This was given to me by a fellow coder with a request for help. Her Encoder is not allowing the services to be billed with any combination of codes based on the new 2017 dialysis circuit guidelines. Looking for anyone who can weigh in for assistance.
PROCEDURES:
1. Open thrombectomy of brachial-axillary AV graft.
2. Fistulogram.
3. Utilization of to 6-French indigo catheter to extract residual thrombus.
4. Balloon angioplasty of subclavian vein using 9 x 8 angioplasty balloon catheter.
5. Balloon angioplasty of cannulation zone of the graft using 7 x 200 angioplasty balloon catheter.
COMPLICATIONS: None apparent.
INDICATIONS FOR PROCEDURE: presented with occluded graft to the Emergency Room. Recommendations were to undergo urgent thrombectomy. I had a long discussion with the patient about the risks and benefits of the procedure, risks of infection, ischemic complications, and limb loss. Patient understood the risks and benefits of the procedure, and consented to the procedure.
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room, placed on the supine position, sedation for anesthesia team. Local anesthetic was used on the table. Left upper extremity was prepped and draped in standard surgical manner. Surgical time-out was initiated and antibiotics were administered, all of it was documented in the chart electronically. Small incision was made in midportion of the graft with a skin knife. It was carried through scar. By using sharp and blunt dissection, graft was dissected and encircled with vessel loop. Patient was given 3000 units of heparin and it was allowed to circulate systematically. Small graftotomy was made with an 11 blade and extended with Potts scissors. By using #4 Fogarty catheter, the venous thrombus was removed. Graft was flushed, clamped. The catheter was reversed and arterial plug was removed. Graftotomy was repaired with interrupted sutures. Upon the restoration of the flow, patient had pulsatile flow within the graft. Graft was cannulated using 6-French sheath in antegrade fashion, a fistulogram was performed, which revealed still residual thrombus within the graft. Utilizing 6-French cath, 6 indigo system was advanced and the residual thrombus was removed from the entire length of the graft and the stent, which is distal down the flow. Another fistulogram was performed, which revealed excellent flow through subclavian brachiocephalic vein and superior vena cava. There is still residual high-grade stenosis at the proximal subclavian vein and high-grade stenosis within the graft. Both areas were angioplastied first with 9 x 80 angioplasty balloon catheter and the graft was angioplastied using 7 x 200. Upon the completion of balloon angioplasty, patient had excellent thrill throughout the entire length of the graft and palpable pulse in radial artery at the wrist. During the inflation of balloon, contrast was refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis and arterial anastomosis. Sheath and the catheter were removed. Hemostasis was achieved with figure-of-eight stitch. Incision was closed in layers by approximating subcutaneous tissues using Vicryl. Skin was closed with Monocryl.
TIA!!!
PROCEDURES:
1. Open thrombectomy of brachial-axillary AV graft.
2. Fistulogram.
3. Utilization of to 6-French indigo catheter to extract residual thrombus.
4. Balloon angioplasty of subclavian vein using 9 x 8 angioplasty balloon catheter.
5. Balloon angioplasty of cannulation zone of the graft using 7 x 200 angioplasty balloon catheter.
COMPLICATIONS: None apparent.
INDICATIONS FOR PROCEDURE: presented with occluded graft to the Emergency Room. Recommendations were to undergo urgent thrombectomy. I had a long discussion with the patient about the risks and benefits of the procedure, risks of infection, ischemic complications, and limb loss. Patient understood the risks and benefits of the procedure, and consented to the procedure.
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room, placed on the supine position, sedation for anesthesia team. Local anesthetic was used on the table. Left upper extremity was prepped and draped in standard surgical manner. Surgical time-out was initiated and antibiotics were administered, all of it was documented in the chart electronically. Small incision was made in midportion of the graft with a skin knife. It was carried through scar. By using sharp and blunt dissection, graft was dissected and encircled with vessel loop. Patient was given 3000 units of heparin and it was allowed to circulate systematically. Small graftotomy was made with an 11 blade and extended with Potts scissors. By using #4 Fogarty catheter, the venous thrombus was removed. Graft was flushed, clamped. The catheter was reversed and arterial plug was removed. Graftotomy was repaired with interrupted sutures. Upon the restoration of the flow, patient had pulsatile flow within the graft. Graft was cannulated using 6-French sheath in antegrade fashion, a fistulogram was performed, which revealed still residual thrombus within the graft. Utilizing 6-French cath, 6 indigo system was advanced and the residual thrombus was removed from the entire length of the graft and the stent, which is distal down the flow. Another fistulogram was performed, which revealed excellent flow through subclavian brachiocephalic vein and superior vena cava. There is still residual high-grade stenosis at the proximal subclavian vein and high-grade stenosis within the graft. Both areas were angioplastied first with 9 x 80 angioplasty balloon catheter and the graft was angioplastied using 7 x 200. Upon the completion of balloon angioplasty, patient had excellent thrill throughout the entire length of the graft and palpable pulse in radial artery at the wrist. During the inflation of balloon, contrast was refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis and arterial anastomosis. Sheath and the catheter were removed. Hemostasis was achieved with figure-of-eight stitch. Incision was closed in layers by approximating subcutaneous tissues using Vicryl. Skin was closed with Monocryl.
TIA!!!