# Venogram/tunneled line/port removal



## margaret fahy (May 12, 2014)

05/12/14
Guys,
Want to be sure of my codes here...Is it 36558, 36590, 36005-59,77001, 76937,75820-59?....22 yr. old patient.

 Reason:removing port
infected port, needs central access
picc    

Interpretation:    

Procedures: Left upper extremity venography, placement of single
incision tunneled dual lumen right internal jugular vein PICC,
removal of left chest port

PROCEDURE: A limited ultrasound of both upper extremities and the
thoracic inlet was performed to choose a site for insertion of
the PICC. No left internal jugular vein is seen. There was
patency from the left brachial vein to the left subclavian vein.
Following sterile preparation, a 21-gauge needle puncture of the
left brachial vein was performed. A guidewire could not be passed
centrally medial to the left clavicle . A 3 French sheath was
placed. Venography from the left upper extremity was performed
showing complete occlusion of the left subclavian vein medially
with collateralization cephalad in the deep soft tissues of the
left neck and caudad into the mediastinum. The sheath was removed
from the left arm and hemostasis achieved. A gauze and Tegaderm
dressing was placed. Examination of the right upper extremity
shows multiple collaterals and occlusion of the right subclavian
vein. The right internal jugular vein is patent, and its Doppler
spectral waveform has a central venous configuration.

Decision was made to proceed with a tunneled right internal
jugular PICC with a single incision .  The skin of the right
upper chest and neck was prepped and draped in sterile fashion.
From a right infraclavicular subcutaneous approach, avoiding the
pacemaker wires,  using real-time ultrasound guidance, the right
internal jugular vein was punctured with a curved 21-gauge needle
.  Once venous blood was obtained a .018" Mandril wire was placed
into the vein and advanced along side the pacemaker wires and
port catheter to the right atrium.  A small  dermatotomy was
made, the tract was dilated, and a 5 F peel-away sheath was
placed into the vein.  The distance to the cavo-atrial junction
was measured and a 5 F double lumen PICC was cut to 16 cm.  Via
the peel-away sheath the PICC was placed into the vein and
advanced with fluoroscopic guidance until the tip was at the
right atrium..  The peel-away sheath was then removed.   The
catheter was fixed to the skin with 2 3-0 Prolene sutures, and a
sterile occlusive dressing with gauze was applied.  The catheter
aspirated and flushed easily and was heparinized with 200 units
in each lumen.  

Attention was directed to the left anterior chest. Following
sterile prepping and draping and injection of 16 mg of
ropivacaine 0.2%,, a 4 cm transverse incision was made caudal to
the reservoir of the dual port. Using blunt dissection, the
capsule of the port was encountered and sharply incised. The port
was delivered with a towel clamp, and the fibrous tissue
gradually removed, freeing the port, connector and catheter. The
catheter was withdrawn readily totaling 26.5 CM in length. The
wound was closed in 2 layers with the subcutaneous layer sutured
with interrupted 3-0 Vicryl. Running 4-0 subcuticular Vicryl
suture closed the skin. Dermabond was applied. Steri-Strips were
applied. The site was covered with gauze and Tegaderm.


FINDINGS: Occlusion of the left internal jugular vein and
bilateral subclavian veins.

Permanent ultrasound and fluoroscopic images were obtained and
stored in the PACS system.

IMPRESSION
 Challenging vascular access with occlusion of both
subclavian veins and the left internal jugular vein. Successful
placement of a right infraclavicular 16 cm, 5 F double  lumen
PICC tunneled via the right internal jugularl vein with tip at
the right atrium.
Successful removal of dual vortex and its catheter.


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## margaret fahy (May 15, 2014)

*Take a look...the venogram code, thanks...*

Hey Guys,
Can someone take a look at this...it's pretty simple...just a little confused on the Venogram code...thanks so much.


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## JGolamco (May 16, 2014)

It will be just 36558, 36590, 77001, 76937.

It is included with device placement.


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## margaret fahy (May 16, 2014)

But Joe...it's a different site...if it's a different site, we can bill for the venogram....if you were to bill for this venogram, would you bill 36005?


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## JGolamco (May 16, 2014)

Hi Margie,

Sorry just quickly browsed through the report earlier... Yes, I would bill for 36005 since it is in a different anatomical site/access.


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## margaret fahy (May 16, 2014)

Aww...thanks so much Joe.
Pouring rain where I am...hope you're having better weather.
Have a pleasant day.
Margie


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## margaret fahy (May 16, 2014)

Aww...thanks so much Joe.
Pouring rain where I am...hope you're having better weather.
Have a pleasant day.
Margie


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