGNOSES:
1. End-stage renal disease.
2. Thrombosed left axilloaxillary loop ePTFE arteriovenous graft
   (ICD-9-CM:  585.6; 996.73).

POSTOPERATIVE DIAGNOSES:
1. End-stage renal disease.
2. Thrombosed left axilloaxillary loop ePTFE arteriovenous graft
   (ICD-9-CM: 585.6; 996.73).

OPERATION PERFORMED:
1. Thrombectomy of left axilloaxillary ePTFE arteriovenous.
2. Left axilloaxillary arteriovenous graft fistulography, central venous
   and superior vena cava venography.
3. Left axilloaxillary arteriovenous graft efferent limb balloon
   angioplasty and stenting (Bard Flair 8 mm x 5 cm flared covered
   endograft).

ASSISTANT SURGEON:  
ANESTHESIA:  General endotracheal anesthesia.

INDICATIONS FOR PROCEDURE:  The patient is a XX-year-old male with
a longstanding history of end-stage renal disease requiring hemodialysis
3 times a week.  The patient most recently had construction of a left
axilloaxillary loop ePTFE arteriovenous graft for primary vascular
access.  He has also had a right internal jugular central venous
tunneled hemodialysis catheter for interval access while this newly
constructed graft had been healing.  The patient was transitioning to
the arteriovenous graft at this time.

The patient presents with acute thrombosis of the arteriovenous graft
with noted loss of bruit and palpable thrill.  The patient therefore is
brought urgently to the hybrid operating room for thrombectomy of the
arteriovenous graft and performance of arteriovenous fistulography to
determine the causation of failure.  Appropriate percutaneous
intervention and/or open revision to be performed as deemed necessary.

PROCEDURE IN DETAIL:  The patient was transferred to the hybrid
operating room whereupon general endotracheal anesthesia was
administered.  The patient was placed supine onto the operating room
table and all bony prominences secured.  The patient's left upper
extremity was extended onto a radiolucent surgical armboard.  The
patient's left upper extremity was then circumferentially prepped with
ChloraPrep including the axilla and left anterior chest wall.  This was
then sterilely draped.

A "timeout brief" was then undertaken per established protocol.
Antibiotics had been administered per SCIP protocol.  A short incision
was made at the apex of the left axilloaxillary arteriovenous graft and
carried down through the subcutaneous tissue.  The underlying ePTFE
graft was circumferentially dissected and isolated.  A transverse
incision was made across the graft.  A #4 Fogarty catheter was then
passed into the efferent limb of the arteriovenous fistula.  Significant
amount of fresh thrombus was removed.  This was advanced to the point
where fresh venous blood returned through the efferent graft.  This was
then flushed with dilute heparinized saline solution and clamped.  The
afferent limb was also thrombectomized using the #4 Fogarty catheter.
Additional amounts of fresh thrombus was extracted.  There was
re-establishment of brisk arterial inflow whereupon heparinized saline
solution was injected and the graft clamped.

I then advanced a 0.035 inch hydrophilic Glidewire into the efferent
limb of the arteriovenous graft over which a 14-French 6 cm sheath was
placed into the graft.  Efferent left axilloaxillary arteriovenous
fistulography, central venous and superior vena cava venography were
performed.  In doing so, this demonstrated a hemodynamically significant
stenosis at the efferent paraanastomotic location where the graft had
been sewn onto the axillary vein.  I used a Bard Rival 8 mm x 4 cm
dilatation catheter to dilate this segment.  This was inflated to
nominal and supranominal pressures.  Re-examination of the
paraanastomotic stenosis showed moderate recoil at this location.  Due
to its configuration, I judged that this would be an appropriate
location to place a Bard Flair 8 mm x 5 cm flared covered endograft.
This was delivered to the location of the transition between the ePTFE
graft and the outflow axillary vein.  Once in proper position, this was
deployed.  Following deployment, the endograft was postdilated again
using the Bard Rival 8 mm x 4 cm dilatation catheter.  Completion
arteriovenous fistulography, central venous and superior vena cava
venography showed resolution of the outflow stenosis with continued
patency into the superior vena cava.

The 14-French sheath was then removed and placed into the afferent limb
of the arteriovenous graft over a 0.035 inch hydrophilic Glidewire.
Retrograde arteriovenous fistulography was then performed demonstrating
the arterial anastomosis.  This was widely patent with no compromise of
inflow.

Both the afferent and efferent limbs of the graft were flushed with
dilute heparinized saline solution and clamped.  The transverse
graftotomy was then closed with interrupted 5-0 Prolene sutures.  Upon
repair of the opening within the graft, blood flow was restored through
the arteriovenous graft with release of proximal distal clamps.

The thrombectomy site was inspected for complete hemostasis.
Thrombin-soaked Gelfoam was placed over it.  The deep subcutaneous layer
was then closed with 4-0 Vicryl suture.  The skin was approximated with
3-0 Ethilon suture vertical mattress fashion.

The patient tolerated the procedure very well with no periprocedural
complications.  He was awakened, extubated, and transferred to the
postanesthesia care unit in good condition.

ANGIOGRAPHIC INTERPRETATION:  Initial efferent left axilloaxillary
arteriovenous graft fistulography showed patency of the prosthetic
segment of the graft with a transitional focal stenosis at the efferent
paraanastomotic location where it had been anastomosed onto the axillary
vein.  The outflow axillosubclavian vein was widely patent as was the
left innominate vein and superior vena cava.  Following balloon
angioplasty and covered stenting (Bard Flair 8 mm x 5 cm flared covered
endograft), the paraanastomotic stenosis was minimal.  Afferent
arteriovenous fistulography showed wide patency of the arterial
anastomosis onto the axillary artery.

FINAL INTERPRETATION:  Thrombosed left axilloaxillary looped ePTFE
arteriovenous graft likely due to outflow efferent paraanastomotic
stenosis successfully treated balloon angioplasty and covered stenting.


----------



## jkayser (Apr 22, 2014)

Hello, there was no response to the initial inquiry because the requested op report was not posted.

Looking at your procedure report, I agree with your coding of 36831-59 and 37238.  EncoderPro shows that these 2 codes are billable together with the 59 modifier on 36831.  The pre and post-dilation for the stent placement plus the completion fistulagram are all included in CPT 37238.  

You could add 75791 for the diagnostic arteriovenous shunt angiography through superior vena cava.  It was performed via the same open access created for the other procedures.  The report indicates that it was done for diagnostic reasons to determine the "causation of failure" with intervention to be performed as "deemed necessary."  It was performed after the thrombectomy for this stated purpose.  The decision to place the stent was made following the filstulagram findings.  Add modifier 26 if performed in a facility setting with professional/technical billing split required.  

The thrombectomy is separately billable from the stent placement.  The rule you are referencing applies to angioplasties and/or stent placement for AV dialysis shunts.  For those procedures, the angioplasty and/or the stent placement are reported only once to describe all work within the shunt segment from the peri-arterial anastomosis through the axillary and cephalic 
veins. 

I hope this info is helpful.

Jean Kayser CPC CIRCC


----------



## lgrogan (Apr 22, 2014)

Thanks Jean for your quick reply!


----------

