# Angioplasty with stent placement



## birky (Nov 18, 2010)

Please help with the coding of this report:

The patient was placed on the angiography table in a supine position with the left arm abducted. The left arm was prepped and draped in standard sterile fashion.

Ultrasound was used to localize the arteriovenous 

fistula. The arteriovenous anastomosis was widely patent on sonographic imaging. Next, 2% lidocaine was used to anesthetize the skin overlying the venous outflow of the fistula. Percutaneous access into the fistula was then obtained using a 21-gauge needle and direct sonographic guidance. The percutaneous access was gained in the direction of the central venous system. The percutaneous access was dilated to accept a 5-French micropuncture introducer. Fistulography was then performed to include assessment of the central venous system This elucidated the presence of a cephalic arch stenosis which showed hemodynamic significance. As such, intervention was pursued. The cephalic arch was traversed using a 0.035 inch glidewire and Berenstein catheter. The glidewire was exchanged for a 0.035 inch Bentson wire. The percutaneous access was then dilated to accept a 6-French vascular sheath, through which a 6-mm x 4-cm balloon was inserted and was used to balloon angioplasty the cephalic arch. Interval venography was performed, demonstrating persistent stenoses. As such, the stenosis was retreated using an 8- mm x 4-cm balloon. Interval venogram showed persistence of the stenosis and persistent hemodynamic significance. As such, stent insertion was pursued. To this end, a 10-mm x 4-cm stent was uneventfully deployed across the cephalic arch. Post deployment angioplasty was performed using a 10-mm x 4-cm balloon. Final venogram was performed. All vascular devices were then removed. Hemostasis was obtained at the vascular access site using a pursestring suture, which was removed prior to patient discharge from interventional radiology.

A sterile bandage was applied over the puncture site.


FINDINGS:
Arteriovenous fistulography reveals enlarged and tortuous cephalic venous outflow. The distal cephalic vein at the level of the cephalic arch shows tandem flow- limiting stenoses with flowing of collateral vessels at the level of the cephalic arch. The left subclavian vein is patent and shows a valve or areas of band-like stenosis at its proximal segment with retrograde filling of the axillary vein and brachial venous system. The left innominate vein and superior vena cava are widely patent.

Following balloon angioplasty and stent of the cephalic arch, improved flow through this area is noted with 

reduced filling of collateral vessels.

An excellent palpable thrill was present within the arteriovenous fistula on clinical inspection.

Thanks to anyone that can help me with this


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## Jim Pawloski (Nov 22, 2010)

birky said:


> Please help with the coding of this report:
> 
> The patient was placed on the angiography table in a supine position with the left arm abducted. The left arm was prepped and draped in standard sterile fashion.
> 
> ...



Hello,
What you have is an A-V Shuntogram coded 36147, venous angioplasty-36476/75978 and stent placement 37205/75960.

HTH,
Jim Pawloski, CIRCC


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## sdodson (Nov 23, 2010)

*Ultrasound guidance*

Had the physician documented the fact that an ultrasound picture was obtained during guidance for access for permanent record, and placed in the medical records, you could have billed 76937.


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## birky (Dec 3, 2010)

Thank you both so much for the help


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