schmsuz
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I coded this as 37236 with a dx of I77.0. It is getting denied as not medically necessary. Am I using the correct codes for this report? Thank you!
INDICATION: This patient presented to our attention with symptoms of claudication/critical limb ischemia. Non invasive testing included CT angiogram showing significant AV fistula with excessive flow. CT and/or MR angio indicated the findings as well. As such, there was good indication to proceed with diagnostic angiographic study and/or intervention.
*
RISKS AND BENEFITS: Patient was advised of all pertinent risks and benefits, as well as alternatives. Specifically, the risk of death, stroke, lethal arrhythmia, and significant MI were quoted at 0.1-1%. Vascular access bleed or complication, general bleeding, pain and infection were mentioned and described collectively at 1%. Risk of contrast nephropathy, renal failure requiring dialysis and need for emergent surgery were described, and described at a rate of 1/200 to 1/50. In case of blood loss, risks of transfusion were described including allergic reactions and blood-borne illness. In case of needle stick, HIV or hepatitis testing of the patient or care provider may be warranted.
*
TECHNIQUE: Access was obtained via 8F left femoral system. Micropuncture technique was employed. Documentation of appropriate intact peripheral circulation was made prior to undertaking the puncture.
*
*
Hemodynamics: No significant pull back pressure gradients across any lesion.
*
Descending Aorta/DSA:
Infra Renal Aorta: Free of significant disease. Aortogram was visualized
Renal Arteries:
Right: n/a
Left: n/a
Selective Left Leg (1st and 2nd order vessels on left visualized)
*
Common Iliac Artery: Free of significant disease
Internal Iliac Artery: free of significant disease
External Iliac Artery: free of significant disease
Common Femoral Artery: free of significant disease
Profundus Artery: free of significant disease
Superficial Femoral Artery: free of significant disease
Popliteal Artery: n/a
Anterior Tibial Artery:n/a
Posterior Tibial Artery:n/a
Peroneal Artery:n/a
*
Selective Right Leg (1st, 2nd, 3rd order vessels seen):
Common Iliac Artery: free of significant disease
Internal Iliac Artery: free of significant disease
External Iliac Artery: free of significant disease
Common Femoral Artery: free of significant disease. There is a small branch vessel arising from common femoral artery that leads to aneurysmal sac that drains into right common femoral vein via a fistula
Profundus Artery: free of significant disease
Superficial Femoral Artery: free of significant disease
Popliteal Artery: free of significant disease
Anterior Tibial Artery:free of significant disease
Posterior Tibial Artery:free of significant disease
Peroneal Artery:free of significant disease
*
Intervention: We used an 8F, 45 cm Pinnacle Sheath placed in left common femoral artery up and over into the right common femoral artery. We selected the right PFA using a Wholey wire. We placed a 5 mm by 75 mm Viabahn stent and deployed it based on our QCA analysis and sizing. This size ultimately proved too small, and the stent was non-adherent and mobile. We traversed the stent with a wire and conducted it down into distal profunda vessel where it was appropriately sized and adherent to vessel wall. It was post dilated with 5.0 mm balloon in distal profunda and gave a nice apposition. We re-visited the PFA with a 7.0 mm by 75 mm Viabahn which was post dilated with 7.0 mm balloon. This gave a nice apposition but in and of itself did not exclude the AV fistula. We decided to do a dedicated bifurcation stent into SFA and PFA extending into common femoral to definitively exclude the AV fistula. Two additional Viabahn stents were selected (7.0 mm by 100 mm for SFA, and 7.0 mm by 75 mm for PFA extension). They were deployed sequentially and each post dilated up to 14 atm with 7.0 mm balloon. The AV fistula was diminished , but not obliterated. We suspect type I endoleak and the culprit vessel was certainly covered by the stent. Incomplete apposition of double barrel Viabahn stents in CFA leading to type I endoleak was suspected. We post dilated the PFA Viabahn to 20 atm but were not able to abolish that. We thereafter attempted to exclude the CFA proximal to Viabahn stents with a balloon expandible 10 mm by 29 mm covered stent (Gore). This clipped off branch vessels that may contribute to a possible type II endoleak, but there was still opacification of the AV fistula (diminished but present) even after this maneuver.
*
Recommendations: Deployment of Viabahn stents in profunda femoral and superficial femoral arteries with decrease, but not eradication of AV fistula. Will obtain follow up ultrasound 2-4 weeks. If flow is still present and fistula has not thrombosed, then will make referral for surgical closure.
INDICATION: This patient presented to our attention with symptoms of claudication/critical limb ischemia. Non invasive testing included CT angiogram showing significant AV fistula with excessive flow. CT and/or MR angio indicated the findings as well. As such, there was good indication to proceed with diagnostic angiographic study and/or intervention.
*
RISKS AND BENEFITS: Patient was advised of all pertinent risks and benefits, as well as alternatives. Specifically, the risk of death, stroke, lethal arrhythmia, and significant MI were quoted at 0.1-1%. Vascular access bleed or complication, general bleeding, pain and infection were mentioned and described collectively at 1%. Risk of contrast nephropathy, renal failure requiring dialysis and need for emergent surgery were described, and described at a rate of 1/200 to 1/50. In case of blood loss, risks of transfusion were described including allergic reactions and blood-borne illness. In case of needle stick, HIV or hepatitis testing of the patient or care provider may be warranted.
*
TECHNIQUE: Access was obtained via 8F left femoral system. Micropuncture technique was employed. Documentation of appropriate intact peripheral circulation was made prior to undertaking the puncture.
*
*
Hemodynamics: No significant pull back pressure gradients across any lesion.
*
Descending Aorta/DSA:
Infra Renal Aorta: Free of significant disease. Aortogram was visualized
Renal Arteries:
Right: n/a
Left: n/a
Selective Left Leg (1st and 2nd order vessels on left visualized)
*
Common Iliac Artery: Free of significant disease
Internal Iliac Artery: free of significant disease
External Iliac Artery: free of significant disease
Common Femoral Artery: free of significant disease
Profundus Artery: free of significant disease
Superficial Femoral Artery: free of significant disease
Popliteal Artery: n/a
Anterior Tibial Artery:n/a
Posterior Tibial Artery:n/a
Peroneal Artery:n/a
*
Selective Right Leg (1st, 2nd, 3rd order vessels seen):
Common Iliac Artery: free of significant disease
Internal Iliac Artery: free of significant disease
External Iliac Artery: free of significant disease
Common Femoral Artery: free of significant disease. There is a small branch vessel arising from common femoral artery that leads to aneurysmal sac that drains into right common femoral vein via a fistula
Profundus Artery: free of significant disease
Superficial Femoral Artery: free of significant disease
Popliteal Artery: free of significant disease
Anterior Tibial Artery:free of significant disease
Posterior Tibial Artery:free of significant disease
Peroneal Artery:free of significant disease
*
Intervention: We used an 8F, 45 cm Pinnacle Sheath placed in left common femoral artery up and over into the right common femoral artery. We selected the right PFA using a Wholey wire. We placed a 5 mm by 75 mm Viabahn stent and deployed it based on our QCA analysis and sizing. This size ultimately proved too small, and the stent was non-adherent and mobile. We traversed the stent with a wire and conducted it down into distal profunda vessel where it was appropriately sized and adherent to vessel wall. It was post dilated with 5.0 mm balloon in distal profunda and gave a nice apposition. We re-visited the PFA with a 7.0 mm by 75 mm Viabahn which was post dilated with 7.0 mm balloon. This gave a nice apposition but in and of itself did not exclude the AV fistula. We decided to do a dedicated bifurcation stent into SFA and PFA extending into common femoral to definitively exclude the AV fistula. Two additional Viabahn stents were selected (7.0 mm by 100 mm for SFA, and 7.0 mm by 75 mm for PFA extension). They were deployed sequentially and each post dilated up to 14 atm with 7.0 mm balloon. The AV fistula was diminished , but not obliterated. We suspect type I endoleak and the culprit vessel was certainly covered by the stent. Incomplete apposition of double barrel Viabahn stents in CFA leading to type I endoleak was suspected. We post dilated the PFA Viabahn to 20 atm but were not able to abolish that. We thereafter attempted to exclude the CFA proximal to Viabahn stents with a balloon expandible 10 mm by 29 mm covered stent (Gore). This clipped off branch vessels that may contribute to a possible type II endoleak, but there was still opacification of the AV fistula (diminished but present) even after this maneuver.
*
Recommendations: Deployment of Viabahn stents in profunda femoral and superficial femoral arteries with decrease, but not eradication of AV fistula. Will obtain follow up ultrasound 2-4 weeks. If flow is still present and fistula has not thrombosed, then will make referral for surgical closure.