Need some help coding. per CCI I cant bill the 36558 w/ 36010 but I feel that I should include it. What are your thoughts.
PREOPERATIVE DIAGNOSIS: Chronic renal failure, need for dialysis with failure of both tunnel catheter left groin and a peritoneal dialysis catheter.
POSTOPERATIVE DIAGNOSIS: Chronic renal failure, need for dialysis with failure of both tunnel catheter left groin and a peritoneal dialysis catheter.
OPERATION:.
1. Catheterization of both the inferior and superior vena cava with venogram x2.
2. Placement of new tunnel catheter right groin with fluoroscopic guidance.
3. Removal of tunnel catheter left groin.
4. Removal PD catheter.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TRANSFUSIONS: None.
COMPLICATIONS: None.
FINDINGS: All major veins in the chest were occluded with only collateral draining into the heart. Inferior vena cava also appeared to be occluded shortly below the level of the diaphragm.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under general anesthesia. Neck and chest area were prepped and draped in sterile fashion. Multiple attempts were made to cannulate the internal jugular vein successfully. The right subclavian vein was cannulated and the catheter advanced, but would not get direct access into the right atrial level. A Kelly catheter was used to try to direct the guidewire successfully and then this was used to do a venogram of inferior vena cava which showed that the SVC and dominant subclavians and juglar veins were all occluded. Attempt was then abandoned for further placement of a catheter in the superior system. The right groin was then prepped and draped, the groin was then approached and the right common femoral vein percutaneously catheterized. A guidewire advanced up into the IVC, but would not cross into the atrium again due to the proximal IVC occlusion. However, the iliac veins and distal IVC were patent, so a counter incision was made and a 22 catheter was pulled through and then advanced up through a dilator and sheath. It was advanced over the guidewire into the right iliac vein and secured in place. Assessment had good inflow and outflow. Each lumen was irrigated with saline and filled 1000 units of heparin and capped and secured with nylon stitches. Then an incision was made in the left groin area and the left tunnel catheter in the left groin was removed in its entirety and the tract oversewn with a silk suture and the wound closed with 3-0 Vicryl, skin clips to the skin. Then an incision was made along the entry site of the PD catheter. It was traced down to the fascia level with 2 cuffs removed, dissected free and the catheter removed. The fascia was closed with interrupted figure-of-eight 0 Vicryl stitches, skin and the wound closed with 3-0 Vicryl in layers and skin closed. Dressing applied. Patient reversed from anesthesia and taken to recovery room in satisfactory condition.
PREOPERATIVE DIAGNOSIS: Chronic renal failure, need for dialysis with failure of both tunnel catheter left groin and a peritoneal dialysis catheter.
POSTOPERATIVE DIAGNOSIS: Chronic renal failure, need for dialysis with failure of both tunnel catheter left groin and a peritoneal dialysis catheter.
OPERATION:.
1. Catheterization of both the inferior and superior vena cava with venogram x2.
2. Placement of new tunnel catheter right groin with fluoroscopic guidance.
3. Removal of tunnel catheter left groin.
4. Removal PD catheter.
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
TRANSFUSIONS: None.
COMPLICATIONS: None.
FINDINGS: All major veins in the chest were occluded with only collateral draining into the heart. Inferior vena cava also appeared to be occluded shortly below the level of the diaphragm.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed under general anesthesia. Neck and chest area were prepped and draped in sterile fashion. Multiple attempts were made to cannulate the internal jugular vein successfully. The right subclavian vein was cannulated and the catheter advanced, but would not get direct access into the right atrial level. A Kelly catheter was used to try to direct the guidewire successfully and then this was used to do a venogram of inferior vena cava which showed that the SVC and dominant subclavians and juglar veins were all occluded. Attempt was then abandoned for further placement of a catheter in the superior system. The right groin was then prepped and draped, the groin was then approached and the right common femoral vein percutaneously catheterized. A guidewire advanced up into the IVC, but would not cross into the atrium again due to the proximal IVC occlusion. However, the iliac veins and distal IVC were patent, so a counter incision was made and a 22 catheter was pulled through and then advanced up through a dilator and sheath. It was advanced over the guidewire into the right iliac vein and secured in place. Assessment had good inflow and outflow. Each lumen was irrigated with saline and filled 1000 units of heparin and capped and secured with nylon stitches. Then an incision was made in the left groin area and the left tunnel catheter in the left groin was removed in its entirety and the tract oversewn with a silk suture and the wound closed with 3-0 Vicryl, skin clips to the skin. Then an incision was made along the entry site of the PD catheter. It was traced down to the fascia level with 2 cuffs removed, dissected free and the catheter removed. The fascia was closed with interrupted figure-of-eight 0 Vicryl stitches, skin and the wound closed with 3-0 Vicryl in layers and skin closed. Dressing applied. Patient reversed from anesthesia and taken to recovery room in satisfactory condition.
