# 37187 with 37201



## Shirleybala (May 13, 2009)

Hello:
Can we code 37187 with 37201 for the below documentation:

37187	
37201	59
36011	
75820	26
75896	26

    The patient's right arm was prepped and draped in usual sterile
      manner and locally anesthetized with 1% lidocaine.  Under
      real-time ultrasound guidance the right brachial vein was accessed
      with a micropuncture set.  An image was stored for the medical
      record.

      Using Seldinger technique a 6-French vascular sheath was placed.
      A 4-French Berenstein catheter was then advanced into the
      subclavian vein.  Contrast was injected and digital subtraction
      venography was performed.

      Findings:

      There is a 2.5-cm long occlusion of the right subclavian vein,
      extending to the level of the confluence with the right
      brachiocephalic vein.  There are numerous enlarged collateral
      veins present.

      Intervention:

      Under digital roadmap guidance the occlusion was successfully
      crossed with a Berenstein catheter and angled Glidewire.  The
      Possis AngioJet device was utilized using power pulse technique.
      5 mg TPA was mixed in 20 cc normal saline, which was laced across
      the thrombus with the outflow valve closed.

      The TPA was allowed to sit in the clot for one hour, and then the
      Possis AngioJet was used in the normal isovolumetric manner with
      the outflow opened, using heparinized saline.  After several
      passes patency was successfully reestablished.  Completion
      angiography was performed with the patient's arm at his side,
      demonstrating debulking of the vast majority of thrombus.  There
      is still a moderate to severe stenosis in the right subclavian
      vein, consistent with thoracic outlet syndrome.

      At the end of the procedure and the vascular sheath was removed
      and hemostasis achieved with manual compression.  The patient
      tolerated the procedure well, left the department in stable
      condition.  He was noted to have red colored urine, consistent
      with hemoglobinuria and hemolysis related to the Possis AngioJet
      device.

      Impression:

      2.5-cm long occlusion right subclavian vein.  Successful
      mechanical and pharmacologic thrombolysis using the Possis
      AngioJet and 5 mg TPA.  No immediate complications.  Red colored
      urine secondary to hemolysis and hemoglobinuria, a known
      phenomenon with the Possis AngioJet.


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