# Removal of Infected AV fistula



## cmblocher (Mar 4, 2009)

Please help,

The surgeon attempted percutaneous thrombectomy of the arteriovenous fistula, however it serverly infected, and it turned into an open procedure.

Here are the two main portions of the report, I am stumped because and don't what all I should bill for- he ended up just removing the graft. Does this fall under CPT code 35903. Also an artery was transected during the procedure, should I be adding an additional code for this? And should I bill for the attempted percutaneous thrombectomy with modifer 52/53?

"Percutaneous needle entry into the graft was accomplished and a sheath inserted. A second sheath was attempted. Percutaneous needle entry was accomplished. However, brown, thick, purulent material was obtained, and the second sheath was not inserted. The purulent material was aspirated and sent for stat Gram stain and culture. The stat Gram stain showed mulitple gram-positive cocci. It was felt that the graft was grossly infected and needed to be removed.  

"A transverse incision was made in the old incision in the right groin, and the limbs of the graft were searched for. There was extreme scar tissue in the groin making dissection extremely difficult. The arterial portion of the fistula was identified and followed down to the femoral artery. However, the femoral artery had no integrity to it. On gently mobilizing the artery it transected. Control of bleeding was obtained using a Fogarty catheter with the ballon inflated. The superficial femoral and profuda femoris arteries were identified, isolated, and doubly looped. Distal control was obtained. The ballon from the Fogarty catheter was passed further up into the external iliac for more proximal control. The arterial limb was removed from the the femoral artery, and the artery was debrided both proximally and distally back to the point where uninfected arterial wall was found and sutures were felt to be able to hold. The venous limb was then found and dissected free around the area, and the vein was then clamped with a Satinsky clamp, the graft removed, and the vein closed primarily using 5.0 Gore-tex sutures."

After the repair was made, Plastic Surgery came in and did a muscle flap reconstruction of the area. 

I know this is long, but if anyone could help... I would be very Happy!


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## MLS2 (Mar 4, 2009)

I would think that 35903 would cover the graft removal and a 36145 for the initial puncture/sheath placement.


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## cmblocher (Mar 5, 2009)

Thank you~ that makes me feel better!


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