# Thrombectomy w/IVC Filter, venograms and angios



## STOMANY (Oct 26, 2010)

I need help with coding the following procedures.  I am coding for the Physician  There are multiple dates of service on the medical notes which compounds the confusion with the coding.  I hope there is a brave soul out there that can take pity on me!   
The hospital coded the following:     For the 26th dos  - the hospital reported the following:

36005 - Injection Ext. Venography
36010 - Place Cath in vein
36012 - place cath in vein
37201 - transcath therapy infuse
37620 - revision of major vein
75820 - vein x-ray - arm/leg
75896 - x-ray transcath therapy
75940 - x-ray placement, vein filter
71010 - chest x-ray
72148 - mri lumbar spine w/o dye
75825 - vein x-ray,trunk
76937 - us guide, vascular access 

 For the 27th dos :

35476 - repair venous blockage
37187 - venous mech thrombectomy
37209 - change iv cath at thromb tx
75898 - follow up angiography  
75900 - intravascular cath exchange
93971 - extremity study
75978 - repair venous blockage
93979 - vascular study

The header states the following:

*Extremity Lower Venous US Left
Thrombectomy Venous*Transcatheter Infusion
Perc Placement of IVC Filter
Venous Access US Guidance
Venogram, Extremity Left
Venogram, Inferior Vena Cava
IVC US
Extremity Lower Venous US LEft
Angio, Existing Cath
Thrombectomy Venous
PTA, Venous
Angio Existing Cath[/B]

Impression:
1.  Status post inferior vena cavogram, IVC filter placement, ultrasound guided venous access left popliteal vein and left posterior tibial vein, and left lower extremity venography, as well as left lower extremity transcatheter infusion of thrombolytics, all performed 8/26/10. with folow up sonography 8/27/10, followed by mechanical venous thrombectomy transcatheter infusion thrombolytics left lower extremity, left lower extremity venography, and left lower extremity PTA venous, all performed without complication.  In addition to followup sonography of 8/28/10, left lower extremity and IVC, followed by thrombolysis and mechanical thrombectomy left lower extremity venous system, left lower extremity venography, again performed without complication.
2.  There is only patency at the level of the posterior tibial vein, presently 8/29/10.  If patency is not reestablished with shortly with antigoagulation repeat inervention including additional thrombplytics and thrombetomy may be necessary as discussed with Dr. AAAA.
3.  Inferior vena carva filter also in good position, as below.

*Indication:*
Patient status post thrombectomy on 8/27.  Please compare to prior ultrasound DVT deep vein thrombosis.

*Procedures:*
8/26/10 Inferior vena carvogram, 8/26/10 Percutaneous fluoroscopic guided placement IVC filter, 8/26/10 Venous access guidance right common femoral vein, Venous access guidance left popliteal vein and left posterior tibial vein, 8/26/10 Left lower extremity venography, 8/26/10 Transcathetheter infusion of thrombolytics through infusion catheters placed through both the left popliteal vein sheath and left posterior tibial vein sheath, 8/27/10 Left lower extremity venous thrombectomy with AngioJet, 8/27/10 Left lower extremity venography perfomred through left popliteal and left posterior tibial previously obtained access, 8/27/10 Left iliac vein angioplasty, 8/27/10 Transcatheter infusion thrombolytics left lower extremity venous thrombus through infusion catheters placed via the left popliteal and left posterior tibial sheaths, 8/28/10 Left lower extremity venous thrombus, 8/28/10 IVC and left lower extremity venous sonography, 8/29/10 left lower extremity venous sonography.

*Technique*
8/27/10 - the right groin was prepped and draped in a sterile fashion and right common femoral vein access was obtained.

A pigtail cath was advanced into the right common illiac vein & inferior vena cavagroam was obtained. 

Focal thrombus was identified extending into the most distal IVC from the left common iliac vein.

Following this initial set of studies, the Tulip Cook IVC Filter was advanced through a 9-French sheath placed in the right common femoral vein and deployed in good position just below the level of the renal veins.

Exchange was made for a right common femoral vein sheath through which subtherapeutic heparinizatin was performed.  

The left popliteal fossa and left medial malleolar region were prepped and draped in a sterile fashion.  Initially, the left popliteal vein was located and was noted to be occluded under sonographic evaluation, and then was selectively catheterized and a 6-French 7 cm sheath was placed into the left common femoral vein.

Subsequently, the left posterior tibial vein was also noted to be thrombosed under ..... visualizatin and again was then selectively catheterized and a 6-French 4 cm sheath was placed in the left posterior tibial vein.  

A 50 cm infusion catheter was then advanced through the popliteal sheath covering the extend of thrombus from the IVC, left common iliac ven, left external iliac vein, left common femoral vein, and left superfcial femoral vein, to just above the level of the sheath.

Thrombolytic TPA was then infused through the infusion catheter at a rate of 0.25 mg per hour. 

1 30 cm infusion catheter was advanced through the left posterior tibial sheath, which reached the proximal tibia, and infusion of thrombolytic TPA was also perfomed.
On 8/27, initial followup sonography of the IVC demonstrated patency; however, sonography of the left lower extremity demonstrating persistent occlusive thrombus throught the left lower extremity.  

Following this , it was elected to bring the pt back to the IR suite.  The infusion catheters advanced via the left popliteal sheath and left posterior tibial sheaths were removed and AngioJet mechanical thrombectomy was utilized with improved result from the level of the IVC through the left common iliac vein, left common femoral vein, and left superficial femoral vein, although patency was not reestablished.

AngioJet was attempted, although unsuccessful through the left posterior tibial vein.

Angioplasty of the left common/external iliac vein was then attempted with a 10 mm, 6cm length angioplasty balloon.

Followup venography os the left lower extremity demonstrating persistent thrombus, although dimished as compared with the prior day.

a 50 cm infusion catheter was repositioned through the left popliteal vein covering the extent of the left lower extremity from the IVC through the left superficial femoral vein and thrombolytic infusion was then again performed overnight initally at 0.5 mg per hour and subsequently at 0.25 mg per hour till about 4 a.m. when it was noted with lab that the patient's fibrinogen level had significantly dropped and the infusion was converted to normal saline.  

on 8/28/10, sonographic studies of the left lower extremity and IVC were repeated, again demonstrating resudual thrombus from the left common iliac vein, left external iliac vein, left common femoral vein, and left superficial femoral vein to the sheath, although again thiw was improved as compared to the prior day. 

Mechanical thrombectomy with AngioJet was then perfomred throughout the course of thrombus left lower extremity from just above the left popliteal sheath in the left superficial femoral vein to the IVC.

The residual thrombus was then laced with TPA with dwell time of 20 minutes and again an AngioJet mechanical thrombectomy was then perfomred again.  

The pt tolerated these procedures well without complication, and the catheters were removed and the sheaths removed as well from both the popliteal vein on the left and the posterior tibial vein on the left.  Repeat sonogram, left lower extremity was then performed in the a.m. 8/29/10, demonstrating, again, patency of the IVC.


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## MARTIN#45 (Oct 26, 2010)

Hello, 

This looks like it would be fun.  Give me till tomorrow, my books are at home.  I love coding for vascular.


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## kbazarte@yahoo.com (Oct 26, 2010)

Hi,

I am an interventional tech as well as coder.  When I get home I will pull my interventional resources and give it a shot.   

Are you coding only the 8-27-10 procedure or both?

If both can you provide op notes for the 26th?

It appears that on the 26th there was a sheath in the popliteal vein and the posterior tibial.  Then on the 27th access was obtained via rt femoral vien.

If coding for both days very important to know all access, and to  know what procedures done on the 26th because that will effect the CPT codes that are allowed to be used for subsequent day / follow up exams.

Look forward to helping :O)


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## STOMANY (Nov 4, 2010)

Thanks for helping me on this one.  To answer your first question about the medical notes for the 26th.  That is part of the problem - This medical note had multiple dates of service as did the remainder for the 28th thru the 30th.  It appears it was the "copy and paste" method of dictation.  I could scan the entire note and send you a copy to your e-mail.  I'm at home now - but I'll send it your way tomorrow morning.  

Thanks again


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