suela923@aol.com
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I billed 36147, 35476, 75978 for fistulagram & plasty
I billed 36558-74, 77001-59 for attempted tunneled cath placement.
The tunneled cath was not a "planned" procedure so I thought it was ok to bill as a discontinued procedure. My tech doesn't think so because the dr never got to the tunneled part. Thought??? Thanks, Sue
Indications for procedure: This is a 56-year-old female with a history of a right brachiocephalic AV fistula. Staff at the dialysis center noted that they were pulling thrombus and fistulogram was requested.
Details of the procedure: The patient was identified and placed supine on the angiography table. The right arm was prepped and draped in the usual sterile fashion. After injection of 2% lidocaine, the right arm fistula was accessed with a micropuncture needle. Wire access was obtained and a micropuncture sheath was placed. Multiple views of the fistula were obtained including retrograde and central views with findings outlined below. On initial imaging, the fistula was patent proximally but there was little to no flow after the midpoint of the fistula. A 7-French sheath was placed in the insertion site. A Glidewire and Berenstein catheter were then advanced into the more distal areas of the fistula where it was noted that there appeared to be a significant amount of thrombus within the fistula. There also appeared to be a high-grade stenosis at the level of the cephalic arch. The decision was made to attempt to treat this lesion. The Glidewire was advanced into the central circulation and a 10 x 40 mm angioplasty balloon was advanced to the level of the cephalic arch and balloon angioplasty was performed. Several serial inflations were performed from the cephalic arch into the more proximal portion of the fistula. Despite this, completion angiography demonstrated minimal improvement in the stenosis and persistence of significant thrombus within the fistula. At this point, it was felt that the fistula was not amenable to percutaneous intervention and the procedure was terminated. All catheters and wires were removed, and the insertion site was closed with a pursestring suture.
I held a detailed discussion with the patient regarding the findings and I recommended that she undergo attempt at operative thrombectomy of her fistula. Given that she has not had adequate dialysis for more than 5 days, I also recommended that we place a tunneled dialysis catheter for treatment in the interim. She agreed to proceed and that procedure will be dictated under separate procedure note.
The patient tolerated the procedure well with no immediate complications.
Findings:
1. Right brachiocephalic AV fistula with no evidence of anastomotic stenosis.
2. The fistula is patent proximally, however, at the midpoint there is significant impedance to flow and appears that there is significant thrombus throughout the remainder of the fistula through the level of the cephalic arch.
3. High-grade stenosis at the level of the cephalic arch.
4. Possible moderate stenosis in the innominate vein centrally.
Indications for procedure: This is a 56-year-old female with a malfunctioning right arm AV fistula which was attempted to have percutaneous intervention, but found to be thrombosed. (Please see details of that procedure dictated under a separate note). The patient requires catheter access for dialysis treatment.
Details of the procedure: The patient was supine on the angiography table. Ultrasound was used to identify an adequate access site and the right internal jugular vein appeared to be adequate for access. The patient's right neck and chest were prepped and draped in the usual sterile fashion using maximal sterile barrier technique. After injection of 2% lidocaine, the right internal jugular vein was accessed with an 18-gauge single wall puncture needle. Wire access was attempted, however the wire would not pass into the central circulation. The wire was attempted to be advanced multiple times under fluoroscopic guidance, but was unsuccessful. Upon further examination with ultrasound lower down in the neck, the internal jugular vein appeared to be reduced in size and likely had significant stenosis precluding wire access. At this point, ultrasound examination of the left internal jugular was performed. However good visualization of the vein could not be obtained therefore access on the left side was not attempted. Ultrasound images were saved for documentation. At this point, the procedure was aborted due to inadequate veins for access.
Findings:
1. Right internal jugular vein with significant stenosis.
2. Poor visualization of the left internal jugular vein.
I billed 36558-74, 77001-59 for attempted tunneled cath placement.
The tunneled cath was not a "planned" procedure so I thought it was ok to bill as a discontinued procedure. My tech doesn't think so because the dr never got to the tunneled part. Thought??? Thanks, Sue
Indications for procedure: This is a 56-year-old female with a history of a right brachiocephalic AV fistula. Staff at the dialysis center noted that they were pulling thrombus and fistulogram was requested.
Details of the procedure: The patient was identified and placed supine on the angiography table. The right arm was prepped and draped in the usual sterile fashion. After injection of 2% lidocaine, the right arm fistula was accessed with a micropuncture needle. Wire access was obtained and a micropuncture sheath was placed. Multiple views of the fistula were obtained including retrograde and central views with findings outlined below. On initial imaging, the fistula was patent proximally but there was little to no flow after the midpoint of the fistula. A 7-French sheath was placed in the insertion site. A Glidewire and Berenstein catheter were then advanced into the more distal areas of the fistula where it was noted that there appeared to be a significant amount of thrombus within the fistula. There also appeared to be a high-grade stenosis at the level of the cephalic arch. The decision was made to attempt to treat this lesion. The Glidewire was advanced into the central circulation and a 10 x 40 mm angioplasty balloon was advanced to the level of the cephalic arch and balloon angioplasty was performed. Several serial inflations were performed from the cephalic arch into the more proximal portion of the fistula. Despite this, completion angiography demonstrated minimal improvement in the stenosis and persistence of significant thrombus within the fistula. At this point, it was felt that the fistula was not amenable to percutaneous intervention and the procedure was terminated. All catheters and wires were removed, and the insertion site was closed with a pursestring suture.
I held a detailed discussion with the patient regarding the findings and I recommended that she undergo attempt at operative thrombectomy of her fistula. Given that she has not had adequate dialysis for more than 5 days, I also recommended that we place a tunneled dialysis catheter for treatment in the interim. She agreed to proceed and that procedure will be dictated under separate procedure note.
The patient tolerated the procedure well with no immediate complications.
Findings:
1. Right brachiocephalic AV fistula with no evidence of anastomotic stenosis.
2. The fistula is patent proximally, however, at the midpoint there is significant impedance to flow and appears that there is significant thrombus throughout the remainder of the fistula through the level of the cephalic arch.
3. High-grade stenosis at the level of the cephalic arch.
4. Possible moderate stenosis in the innominate vein centrally.
Indications for procedure: This is a 56-year-old female with a malfunctioning right arm AV fistula which was attempted to have percutaneous intervention, but found to be thrombosed. (Please see details of that procedure dictated under a separate note). The patient requires catheter access for dialysis treatment.
Details of the procedure: The patient was supine on the angiography table. Ultrasound was used to identify an adequate access site and the right internal jugular vein appeared to be adequate for access. The patient's right neck and chest were prepped and draped in the usual sterile fashion using maximal sterile barrier technique. After injection of 2% lidocaine, the right internal jugular vein was accessed with an 18-gauge single wall puncture needle. Wire access was attempted, however the wire would not pass into the central circulation. The wire was attempted to be advanced multiple times under fluoroscopic guidance, but was unsuccessful. Upon further examination with ultrasound lower down in the neck, the internal jugular vein appeared to be reduced in size and likely had significant stenosis precluding wire access. At this point, ultrasound examination of the left internal jugular was performed. However good visualization of the vein could not be obtained therefore access on the left side was not attempted. Ultrasound images were saved for documentation. At this point, the procedure was aborted due to inadequate veins for access.
Findings:
1. Right internal jugular vein with significant stenosis.
2. Poor visualization of the left internal jugular vein.