smerriweather1
Networker
Hello,
I am trying to determine if the codes I was given for this surgery is being unbundled or not by my provider. Please read the associated operative info and offer any thoughts. My provider gave me the following CPT codes: 35746, 37238 and 36147. The DX codes are 996.74, 459.2 and 585.6.
Additionally does the description of what was done also warrant the use of 36148 as an add on code. Please clearly explain you rationale to me as this is only my second year of vascular coding. If it is easier to explain verbally please email me your number to smerriweather@botsford.org and refer to the title of this link and I can call you back.
Gross Findings:
The patient is a 60-year-old Caucasian female who undergoes hemodialysis through transposed cephalic vein fistula. The patient has no difficulty with dialysis, however, on routine examination there was some mild swelling of the left upper extremity. On examination, the left arm fistula was patent. There was some slight pulsatility to the quality of the thrill. This resulted in the recommendation to preform a fistulogram. There was narrowing of the cephalic vein fistula just beyond the suture line where vein to vein anastomosis was created. This was successfully angioplastied, however, the patient did perforate her cephalic vein. It was necessary to place a covered stent in order to seal it.
Operative Procedure:
The patient was taken to the Special Procedures Room in Radiology, placed in supine position. Left arm prepped and draped appropriately. An 18 gauge Angiocath was placed into the proximal fistula through which multiple images were obtained. There was no central vine stenosis. The next proximal anastomosis widely patent. The 18 gauge Angiocath was then replaced with a short 6 French sheath. Glidewire was advanced across the area of the stenosis. An 8 mm angioplasty balloon was inflated to 26 atmospheres for two minutes, it was deflated and repositioned and re-inflated to 26 atmosphere for two minutes. Completion arteriography did reveal improved caliber of the cephalic vein fistula, however, perforation was suggested. The patient has developed a small hematoma in the anterior upper arm. The balloon was repositioned and re-inflated to 10mmHG compression to control the perforation site. Pressure was being held to a small area of hematoma.
The balloon was deflated and removed. The guide wire was left in place. The sheath was removed and an 8 mm straight flare stent was advanced over the guide wire bareback and positioned across the aortic perforation. The balloon was deployed. The stent delivery device was removed. An 8 mm angioplasty balloon reintroduced into the fistula and this subsequently seated the endograft.
Completion venography revealed a satisfactory result. The sheath was removed. The guide wire was removed. Angioplasty catheter removed. Bleeding controlled with pressure. A sterile dressing was applied. The patient tolerated the procedure well and returned to the Recovery Room in stable condition. I did review the images with the patient. I discussed the operative procedure with the patient's husband. Upon reevaluating the patient in the Recovery Room her left arm was stable.
I am trying to determine if the codes I was given for this surgery is being unbundled or not by my provider. Please read the associated operative info and offer any thoughts. My provider gave me the following CPT codes: 35746, 37238 and 36147. The DX codes are 996.74, 459.2 and 585.6.
Additionally does the description of what was done also warrant the use of 36148 as an add on code. Please clearly explain you rationale to me as this is only my second year of vascular coding. If it is easier to explain verbally please email me your number to smerriweather@botsford.org and refer to the title of this link and I can call you back.
Gross Findings:
The patient is a 60-year-old Caucasian female who undergoes hemodialysis through transposed cephalic vein fistula. The patient has no difficulty with dialysis, however, on routine examination there was some mild swelling of the left upper extremity. On examination, the left arm fistula was patent. There was some slight pulsatility to the quality of the thrill. This resulted in the recommendation to preform a fistulogram. There was narrowing of the cephalic vein fistula just beyond the suture line where vein to vein anastomosis was created. This was successfully angioplastied, however, the patient did perforate her cephalic vein. It was necessary to place a covered stent in order to seal it.
Operative Procedure:
The patient was taken to the Special Procedures Room in Radiology, placed in supine position. Left arm prepped and draped appropriately. An 18 gauge Angiocath was placed into the proximal fistula through which multiple images were obtained. There was no central vine stenosis. The next proximal anastomosis widely patent. The 18 gauge Angiocath was then replaced with a short 6 French sheath. Glidewire was advanced across the area of the stenosis. An 8 mm angioplasty balloon was inflated to 26 atmospheres for two minutes, it was deflated and repositioned and re-inflated to 26 atmosphere for two minutes. Completion arteriography did reveal improved caliber of the cephalic vein fistula, however, perforation was suggested. The patient has developed a small hematoma in the anterior upper arm. The balloon was repositioned and re-inflated to 10mmHG compression to control the perforation site. Pressure was being held to a small area of hematoma.
The balloon was deflated and removed. The guide wire was left in place. The sheath was removed and an 8 mm straight flare stent was advanced over the guide wire bareback and positioned across the aortic perforation. The balloon was deployed. The stent delivery device was removed. An 8 mm angioplasty balloon reintroduced into the fistula and this subsequently seated the endograft.
Completion venography revealed a satisfactory result. The sheath was removed. The guide wire was removed. Angioplasty catheter removed. Bleeding controlled with pressure. A sterile dressing was applied. The patient tolerated the procedure well and returned to the Recovery Room in stable condition. I did review the images with the patient. I discussed the operative procedure with the patient's husband. Upon reevaluating the patient in the Recovery Room her left arm was stable.