# Venogram and PICC catheter



## drobinson1 (Jun 9, 2010)

I am a little confused. I don't think our radiologist changed the line so I was thinking about using 36005/75820 but a lot was going on so I wasn't sure.

Clinical Indication: Lower GI bleed.

We were asked to exchange the patient's midline catheter for a PICC catheter. The intravenous team was unable to advanced the PICC catheter past the axillary region. I cut the PICC catheter passed a wire through the catheter and was meeting resistance in the region of the pacemaker insertion site. Therefore, I injected a small amount of nonionic contrast and performed a right upper extremity venogram and we see a very tight stenosis of the mid subclavian vein in the area of pacemaker insertion. Tear are also extensive collaterals around this point. Utilizing the venogram guidance we were able to pass a nitinol wire through the area of stenosis. However, the PICC catheter would not follow the wire due to significant stenosis at the entry site. We attempted to a pass a long peel-away sheath over the wire but as well could not advance the sheath pass the area of stenosis. Therefore, we cut the PICC catheter to 24 cm and positioned it just proximal to the level of stenosis. Certainly, this midline catheter can be utilized. the tip is in the proximal subclavian vein. This can also be used to aspirate blood. We could not utilize the left upper extremity due to patient's history of left axillary lymph node dissection.


IMPRESSION:
Very tight stenosis in the mid right subclavian vein in the area of pacemaker insertion. PICC catheter could not be advanced past this point. Please see comment above.


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## dpeoples (Jun 10, 2010)

drobinson1 said:


> I am a little confused. I don't think our radiologist changed the line so I was thinking about using 36005/75820 but a lot was going on so I wasn't sure.
> 
> Clinical Indication: Lower GI bleed.
> 
> ...



IMO, this is not a true diagnostic exam but an evaluation of the venous access for guidance purposes. The physician even states " Utilizing the venogram guidance". Therefore I would not code 36005/75820 but instead would code:
36597 for repositioning and 36598 for a catheterogram.

HTH


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