# Intervention outside AV fistula area with 1 puncture through the graft



## nhernandez0784 (Jun 28, 2011)

TECHNIQUE:
Following informed and written consent, with the patient's questions answered and the risks, benefits and alternatives explained, the patient was prepped and draped in the usual fashion.

Standard time-out was performed.
COMPARISON:
01/28/2011 

Under sonographic guidance, and 2% lidocaine local analgesia, micropuncture technique was used to access the patients left upper arm dialysis graft.

A 6-French vascular sheath was placed.

Dialysis fistulogram to include the central draining veins was performed.

Focal stenosis of the basilic vein at the venous anastomoses and in its midportion was noted in a recurrent location to the prior study.

Complete occlusion of the stent in the innominate vein was noted. Multiple collateral veins drain the left upper extremity from a left to right direction.

Superior vena cava and right innominate vein appear patent.

Using an angiographic catheter and glide wire the occlusion was crossed. Serial balloon angioplasty with a 6 mm and 8 mm balloon was performed restoration of flow but with suboptimal restoration of luminal diameter. Intimal hyperplasia was felt to be the cause.

Also noted was stenosis or occlusion of the distal left internal jugular vein.

A 10 mm x 80 mm lumen extent was then deployed to reline the existing stent and cover the additional affected trailing edge stenosis.

The ostium of the stenotic or occluded left internal jugular vein was covered.

Repeat venography demonstrated excellent luminal respiration and in- line flow.

Balloon angioplasty of the basilic vein and venous anastomoses with an 8 mm x 4 cm angioplasty balloon was performed. Residual elastic stenosis remained.

For this reason, the site was treated with overlapping 7 and 8 mm fluency stent grafts.

Repeat fistulogram demonstrate restoration of good luminal diameter.

At the termination of the procedure, the catheters, wires and sheaths were removed and hemostases was achieved using manual compression.

The the patient tolerated procedure well without immediate complication.

The patient received 4 mg of Versed and 200 mcg of Fentanyl intravenously for the purposes of moderate sedation.

The patient was independently monitored by the radiology nurse using automated blood pressure, EKG and pulse oximetry.

Start time: 08:34 a.m. End time:

09:46 a.m.

Fluoroscopy time 9 minutes 58 seconds 

Contrast:
40 ml Isovue 300 
IMPRESSION:
Left upper extremity dialysis fistula with focal stenosis at the venous anastomoses, and a mid basilic vein with complete occlusion of the stent within the innominate vein.

The occlusion was recanalized and balloon angioplasty with a complete resolution of luminal diameter.

For this reason repeat stenting was performed with excellent restoration of luminal diameter and in-line flow.

Balloon angioplasty of the stenosis at the venous anastomoses and in the mid basilic vein was also performed with suboptimal resolution of stenosis. For this reason a stent grafting of the affected area was performed. Restoration of luminal diameter and in-line flow was achieved. 

If the physician punctures the AV shunt but continues to place the catheter outside the area of the graft (passed axillary vein) and also does intervention (angioplasty and stent placement), does CPT code 36147 cover the catheter placement to that area or is appropriate to code a first order catheter placement with a 52 modifier along with CPT code 36147 seeing that the physician never documented a second puncture?

Or our second scenario would be that because selective catheter placement code supersedes a non – selective code (36147), would we use the more selective catheter code and replace CPT code 36147 with CPT code 75791 although the shunt was directly punctured?


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## dpeoples (Jul 1, 2011)

nhernandez0784 said:


> TECHNIQUE:
> Following informed and written consent, with the patient's questions answered and the risks, benefits and alternatives explained, the patient was prepped and draped in the usual fashion.
> 
> Standard time-out was performed.
> ...





36147 includes initial puncture and catheter placement from this access to the SVC, this includes the axillary vein (same path) so no additional code is warranted.  If a "collateral vein" (changed direction/path) is selected you would change 36147 to 36011 and add 75791.

paraphrased from Dr Z's Diagnostic and Interventional Cardiovascular Coding Reference fifth edition 2011.

HTH


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