hcg
Guru
Can someone please help me the correct CPT & what modifier to use on attempted catheter placement. I was thinking of using modifier 52, but should I used modifier 53 instead? Thank you so much for the help.
Here's what I have:
Dx codes: 585.6, 995.91, 996.73
CPT codes: 36558-52, 36556, 76937-26
PREOPERATIVE DIAGNOSIS: Renal failure, sepsis, need for dialysis access.
POSTOPERATIVE DIAGNOSIS: Renal failure, sepsis, need for dialysis access. Question superior vena cava
stenosis.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIA: 1% lidocaine.
OPERATION: 1) Attempted ultrasound guided right jugular Niagara catheter placement. 2) Left femoral Niagara catheter placement (ultrasound guided).
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS
This is a 57-year-old patient with renal failure. Patient is chronically dialyzed through a tunneled dialysis catheters. Patient is admitted to the hospital with sepsis, presumed secondary to a catheter. Patient has subsequently had multiple medical complications including congestive heart failure episodesand apparent myocardial infarction. The indwelling right jugular tunneled dialysis catheter was dislodged which in and of itself suggested it was infected. I was asked to obtain an additional dialysis access. Initial thoughts were to plan for a tunneled catheter, but given the patient's ongoing leukocytosis and associated symptoms including chills, I felt that implantation of a semipermanent catheter was inappropriate. I therefore offered bedside Niagara placement. Risks including bleeding, infection, injury to the veins of the neck, which were discussed with the patient preoperatively and questions were answered. It should be noted that on the day of the placement of the catheter, the patient was somewhat somnolent, perhaps related to some uremia. Previous discussions were undertaken with the patient when patient was more coherent and patient did appear to understand the plan. Because of patient somnolence, I did not ask patient to sign a consent form.
DESCRIPTION OF PROCEDURE
The patient was identified and placed in the Trendelenburg position. Examination of the neck revealed the right jugular vein was patent , the left jugular vein seemed somewhat smaller but also was patent. I chose to approach the right side. I prepped the right neck and chest with ChloraPrep and appropriately draped. Then 1% lidocaine was liberally infiltrated. The thyroid ultrasound device was used to visualize the right jugular vein and a needle was passed under direct ultrasonographic guidance into the vein. The wire passed into the vein, but met resistance at a distance of about 20 cm. The wire was removed. The needle was removed and reaccess was again obtained using ultrasound guidance. Each time that I did this, it was a little harder as there was a little bit of extravasation of blood from the vein and that it made difficult to visualization of the vein itself. Nevertheless, I was able to access consistently the vein, but I could not pass a wire beyond that 20cm mark. I tried several different attempts and all of met with failure. I was able to aspirate blood
while in the vein to confirm that I was still intraluminal, but could not pass the wire. I had fears that perhaps there was proximal stenosis. I therefore chose to abort the procedure. I considered an additional upper extremity approach, but given the distance of 20 cm, I was concerned that patient might have something like superior vena cava stenosis. Therefore, any venous access in the upper extremity might be difficult.
I therefore chose to go to the groin. There was some ecchymosis in the right groin, so I went to the left side. The Site-Rite device again confirmed patency of the femoral vein. I prepped the groin separately with ChloraPrep and then appropriately draped. Additional local anesthesia consisting of 1% lidocaine was infiltrated. An introducer needle was used to gain access to the femoral vein. It should be noted that the patient's obesity made it for a difficult access, but ultimately, I was in the vein. The wire passed without difficulties. The tract was dilated and a dual-lumen 20 cm straight Niagara catheter was passed without difficulty down into the femoral vein. Both lumens aspirated and flushed without difficulties. The catheter were first flushed with saline and then with concentrated heparin. The catheter was sutured to the skin x2 and a dry dressing was applied. The patient tolerated the procedure well without complications except as noted above.
Here's what I have:
Dx codes: 585.6, 995.91, 996.73
CPT codes: 36558-52, 36556, 76937-26
PREOPERATIVE DIAGNOSIS: Renal failure, sepsis, need for dialysis access.
POSTOPERATIVE DIAGNOSIS: Renal failure, sepsis, need for dialysis access. Question superior vena cava
stenosis.
SURGEON: Dr. A
ASSISTANT: Dr. B
ANESTHESIA: 1% lidocaine.
OPERATION: 1) Attempted ultrasound guided right jugular Niagara catheter placement. 2) Left femoral Niagara catheter placement (ultrasound guided).
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS
This is a 57-year-old patient with renal failure. Patient is chronically dialyzed through a tunneled dialysis catheters. Patient is admitted to the hospital with sepsis, presumed secondary to a catheter. Patient has subsequently had multiple medical complications including congestive heart failure episodesand apparent myocardial infarction. The indwelling right jugular tunneled dialysis catheter was dislodged which in and of itself suggested it was infected. I was asked to obtain an additional dialysis access. Initial thoughts were to plan for a tunneled catheter, but given the patient's ongoing leukocytosis and associated symptoms including chills, I felt that implantation of a semipermanent catheter was inappropriate. I therefore offered bedside Niagara placement. Risks including bleeding, infection, injury to the veins of the neck, which were discussed with the patient preoperatively and questions were answered. It should be noted that on the day of the placement of the catheter, the patient was somewhat somnolent, perhaps related to some uremia. Previous discussions were undertaken with the patient when patient was more coherent and patient did appear to understand the plan. Because of patient somnolence, I did not ask patient to sign a consent form.
DESCRIPTION OF PROCEDURE
The patient was identified and placed in the Trendelenburg position. Examination of the neck revealed the right jugular vein was patent , the left jugular vein seemed somewhat smaller but also was patent. I chose to approach the right side. I prepped the right neck and chest with ChloraPrep and appropriately draped. Then 1% lidocaine was liberally infiltrated. The thyroid ultrasound device was used to visualize the right jugular vein and a needle was passed under direct ultrasonographic guidance into the vein. The wire passed into the vein, but met resistance at a distance of about 20 cm. The wire was removed. The needle was removed and reaccess was again obtained using ultrasound guidance. Each time that I did this, it was a little harder as there was a little bit of extravasation of blood from the vein and that it made difficult to visualization of the vein itself. Nevertheless, I was able to access consistently the vein, but I could not pass a wire beyond that 20cm mark. I tried several different attempts and all of met with failure. I was able to aspirate blood
while in the vein to confirm that I was still intraluminal, but could not pass the wire. I had fears that perhaps there was proximal stenosis. I therefore chose to abort the procedure. I considered an additional upper extremity approach, but given the distance of 20 cm, I was concerned that patient might have something like superior vena cava stenosis. Therefore, any venous access in the upper extremity might be difficult.
I therefore chose to go to the groin. There was some ecchymosis in the right groin, so I went to the left side. The Site-Rite device again confirmed patency of the femoral vein. I prepped the groin separately with ChloraPrep and then appropriately draped. Additional local anesthesia consisting of 1% lidocaine was infiltrated. An introducer needle was used to gain access to the femoral vein. It should be noted that the patient's obesity made it for a difficult access, but ultimately, I was in the vein. The wire passed without difficulties. The tract was dilated and a dual-lumen 20 cm straight Niagara catheter was passed without difficulty down into the femoral vein. Both lumens aspirated and flushed without difficulties. The catheter were first flushed with saline and then with concentrated heparin. The catheter was sutured to the skin x2 and a dry dressing was applied. The patient tolerated the procedure well without complications except as noted above.