# revision of basilic vein transposition



## efuhrmann (Oct 5, 2009)

"...his prior A-V fistula was done elsewhere and instead of actually transposing the vein, they superficialized the basilic vein; it was quite medial. The fistula is functioning excellently and looks very good despite the fact that it has infiltrated many times.  There is also old forearm loop graft in the same arm, which is thrombosed.  He has multiple scars all over this area as the transposition was done in stages.  Therefore, we did our best to isolate out the artery at the brachial position just above the antecubital after viewing his old films and records.  At this point there was excessive scarring and due to the limitations of the dissection, we isolated out the hood of the prio basilic vein transposition anastomosis as well as the artery deep to this.  We dicided to leave the vein hood in place as a point of proximal anastomosis for the arterial end.  
Now attention was to the venous end.  We made an incision over the axillary vein, more p[roximal vein than had been used prior, to allow for a clean field.  The vein was isolated out and vessel loop controlled.  The tunnel was created with the Kelly-Wick tunneller from the arterial end to the venous end, lateralizing the graft.  We used an atrium taper to 4X6 mm graft and tunnelled it through on the appropriate tunneller. We trimmed it to size and heparinized with 2000 units.  Clamp placed on the hood of the old anastomosis and the longitidinal arteriotomy was made.  We trimmed the A-V graft and performed the anastomosis using 6-0 prolene.  
Now the venous anastomosis was performed.  A longitudinal arteriotomy was made in the vein. Old fistula was clamped proximally as well as the graft hada clamp just after the proximal anastomosis to ensure hemostasis.  The graft was trimmed to size.  
Now we needed to ligate the other A-V access, the basilic vein transposition.  We made a counterincision over the old puncture sites, placed two ties and divided it.  We still felt somewhat of a pulse and we wanted to ensure that we had in fact ligated the appropriate old basilic vein transposition, so at the incision, near the antecubital area we made a longitudinal incision, dissecting out the A-V fistula once again and ligated it as well as any branches that we saw X2.  The old site had so much induration and infiltration of old hemodialysis fix that I decided to leave a wick in between the 2 middle incisions..."

36832??
I have no idea-can you help?


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## efuhrmann (Oct 6, 2009)

*I am serious*

please-somebody...don't leave me alone with the doctor who doesn't trust coders anyway!


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## dpumford (Oct 6, 2009)

I read quickly not alot of time but from what I can tell I think he may be doing a totally new graft,  Ask the surgeon sometimes it is hard to tell. You should also check out code 37607 for the ligation.  36830 & 37607 had no CCI edits when I put them in flash code. 

Hope this helps some!


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## jillmtom (Oct 7, 2009)

Based on what I am reading the basilic vein transposition fistula was ligated and a new AV graft was placed.  I would bill the following codes:

Placement of an AV graft 36830
Ligation AV fistula 37607

I would discuss this with your doctor as they are not coders and you can explain why you chose these codes.  Doctors can explain their procedures better verbally then what we read from the written report.  That is the best way we learn what codes are the best choice and it helps us write appeal letters to the insurance carrier.

Good Luck!


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