# Av fistulogram -Ultrasound examination of the arteriovenous anastomosis



## Shirleybala (May 15, 2009)

Hello:

In this AV FISTULOGRAM should we need to code for

*1.Brachial artery angiogram.
2.Brachial artery angioplasty.
3.What will be the cath code.*

       Ultrasound examination of the arteriovenous anastomosis was
       performed. After administering local anesthesia, a 7 French
       vascular sheaths were placed into the outflow vein aiming
       caudally. Contrast injection with digital imaging of the venous
       outflow to the level of the superior vena cava was performed
       demonstrating wide patency of the cephalic and central outflow
       veins.  A four French Berenstein catheter and-a guide wire were
       advanced through the upper sheath and guided to the arteriovenous
       anastomosis. Multiple attempts to cross the arteriovenous
       anastomosis were unsuccessful.       
       The inflow brachial artery was accessed in the midportion of the
       upper arm in antegrade fashion using the micropuncture system.
       The 3-French inner dilator from the micropuncture kit was advanced
       into the artery.  Brachial artery angiography in the frontal
       projection was performed.  A 0 .018 inch gold tip Glidewire was
       advanced through the catheter, guided beyond the arteriovenous
       anastomosis and further advanced into the venous sheath.  The
       sheath was removed and the wire withdrawn out of the skin.
       Through-and-through access was then obtained and the sheath
       readvanced over the wire.  A 4 -French Berenstein catheter was
       advanced over the wire and into the inflow brachial artery.  After
       exchanging for a stiff hydrophilic wire, the arteriovenous
       anastomotic stenosis was sequentially dilated using 6 and 7 mm x 4
       cm Cordis Extreme angioplasty balloons.  Severe spasm was noted
       within the inflow brachial artery.  The entire length of the
       brachial artery extending for approximately 10 cm from the
       arteriovenous anastomosis was dilated using a 5 mm x 4 cm
       angioplasty balloon.  A final angiogram was performed
       demonstrating wide patency with minimal recoiling at the
       angioplasty sites. An improved thrill was palpated within the
       fistula at termination of the procedure.  The sheaths were removed
       and hemostasis was obtained with manual compression


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## dhuston (May 21, 2009)

It appears that the brachial artery is the inflow artery.  I may be wrong but that's what I'm getting from the report.  And in that case, your angiogram is part of 75790 fistulagram.  Then you have puncture towards the outflow (36145) and puncture "into the outflow brachial artery" which could mean puncture of the graft toward the outflow (36145 again) or code a direct puncture into the brachial artery 36120.

If this is Medicare, I'd code the brachial PTA as G0392.  For other insurances I'd code 35475. 

Diane Huston, CPC,RCC


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## Shirleybala (May 21, 2009)

arterial angiogram (75710)is not included in 75790 know


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## dhuston (May 22, 2009)

75790 includes all angiography of the extremity up to the central vessels.

Diane


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## Shirleybala (May 24, 2009)

extremity venogram and SVC gram are included in 75790.
But 75710 extremity arteriogram is not included

75790, radiologic S&I, is coded once for each graft or fis-
tula. This code includes imaging and evaluation of the
entire A-V access, including arterial and venous anasto-
moses, the body of the graft, outflow vein(s), and central
veins. Other venogram codes should not be used to
describe the necessary imaging included with the fistula-
gram (do not use 75820—unilateral extremity venogram,
or 75827—superior vena cavagram).

To code for the diagnostic extremity arteriogram, the
75710 code would be used (unilateral extremity arteri-
ogram, radiologic S&I). These codes are used irrespective of
the type of access (fistula, A-V graft) and irrespective of the
location (arm, leg). 

I have endovascular today article also to clarify this can i attach here.


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## dhuston (May 26, 2009)

Shirley...I tried to respond to your message with the link but I'm not sure it went thru.  Sorry if this is a duplicate....

Hi Shirley, Thanks for the article. I see where they're talking about the 75710. I'm still not sure I would code it in this case because the brachial artery is the inflow artery as opposed to having a graft in the lower arm and doing an arteriogram up to the brachial artery. But it also seems that different sources have different opinions. And (a little late) I also see that CMS has revised their coding guidelines (yet to be finalized but posted on RBMA in draft) and G0392 is only for the arterial anastomosis so your PTA outside the graft would be 35475. I've heard that there's info on Dr. Z's site about this change. Diane


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