# another case



## MLS2 (Jul 1, 2009)

TECHNIQUE: Following informed consent and verification of the correct patient identity and planned procedure, the right neck and chest was prepped and draped using sterile technique. The heparin was aspirated through each lumen and discarded. Local anesthesia around the catheter was achieved using 2% Lidocaine. Through each lumen, a 035 Stiff Terumo wire was introduced and advanced to the IVC. The catheter cuff was then freed from the surrounding tissues using a combination of blunt and sharp dissection. The catheter was retracted into the proximal right cephalic vein, and venography was performed.

Review of the images revealed a fibrin sheath involving the entire length of the catheter including the superior vena cava.  This resulted in severe narrowing of the SVC.  The decision was made to disrupt the fibrin sheath.  Over a wire the catheter was removed and a 12 mm x 4 cm angioplasty balloon was advanced into the SVC, and was inflated along the entire length of the SVC and right cephalic vein.  Follow-up venography revealed a good venographic result.

Subsequently, over the wires, and new 14.5FR Palindrome catheter (23cm tip to cuff) was introduced until the tip was positioned in the upper right atrium. Following placement, the catheter flushed freely and the catheter course was normal fluoroscopically. The catheter was sutured to the skin using 2-0 Ethilon.

INTERPRETATION:
1. Large fibrin sheath occupying the majority of the superior vena cava, and surrounding the entire catheter, successfully treated with balloon angioplasty as described.
2. Successful over the wire exchange of the right chest 14.5FR Palindrome catheter (23cm tip to cuff).
3. The catheter may be used immediately.
4. Sutures may be removed in 3-4 weeks.


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## dpeoples (Jul 1, 2009)

MLS2 said:


> TECHNIQUE: Following informed consent and verification of the correct patient identity and planned procedure, the right neck and chest was prepped and draped using sterile technique. The heparin was aspirated through each lumen and discarded. Local anesthesia around the catheter was achieved using 2% Lidocaine. Through each lumen, a 035 Stiff Terumo wire was introduced and advanced to the IVC. The catheter cuff was then freed from the surrounding tissues using a combination of blunt and sharp dissection. The catheter was retracted into the proximal right cephalic vein, and venography was performed.
> 
> Review of the images revealed a fibrin sheath involving the entire length of the catheter including the superior vena cava.  This resulted in severe narrowing of the SVC.  The decision was made to disrupt the fibrin sheath.  Over a wire the catheter was removed and a 12 mm x 4 cm angioplasty balloon was advanced into the SVC, and was inflated along the entire length of the SVC and right cephalic vein.  Follow-up venography revealed a good venographic result.
> 
> ...




I would code this way:

35476/75678 (venoplasty; this is not a fibrin sheath removal)
75827-59 (this will likely bundle with fluoro)
36581 (includes cath placement into VC)
77001

I hope this helps,


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## MLS2 (Jul 1, 2009)

per my 2008 Interventional Radiology Users' Guide:

Can the venous angioplasty codes be used to report fibrin sheath disruption?

Answer:  No. Dilating a clot or macerating fibrin sheath with a balloon is not considered to be dilating a vessel stricture and is not considered to be an angioplasty service.  If balloon fibrin sheath maceration is performed from a separate access, the accurate code to describe the service is 36595.  If performed through the same access site, modifier -52 must be appended to code 36595 indicating that a "reduced" level of service has been provided.


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## Shirleybala (Jul 2, 2009)

*Same acess - 36596*

If performed thro' same access we have code
36596	-Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen

Intraluminal obstructive material, such as a thrombus or fibrin sheath, is removed from inside a central venous device through the lumen of the device. This does not require a separate access incision. The central venous catheter is first checked that it can aspirate and flush forward. The obstructing material is disrupted and removed mechanically by using an angioplasty balloon or other catheter introduced into the central venous catheter through its entry site on the skin. The catheter is checked for unimpeded, restored flow and the process may be repeated until the central venous catheter is cleared.


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## dpeoples (Jul 2, 2009)

I think neither 36595 or 36596 would apply in this case because
A) the balloon was placed in the Vena Cava, not in the catheter/device
B) no material was removed.

I selected 35476/75968 based on the "narrowing" of the vena cava. 

Other than that, you are left with not coding the plasty and considering it just part of the exchange (Zhealth IR Coding Ref 2006, not sure if that has changed), or using an unlisted code. It is not a fibrin sheath removal IMO.

I hope this helps.


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## MLS2 (Jul 8, 2009)

36595:  Pericatheter obstructive material such as a fibrin sheath is removed from around a central venous device via separate venous access (-52 mod if done through the same access site)

36596 would be removal from within the catheter itself (intraluminal)...36595 is removing the obstructive material from around the catheter.


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## dpeoples (Jul 8, 2009)

MLS2 said:


> 36595:  Pericatheter obstructive material such as a fibrin sheath is removed from around a central venous device via separate venous access (-52 mod if done through the same access site)
> 
> 36596 would be removal from within the catheter itself (intraluminal)...36595 is removing the obstructive material from around the catheter.




I would usually agree but...

36595 is generally performed by a snare/loop catheter placed over the obstructed central cath/device and pulled down the lenght of the central cath/device thereby stripping the fibrin sheath from around the central cath/device. The central cath/device is then checked and left in place.

In this case, the obstructed central catheter had been removed prior to the balloon being used. After the balloon, a new catheter was placed making this an exchange.

I appreciate the discussion, I know others have questions about these procedures. We all learn from each other in this forum. 

I hope this helps.


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