# Thrombolysis



## prabha (Jul 24, 2009)

37620
35476
37201
36010
36010-59
75940-26
75825-2659
75825-2659
75820-26
75896-26
75978-26

Pls confirm the above set of codes for the below procedure.Can we use 37187 instead of 37201 & 75896?


       IVC Gram/IVC Filter:       
       With the patient in the supine position, the right neck was
       prepped and draped in a sterile fashion.  Using real-time
       ultrasound guidance, a 21-gauge needle was advanced into the right
       internal jugular vein.

       A 5-French sheath was placed.  A guidewire was manipulated into
       the infrarenal inferior vena cava.  A 5-French sizing pigtail
       catheter was placed in the peripheral IVC.  Contrast was injected
       and digital subtraction IVC examination was performed.

       Catheter exchange for was performed for a deployment sheath for a
       Gunther Tulip IVC filter.  Infrarenal deployment of the Gunther
       Tulip (potentially retrievable) IVC filter was performed.

       Left Lower Extremity Venous Thrombolysis:       
       A sterile prep and drape of the left popliteal region and upper
       left calf was performed.  Using real time ultrasound guidance, a
       21 gauge needle was advanced into a upper calf muscular vein.   A
       guide wire was passed in antegrade fashion.  A 4 French
       angiographic catheter was placed.  Contrast injections of were
       performed and digital subtraction venography of the left lower
       extremity was obtained.

       The catheter was exchanged for a six French vascular sheath.  A
       5-French angiographic catheter was manipulated into the left
       external iliac vein.  Contrast was injected and digital images
       were obtained.  A guidewire was manipulated across the external
       iliac vein and into the left common iliac vein and then into the
       infrarenal IVC.  Contrast was injected and digital images were
       obtained.  The patient was given a systemic bolus of heparin.Using
       a  Possis mechanical thrombectomy system, Power pulse thrombolysis
       of the left common iliac vein, external iliac, common femoral and
       femoral vein was performed with the 6 Fr. DVX catheter.  The Power
       Pulse  was performed using 20 mg tPA in 100 cc of normal saline.
       The TPA was allowed to dwell within the treated segment for 90
       minutes.  The patient remain on the table during this interval
       with continuous physiologic monitoring by anesthesia.

       The Possis system was then used to perform mechanical lumpectomy
       using both antegrade and retrograde passage over the treated
       segment for a total of 200 cc normal saline.       
       Follow-up venography was performed.       
       The left calf sheath was exchanged for a 7-French vascular sheath.
       A central left external iliac vein, left common iliac vein and
       iliac vein bifurcation was dilated to 10 mm.  Subsequently the
       same venous segments were dilated to 12 mm and then to 14 mm.

       The balloon catheter was exchanged for a 5-French 50-cm long
       infusion catheter for continuous overnight infusion of TPA in the
       ICU.  The patient's infusion was started at  2mg tPA per hour with
       the dose being split via the infusion catheter and the calf
       sheath.

       Specific instructions were discussed with the SICU physician team
       regarding TPA infusion, intravenous heparin infusion and
       monitoring of lab work.

       FINDINGS:       
       Transjugular IVC Gram demonstrates nonocclusive thrombus along the
       left lateral infrarenal IVC wall.  The right and left renal veins
       are patent.  The right common iliac vein is patent.  The
       suprarenal IVC is patent without thrombus.   

       A potentially retrievable (Gunther Tulip IVC filter) was deployed
       in the infrarenal IVC.

       Left lower extremity venography demonstrates occlusion of the
       length of the left femoral vein, common femoral vein, left
       external iliac vein and left common iliac vein.  Filling defects
       are noted throughout the above veins consistent with acute and
       subacute thrombosis. The findings are consistent with left iliac
       vein compression syndrome (May Thurner syndrome).

       Power pulse from the lysis of the above occluded venous segments
       of the left lower extremity was performed using 20 mg TPA.
       Following follicle mechanical thrombolyzes, there is significant
       improvement in the appearance of the veins with some antegrade
       flow.  Percutaneous balloon angioplasty of the iliac veins was
       performed using 10 mm, 12-mm and 14-mm balloons.  Subsequently
       continuous infusion of TPA was performed in order to lyse
       residual, persistent thrombus in the femoral, common femoral,
       external iliac and common iliac veins..

       IMPRESSION:       
       Real-time ultrasound guided access of a patent right internal
       jugular vein.

       IVC contrast exam:
       Patent suprarenal and juxtarenal inferior vena cava.  Nonocclusive
       thrombus along the left lateral wall of the infrarenal IVC.
       Patent right common iliac vein.

       Infrarenal deployment of Gunther Tulip IVC filter.

       Real-time ultrasound guided access of a patent left upper calf
       muscular vein.

       Left Lower Extremity Angiogram:
       Subacute to acute thrombus in the left femoral vein, common
       femoral, external iliac and common iliac veins.  The junction of
       the left common iliac vein with the IVC is consistent with iliac
       compression syndrome or May Thurner syndrome.

       Pharmaco- mechanical thrombolysis was performed as described
       above.  Follow-up venography demonstrates improvement in
       thrombosis following chemical mechanical thrombolysis using a
       power pulse protocol.

       Percutaneous left  iliac venous balloon dilatation up to 14 mm as
       described above.

       Overnight continuous TPA infusion initiated as described above.


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## dhuston (Jul 24, 2009)

I think you can code both 37187 for the mechanical thrombectomy and 37201 for the infusion that was left overnight.

Diane Huston, CPC,RCC


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## Jim Pawloski (Jul 24, 2009)

prabha said:


> 37620
> 35476
> 37201
> 36010
> ...



I think you may have missed the S&I code for the filter 75940


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## dpeoples (Jul 24, 2009)

dhuston said:


> I think you can code both 37187 for the mechanical thrombectomy and 37201 for the infusion that was left overnight.
> 
> Diane Huston, CPC,RCC



I agree with Diane, you can bill both. You might need to modify 37201/75896 (59) depending on your payor. It is clearly a separate service.

HTH


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