# stent placement with questionable PTA



## carriebeth (Mar 25, 2010)

I coded 36147 37205 75960. my doctor believes there should also be a 35476 75978

HISTORY: The patient presents with continued difficulty with cannulation, particularly with the venous needle. Last angioplasty was only 3 weeks ago. On physical exam, the fistula has areas of infiltration around the venous cannulation site. The fistula begins to dive deep and medially in this area. He saw Dr. ______ with these problems who recommended repeat fistulogram with probable stent placement and if this does not work, he might need repeat surgery. 

EXAM: Left upper arm fistulogram with venous angioplasty and stent placement 

PREOP DIAGNOSIS: Difficult cannulation AV fistula 
POSTOP DIAGNOSIS: Venous stenosis, AV fistula 

PROCEDURE: After informed consent and under sterile conditions the left upper arm native brachiobasilic fistula was accessed in the venous direction and fistulogram was performed to the SVC. There was 50% stenosis at the swing site within the main outflow of the fistula which is tortuous as it dives deep and medially. The central veins were patent without stenosis. Next, a 10 mm by 80 mm Fluency (gortex covered) stent was placed across the stenosis and then the lesion was dilated to full effacement with a 10 mm balloon. Follow-up fistulagram showed no residual stenosis at the swing site with rapid flow. The previously tortuous segment is now completely straight. The catheter was then removed and hemostasis was easily obtained. IMPRESSION: The left arm fistula was treated with angioplasty and stent placement. He has limited cannulation sites, so it is likely the stent will need to be cannulated with the venous needle. This is okay and in fact may provide easier cannulation. Please do not develop a buttonhole for the venous needle due to the presence of the stent. The stent site was marked on his skin with a permanent marker and a diagram is attached to this report. The inflow artery is from a radial artery with a high takeoff from the brachial artery.


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## dpeoples (Mar 25, 2010)

carriebeth said:


> I coded 36147 37205 75960. my doctor believes there should also be a 35476 75978
> 
> HISTORY: The patient presents with continued difficulty with cannulation, particularly with the venous needle. Last angioplasty was only 3 weeks ago. On physical exam, the fistula has areas of infiltration around the venous cannulation site. The fistula begins to dive deep and medially in this area. He saw Dr. ______ with these problems who recommended repeat fistulogram with probable stent placement and if this does not work, he might need repeat surgery.
> 
> ...



IMO, your code selection is correct. It seems as though he "dilated" the lesion after stenting the same, which to me means he dilated the stent. As such, angioplasty/venoplasty should not be separately billed. 

HTH


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## carriebeth (Mar 26, 2010)

Thank you, Danny.

On another note how was the CIRCC my employer is having me take it this summer?


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## dpeoples (Mar 26, 2010)

carriebeth said:


> Thank you, Danny.
> 
> On another note how was the CIRCC my employer is having me take it this summer?



 I understand it is a challenging test. I was actually "grandfathered" in because I had a previous designation of CIC from a company in Atlanta. I did take their test several years ago (I am sure the CIRCC is similar) and it was very difficult. My advise is to get a good study guide and study it often.

HTH


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## Jim Pawloski (Mar 26, 2010)

carriebeth said:


> Thank you, Danny.
> 
> On another note how was the CIRCC my employer is having me take it this summer?



I took the CIRCC last year, and it took me three times!  And I am a Interventional Technologist as my main profession.  Get the study book as it was a great help and know your catheter codes from the different access sites.  You can take charts of vessle amatomy and label your CPT and HPCPS book for the different sections of Interventional Radiology and Cardiology.  It was a difficult test, just don't overread the reports.  Look for the info that you need.  Good Luck,
Jim Pawloski, CIRCC, MSA, R.T.(CV)


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