# azygos venogram



## carriebeth (Sep 28, 2010)

I am having issues finding a code for the azygos venogram, would I code an SVCgram?


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## msncoder (Sep 28, 2010)

Depends....where was the initial puncture? Were there more catheterizations besides the azygos? In most cases the only code you could use for the RS&I portion would be 75774 (selective VESSEL-which SHOULD cover both arteries & veins however not all insurance companies agree with that). Without knowing all the details of the procedure it's hard to give you a better answer. I want to say that this same issue was recently discussed on a radiology coding forum I subscribe to. I'll look and see what I find and forward to you!


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## carriebeth (Sep 28, 2010)

PRE DIAGNOSIS: Central venous occlusive disease
POST DIAGNOSIS:  Same

DETAILS OF PROCEDURE: 
EKG was interpreted throughout the procedure.  The left groin was prepped and draped.  An 8F sheath was placed and a catheter was used to select the right IJ.  A venogram was performed which showed a diffuse narrowing within the mid portion of the vein and a 50% stenosis at the level of the valve inferiorly.  An 8mm balloon was initially used to treat both portions of the IJ with no improvement.  Thus a 10mm balloon was also used with a  waist that resolved upon full inflation of the balloon at the level of the valve.  However, the mid portion of the jugular was still had a 90% stenosis.

The left internal jugular vein was then selectively catheterized.  A venogram was performed which showed findings similar to the MRV performed yesterday.  The IJ from the skull base to the lower neck was very small in caliber with an equally sized collateral running parallel to it into the skull base.  Both were approximately 5-6mm in diameter.  In the lower neck, the IJ and it's collateral joined and the IJ was approximately 10mm with a 50% stenosis at the level of the inlet to the subclavian vein.  The flow through the IJ system was very minimal and slow due to the small caliber throughout.  To treat the valve region a 10mm balloon was used with a residual waist so a 12mm balloon was used.  A residual waste was seen so a high pressure Conquest balloon was used to treat the valve with resolution of the waist.  Repeat venogram showed residual slow flow through the IJ system.  A small amount of intimal disruption but no extravastation was seen within the venoplasty region so 5000U of heparin were given.

A Cobra catheter was used to catheterize the Azygus vein and venogram was performed.  No evidence of disease was seen with rapid antegrade flow throughout the vein.  Thus the catheter was removed.

The RIJ was re-examined and venogram showed residual 90% mid stenosis with significant collateral flow.  Thus despite aggressive angioplasty, recoil was present.  A 14mm x 6cm Zilver uncovered stent was deployed across the lesion and completion venogram showed rapid antegrade flow with no collaterals.

The LIJ was selected and venogram showed stagnant flow due to residual stenosis at the inferior portion.  A small amount of thrombus could not be ruled out so 2mg of tPA was given in that region.  Further angioplasty with the 12mm balloon was also performed.  Completion venogram showed a small amount of mobile filling defects but with antegrade flow.


IMPRESSION:  Central venous occlusive disease.  RIJ mid stenosis treated with 10mm PTA and ultimately a 14mm x 6cm stent.  Left IJ small in caliber as described above.  Inferior portion treated with 10 and 12mm balloon.  Intimal disruption and subsequent filling defects.  Ultimately resultant antegrade flow with small intra luminal filling defects.  Normal Azygus vein.

PLAN:  Pt will be given a prescription for lovenox to take for the next several days to allow the intimal tear to heal within the left IJ.  Pt will see me in the office tomorrow for ultrasound to ensure no evidence of DVT.


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## msncoder (Oct 4, 2010)

This was just posted on the RBMA (Radiology Business Managers Association) coding forum regarding the azygos vein imaging. There are 2 different posts, one from 10/1/10 & the other from 8/3/10. 
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From: Walt Blackham
Sent: Friday, October 01, 2010 3:30:53 PM 
To: RBMA Coding Forum 
Subject: Re: azygos vein? 
Auto forwarded by a Rule


There is nothing for azygos vein imaging.  75774, angio after basic exam, would be OK except that lately the use of this code has been discouraged when coding imaging after selecting a vein not mentioned in CPT.  So if you want anything it would have to be UPC for the time being.  
Walt Blackham

On 10/1/2010 1:11 PM,  wrote: 

Hi All- Rad selects rt and lt internal jugular veins and then advances the catheter into the azygos vein and lumbar vein. Jugular veins are 36012, I believe. What order would the azygos and lumbar veins be? I have no good resources (diagrams) for this one...thanks!

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From: Jeff Majchrzak
Sent: Wednesday, August 04, 2010 9:57:47 AM
To: RBMA Coding Forum
Subject: RE: azygos venogram coding - 2nd request Auto forwarded by a Rule


I agree with Walt on 75774.  Cross-reference in CPT 2010 leads us only to arterial codes, but the true spirit of the code seems to me to be for any selective vessel after basic exam.  Maybe 2011 cross-reference notes will be updated in CPT?

Jeff


Jeff Majchrzak BA, RT(R), CNMT, RCC, CIRCC Vice President of Radiology Services

MedLearn. Clearly the Answer.

In a message dated 8/3/2010 1:54:30 P.M. Eastern Daylight Time, Walt Blackham wrote:

There is no close match for the azygos.  I would use 75774 and hope that the payer thinks that angiogram in the code descriptor can refer to arteries or veins.


Walt Blackham

On 8/2/2010 1:12 PM, Pat wrote: 



Right common femoral vein punctured, advanced to IVC, then into SVC, right and then left internal jugular venogram performed. Then the azygos vein was selected and venogram performed. 

The azygos vein is the issue. Im not sure which venography code this vein would fall under. SVC?

Thanks! 
Pat


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## chembree (Oct 18, 2010)

Per ZHealth Online Newsletter for August 11, 2010


The American Medical Association (AMA) recently instructed that code 75774, Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure), is to only be used as an add-on code to arteriography procedures.  It is limited to being used as an add-on code with only those procedures specifically indicated in the footnote to code 75774 in the CPT Code Book.  The foot note lists codes 36147, 75600 – 75756, and 75791.

Fortunately there is much less selective catheterization performed with venography, so it should not have a major impact.  If there is significant impact in your practice, you may want to contact the AMA and request a code be established for additional selective imaging of veins or that the definition of 75774 expanded to include the venous system.


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