smerriweather1
Networker
Good morning, I have been having a professional discussion with one of my vascular doctors regarding how this operative note was coded and I would appreciate some other thoughts please.
Provider codes: 36147--he states the fistulogram was done via a separate incision so it should be reportable.
36831
37230
This case was coded and billed with a 36883,GC-- as a revision with thrombectomy
I did not code this case and I personally am thinking the following codes should apply:
37230, GC
36883,59,GC
I believe even with the separate incision the purpose of the 36147 was to check the outflow of the thrombectomy, 36883, and therefore is inclusive to the procedure. The decision to do the stenting (37230) is the treatment to the stenosis and the completion fistulogram done at the end of that portion of the procedure remains inclusive to the 36883 still.
Here is the Operative Note:
DATE OF SURGERY: 09/06/2016
SURGEON: Bugs Bunny, MD
ASSISTANT: Donald Duck, MD-Resident
SECOND ASSISTANT: Mickey Mouse, PA-C (no qualified surgical resident available to assist).
PREOPERATIVE DIAGNOSIS: Occluded basilic vein transposition of left upper extremity.
POSTOPERATIVE DIAGNOSIS: Reopening of the fistula.
PROCEDURES:
1. Open thrombectomy of basilic vein transposition fistula.
2. Fistulogram.
3. Stenting of the outflow with 8 x 100 Viabahn stent graft.
4. Balloon angioplasty of basilic vein with 10 x 40 angioplasty balloon catheter.
COMPLICATIONS: None apparent.
INDICATIONS FOR PROCEDURE: Mr. X is a patient of ABC Hospital, he has been dialyzed through the left basilic vein transposition fistula, developed thrombosis of the fistula and recommendations were for 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. The patient understood the risks and benefits of the procedure and consented to the procedure.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed on surgical table in supine position. Sedation was provided by anesthesia team. Local anesthetic was used on the table. A surgical time-out was initiated and antibiotics were administered, all of it was documented in the chart electronically. Left upper extremity was prepped and draped in standard surgical manner. A longitudinal incision was made over the arterial anastomosis with a skin knife. It was carried through subcutaneous tissue using electrocautery. By using sharp and blunt dissection, basilic vein was dissected and encircled with vessel loop. The patient was given 3000 units of heparin and it was allowed to circulate systematically. Transverse arteriotomy was made with an 11 blade and extended with Potts scissors. Multiple _____ thrombus was removed from the venous outflow. A large thrombus was milked out using #4 and #5 Fogarty catheter, thrombectomy was successfully performed. Arterial thrombus was removed and the arterial bullet was passed off surgical table as a pathology specimen. Arteriotomy was made with interrupted sutures. Upon the completion of the repair, the patient had thrill throughout the entire length of the fistula. Fistula was cannulated through the separate incision and 6-French sheath was introduced and fistulogram was performed, which revealed high-grade stenosis at the confluence of the basilic and brachial veins. Decision was made to perform stenting. An 0.018 wire was introduced, parked in the right atrium and 90% stenosis was stented with 8 x 100 Viabahn stent graft. It was _____ with 8-mm balloon. In the midportion of the graft, there was still residual stenosis, which was post-balloon dilated with 10 mm balloon. During the inflation of balloon, contrast refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis of arterial anastomosis. Balloon was deflated. Completion fistulogram was performed, which revealed excellent flow through all the segments of the veins including axillary, subclavian, and brachiocephalic. Decision was made to stop the procedure. Sheath and the catheter were removed. Hemostasis achieved with figure-of-eight stitch. Incisions were inspected. Hemostasis was excellent. Incision was closed in layers by approximating subcutaneous tissues using Vicryl. Skin was closed using Monocryl. Upon the completion of the procedure, patient had excellent thrill throughout the entire length of the fistula and palpable pulse in radial artery at the wrist.
Provider codes: 36147--he states the fistulogram was done via a separate incision so it should be reportable.
36831
37230
This case was coded and billed with a 36883,GC-- as a revision with thrombectomy
I did not code this case and I personally am thinking the following codes should apply:
37230, GC
36883,59,GC
I believe even with the separate incision the purpose of the 36147 was to check the outflow of the thrombectomy, 36883, and therefore is inclusive to the procedure. The decision to do the stenting (37230) is the treatment to the stenosis and the completion fistulogram done at the end of that portion of the procedure remains inclusive to the 36883 still.
Here is the Operative Note:
DATE OF SURGERY: 09/06/2016
SURGEON: Bugs Bunny, MD
ASSISTANT: Donald Duck, MD-Resident
SECOND ASSISTANT: Mickey Mouse, PA-C (no qualified surgical resident available to assist).
PREOPERATIVE DIAGNOSIS: Occluded basilic vein transposition of left upper extremity.
POSTOPERATIVE DIAGNOSIS: Reopening of the fistula.
PROCEDURES:
1. Open thrombectomy of basilic vein transposition fistula.
2. Fistulogram.
3. Stenting of the outflow with 8 x 100 Viabahn stent graft.
4. Balloon angioplasty of basilic vein with 10 x 40 angioplasty balloon catheter.
COMPLICATIONS: None apparent.
INDICATIONS FOR PROCEDURE: Mr. X is a patient of ABC Hospital, he has been dialyzed through the left basilic vein transposition fistula, developed thrombosis of the fistula and recommendations were for 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. The patient understood the risks and benefits of the procedure and consented to the procedure.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, placed on surgical table in supine position. Sedation was provided by anesthesia team. Local anesthetic was used on the table. A surgical time-out was initiated and antibiotics were administered, all of it was documented in the chart electronically. Left upper extremity was prepped and draped in standard surgical manner. A longitudinal incision was made over the arterial anastomosis with a skin knife. It was carried through subcutaneous tissue using electrocautery. By using sharp and blunt dissection, basilic vein was dissected and encircled with vessel loop. The patient was given 3000 units of heparin and it was allowed to circulate systematically. Transverse arteriotomy was made with an 11 blade and extended with Potts scissors. Multiple _____ thrombus was removed from the venous outflow. A large thrombus was milked out using #4 and #5 Fogarty catheter, thrombectomy was successfully performed. Arterial thrombus was removed and the arterial bullet was passed off surgical table as a pathology specimen. Arteriotomy was made with interrupted sutures. Upon the completion of the repair, the patient had thrill throughout the entire length of the fistula. Fistula was cannulated through the separate incision and 6-French sheath was introduced and fistulogram was performed, which revealed high-grade stenosis at the confluence of the basilic and brachial veins. Decision was made to perform stenting. An 0.018 wire was introduced, parked in the right atrium and 90% stenosis was stented with 8 x 100 Viabahn stent graft. It was _____ with 8-mm balloon. In the midportion of the graft, there was still residual stenosis, which was post-balloon dilated with 10 mm balloon. During the inflation of balloon, contrast refluxed in the arterial system, which revealed absence of any hemodynamically significant stenosis of arterial anastomosis. Balloon was deflated. Completion fistulogram was performed, which revealed excellent flow through all the segments of the veins including axillary, subclavian, and brachiocephalic. Decision was made to stop the procedure. Sheath and the catheter were removed. Hemostasis achieved with figure-of-eight stitch. Incisions were inspected. Hemostasis was excellent. Incision was closed in layers by approximating subcutaneous tissues using Vicryl. Skin was closed using Monocryl. Upon the completion of the procedure, patient had excellent thrill throughout the entire length of the fistula and palpable pulse in radial artery at the wrist.