# Venography with PICC placement



## stgregor (Jan 20, 2011)

I've got another one I'm stuck on. I'm not sure whether it's appropriate to code for the venous catheterizations on this case, and if so, which code(s) to use. I did not code for the venography of the SVC or brachiocephalic veins as it seems those were done only to lay out anatomy for the intervention. Currently my codes are 36010-59-LT, 36005-59-RT, 76937, 37205/75960-LT, 37206/75960-59-RT, 36569, 77001. If you have a moment, I'd love to hear your opinions. Thank you again for all of your assistance!

PROCEDURE: SUP VENA CAVA ANGIO
INDICATION: Patient with large mediastinal tumor significantly
encroaching upon the superior vena cava and bilateral brachiocephalic
veins. Patient presents with bilateral upper arm and facial swelling.
PROCEDURES PERFORMED
1. Ultrasound-guided puncture of the left basilic vein.
2. Catheterization of the superior vena cava.
3. Ultrasound-guided puncture of the right brachial vein.
4. Catheterization of the superior vena cava from the right arm
puncture.
5. Central venous angiogram.
6. Stenting of the superior vena cava and bilateral brachiocephalic
veins with post stent deployment angioplasty.
7. Repeat central venogram.
8. IV conscious sedation.
9. Fluoroscopic placement of a dual-lumen 5-French PICC line catheter
with tip in the cavoatrial junction.
Preprocedure evaluation confirmed that the patient was an appropriate
candidate for conscious sedation.
Vital signs, pulse oximetry, and response to verbal commands were
monitored and recorded by the nurse throughout the procedure and the
recovery period. All medications for conscious sedation including the
doses administered were placed in the medical record. The patient
returned to baseline neurologic and physiologic status prior to
leaving the department. No immediate sedation-related complications
were noted.
Informed and written consent was obtained from the patient after
discussion of the risks, benefits, and alternatives for this
procedure. The patient expressed full understanding and agreed to
proceed forward.
The patient placed supine on the angiography table. The bilateral
arms were prepped and draped in normal sterile fashion.
Ultrasound evaluation was performed of the left upper extremity. The
basilic vein is prominent in size without internal echoes or
thrombus. This vessel is compressible. A generous amount of 1%
buffered lidocaine was infused in the skin and subcutaneous soft
tissues. Under direct ultrasound guidance, a 21-gauge micropuncture
needle was advanced into the center of the left basilic vein. A
0.018-wire was inserted and serial dilatation was performed at the
site. Following, a 0.035 was negotiated through the left
brachiocephalic vein and advanced into the superior vena cava. A
7-French Raabe sheath was then inserted into the left subclavian
vein.
Next, ultrasound evaluation was performed of the upper extremity
venous structures of the right arm. The parabrachial veins were
identified. One of the paired brachial veins was noted to be most
prominent in size, without internal echoes or thrombus and was
readily compressible with the transducer. As on the left, a generous
amount of 1% buffered lidocaine was infused into the skin and
subcutaneous soft tissues, and a 21-gauge micropuncture needle was
advanced into the center of the right brachial vein. A 0.018-wire was
advanced and serial dilatation was performed at the venotomy site. A
0.035-wire was then inserted into the superior vena cava. A 6-French
sheath was then inserted into the subclavian vein.
Injection of contrast was performed through the left access sheath
(tip within the subclavian vein) demonstrating high-grade stenosis of
the central aspect of the left brachiocephalic vein with marked
stenosis of the inferior vena cava. Venous chest wall collaterals are
noted to opacify with contrast injection.
Following, primary stenting was performed of the superior vena cava
using a 14-4 SMART stent. A 7-80 stent was then extended from the
cranial most aspect of the superior vena cava stent into the left
brachiocephalic vein.
Attention was then turned to the right arm. Injection of contrast was
performed through the right arm sheath (tip in the subclavian vein)
demonstrating high-grade stenosis of the cranial most aspect of the
brachiocephalic vein. Primary stenting was performed using a 7-60
stent. The distal aspect of the stent parallels the distal aspect of
the left brachiocephalic stent. Balloon molding was performed
throughout the bilateral stents with a 6-4 balloon. Both 6 mm
balloons were inflated inside of the 14 mm stent to achieve improved
luminal diameter post stent placement.
Repeat injection of contrast was then performed through the bilateral
upper arm sheaths. Injection of contrast demonstrates fast forward
flow through the stented brachiocephalic vein as well as the superior
vena cava. The previously seen chest wall collaterals are not noted
to opacify. Given the patient's difficult access, a 5-French slip
catheter was then inserted over the right 0.035-wire and a 0.018-wire
was placed. Over this wire a 5-French dual-lumen PICC line catheter
was then placed with tip terminating in the cavoatrial junction,
caudal to the inferior most aspect of the superior vena cava stent.
The PICC line was then secured to the arm using 2-0 Prolene suture. A
sterile dressing was placed. The line flushes and aspirates
appropriately. Fluoroscopy confirmed the line to be intact without
disconnect or kink. On the left, the 7-French sheath was removed and
hemostasis was obtained with manual compression.
The patient tolerated the procedure well. There were no immediate
complications.


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## dpeoples (Jan 21, 2011)

stgregor said:


> I've got another one I'm stuck on. I'm not sure whether it's appropriate to code for the venous catheterizations on this case, and if so, which code(s) to use. I did not code for the venography of the SVC or brachiocephalic veins as it seems those were done only to lay out anatomy for the intervention. Currently my codes are 36010-59-LT, 36005-59-RT, 76937, 37205/75960-LT, 37206/75960-59-RT, 36569, 77001. If you have a moment, I'd love to hear your opinions. Thank you again for all of your assistance!
> 
> PROCEDURE: SUP VENA CAVA ANGIO
> INDICATION: Patient with large mediastinal tumor significantly
> ...



This does not seem to be a standard PICC placement to me, more a diagnostic test, followed by stent placement and PICC placement. I would code thus:
37205/75960(26)
37206/75960(26)-59
36010-59 (bundles with 36569)
36005-59 (bundles with 36569)
36569 (or 36568 depending on patient age)
75827(26)  (may bundle with 75960)
75822(26)-59(probably bundles with 75960)
76937(26)

The cath placement and venographies will probably need a 59 to avoid bundling with the PICC. I would not additionally code for the fluoro guidance because there was plenty of imaging work performed. If you decide to code for the fluoro, there will be more bunding issues with venographies. 
HTH


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## cziser (Jan 24, 2011)

i would code:
75827-26,59 36010-59
75822-26,59
36005-59
76937-26
36569
75960-26. 37205
75960-26,59 37206 (x2)
The physician does dictate a venogram and vena cava gram and these would definitely require 59 modifiers. Also, it reads like 3 vessels stented to me. The superior vena cava, CENTRAL portion ( I am thinking that this excludes it as a bridging lesion)  of the left brachiocephalic vein, and the rt brachiocephalic vein. I would love to know the final outcome of this. We all need to stick together.
Chris McCoy, CPC, CIRCC, RTRCV


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