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Failing right ateriovenous fistula with right arm swelling

Hi,

Would 36821 be the appropriate CPT code for each arm?

Thank you in advance!

PREOPERATIVE DIAGNOSES
1. Failing right arteriovenous fistula with right arm swelling.
2. End stage renal disease.

PROCEDURES
1. Left radial Cimino arteriovenous (AV) fistula.
2. Ligation of branch of left radial Cimino arteriovenous (AV) fistula.
3. Access to fistula, right arm, with fistulogram (distinct).
4. Ligation right Cimino fistula (distinct).
5. Left cephalic, subclavian, and brachiocephalic venography.

FINDINGS
The cephalic vein was occluded in the distal upper arm on the right and the basilic vein had a long, severe stenosis in the mid to proximal upper arm. The right fistula was not felt to be salvageable. Venography on the left side showed no central stenosis despite pacemaker wires.

PROCEDURE
After satisfactory induction of general anesthesia, the patient was sterilely prepped and draped. An IV placed in the left cephalic vein at the antecubital fossa was used for a single contrast central venogram going from the cephalic to the subclavian. Brachiocephalic and superior vena cava showing no stenosis despite the pacemaker wires. On that basis, I then went to the right arm, which was sterilely prepped and draped. Access to the fistula was made after local anesthesia with the micropuncture set through a 4 French sheath over the micro-wire. A fistulogram was shot showing the fistula to be patent, tortuous, and very enlarged in the forearm, but the cephalic vein cutoff just proximal to the antecubital fossa. It drained via collaterals into the basilic, but the basilic vein had a significant stenosis in the mid-proximal third junction of the humerus and then, no central stenosis was noted on that side as well. After reviewing the films carefully, I felt there was no chance to salvage this fistula and, knowing that the fistula could be placed on the other side, I then removed the sheath, secured it with a 4-0 Monocryl suture. Then, after additional local anesthesia, made a short, transverse incision over the proximal fistula, dissected down to and around it completely, and it was doubly ligated with double 3-0 silk ties, but not divided. The incision was hemostased and closed with running 4-0 Monocryl in layers and a Steri-Strip was placed.

I then went to the patient’s left arm, which was then prepped and, after local anesthesia between the cephalic vein and radial artery, the fistula was dissected free. The vein was clamped distally, divided, ligated, mobilized to reach the artery. The artery was dissected free, clamped proximally and distally, after 2500 units of heparin were given. Then, the vein was mobilized, trimmed to length, and spatulated. The artery was clamped proximally and distally. Longitudinally, arteriotomy of 1.25 cm was made and the anastomosis was created with running 7-0 Prolene suture. Flow was established. There was a nice thrill in the fistula. There was a lateral branch that was tethering it. This was ligated proximally and distally with 3-0 silk ties and divided, allowing the vein to lay in a gentle curve from its native position to the anastomosis. The wound was hemostatic and it was closed with running 4-0 Monocryl in layers. Steri-Strips were placed. The right arm was then wrapped from palm to proximal forearm with Kerlix and Coban to compress blood out of the enlarged fistula to reduce clot burden in it. The patient was then allowed to wake up, taken to the recovery room in stable condition, having tolerated the procedure well. Sponge, needle, and instrument counts reported as correct x2.

Medical Billing and Coding Forum

Revision AV Fistula, LEFT ARM ARTERIO-VENOUS FISTULA REVISION WITH FISTULOGRAM

Can someone help me with this?

The patient was seen in the holding area and brought to the OR where after the timeout procedure he underwent general anesthesia with no complications. The left arm, shoulder and axilla were prepped and draped in a sterile fashion. I proceeded to do a longitudinal skin incision over the cephalic vein fistula on the lateral aspect of the upper arm, and after cutting the skin with a knife dissection of subcutaneous tissues continue with electrocautery until the cephalic vein is identified. I proceeded to dissect it all around and isolated with a vessel loop. Now I proceeded to dissect the cephalic vein proximally and distally to have adequate length for the placement of vascular clamps. So I proceeded to clamp the cephalic vein proximally and distally with atraumatic vascular clamps, and a partial transverse venotomy is done with an 11 blade. The cephalic vein is clamped proximally with a DeBakey clamp and the proximal vascular clamp is removed. The DeBakey clamp is open to allow some backflow, that he is weak, and consists in dark red blood. A #4 Fogarty catheter was passed proximally and no clots were coming out but I was feeling a resistance on the passing of the catheter after 20 cm of the catheter introduced in the vein. I proceeded to flush the proximal cephalic vein with heparinized saline and the vascular clamp is placed. Now the distal cephalic vein is clamped with a DeBakey clamp and the vascular clamp is removed. After a partial release of the DeBakey clamp I had an excellent arterial flow. The Fogarty catheter #4 is passed distally once, and I was able to pass the arterial anastomosis with no clots removed. The distal cephalic vein is flushed with heparinized saline and clamped with the vascular clamp. I proceeded to close the partial venotomy with a running suture of a 6-0 Prolene. After the closure is completed the fistula is cannulated on the distal arm with a #18 Angiocath, next to the arteriovenous anastomosis, and I proceeded to do the fistulogram. The fistulogram was showing a patent left brachiocephalic fistula with the cephalic and axillary veins having no gross abnormalities, but the axillary vein was joining the subclavian vein inside the chest forming a 90° angle, that even though looked stenotic, there was an excellent flow of contrast flow into the subclavian vein. The subclavian vein also had no gross abnormalities and it was patent. Considering the right angle of the axillary vein joining the subclavian vein I decided not to attempt any possible angioplasty or stent placement. The left upper arm wound is clean and I proceeded to close it approximating the subcutaneous tissue with a running suture of 3-0 Vicryl and the skin is closed with Monocryl 4-0 subcutaneously. The wound is covered with a dressing and the procedure was terminated. Patient tolerated procedure well there were no incidents or complications. He goes to recovery room.

Medical Billing and Coding Forum

Please help code Ulcer resection and aneurysmectomy off/at AV fistula

DX: Right arm AV fistula with ulceration and aneurysm in the setting of end stage renal disease.

Operation performed:

1. Aneurysmectomy of the right upper extremity AV fistula aneurysm.
2. Ulcer resection of this ulceration of the skin in the right upper extremity.
3. Aneurysmorrhaphy and aneurysmectomy with ulcer resection.

Indications for procedure: t
This is a patient, who has right upper extremity AV fistula and he then has had aneurysmal disease dilatation in _____ segments as well as an ulceration of the skin that is at risk of rupturing.

Procedure:
The patient was appropriately consented and brought to the operating room, prepped and draped in sterile fashion. Right upper extremity was prepped in sterile field. Infusion of lidocaine anesthetic was infused around the larger of the 2 masses and an encompassing separation of the ulceration from the AV fistula took place. Sharp elliptical incision was made around the larger of the 2 masses _____ was made, carried around the proximal and distal portions of the AV fistula and the ulceration was resected, sent off to pathology. The same was done for the aneurysm. Aneurysm was encircled proximally and distally. There was control that was made and a subsequent aneurysmectomy took place with aneurysmorrhaphy using running 6-0 prolene suture as well as a endo-gia stapler _____ . After the case, there was a good thrill through the fistula and good hemostasis and the fistula was in good shape and much more _____ caliber and size postprocedure. the patient tolerated the procedure well. A running 3-0 nylon was used to close the suture.

Medical Billing and Coding Forum

Please help code Ulcer resection and aneurysmectomy off/at AV fistula

DX: Right arm AV fistula with ulceration and aneurysm in the setting of end stage renal disease.

Operation performed:

1. Aneurysmectomy of the right upper extremity AV fistula aneurysm.
2. Ulcer resection of this ulceration of the skin in the right upper extremity.
3. Aneurysmorrhaphy and aneurysmectomy with ulcer resection.

Indications for procedure
: t
This is a patient, who has right upper extremity AV fistula and he then has had aneurysmal disease dilatation in _____ segments as well as an ulceration of the skin that is at risk of rupturing.

Procedure:
The patient was appropriately consented and brought to the operating room, prepped and draped in sterile fashion. Right upper extremity was prepped in sterile field. Infusion of lidocaine anesthetic was infused around the larger of the 2 masses and an encompassing separation of the ulceration from the AV fistula took place. Sharp elliptical incision was made around the larger of the 2 masses _____ was made, carried around the proximal and distal portions of the AV fistula and the ulceration was resected, sent off to pathology. The same was done for the aneurysm. Aneurysm was encircled proximally and distally. There was control that was made and a subsequent aneurysmectomy took place with aneurysmorrhaphy using running 6-0 prolene suture as well as a endo-gia stapler _____ . After the case, there was a good thrill through the fistula and good hemostasis and the fistula was in good shape and much more _____ caliber and size postprocedure. the patient tolerated the procedure well. A running 3-0 nylon was used to close the suture.

Medical Billing and Coding Forum

Multi Provider repair of Enterovesicular Fistula

This is a concurrent case with general surgery and urology, any guidance will be much appreciated.
I have posted scrubbed note highlights. I have also added codes next to the listed procedures.
Thank you in advance for any guidance.

Will this also need modifiers for multiple surgeons??
Patient is male.

UROLOGY NOTE:

PREOPERATIVE DIAGNOSIS: Colovesical fistula. N32.1

POSTOPERATIVE DIAGNOSIS: Colovesical fistula.

PROCEDURES PERFORMED:
1. Cystourethroscopy with bilateral ureteral catheter placement (will be removed postoperatively) 52005-50
2. On table cystogram. 51600 (NCCI edits say it cannot be coded with 52005 – no unbundling allowed)
** imaging for cystogram 74430
3. Cystorrhaphy 51865
** with omental interposition. 49905????

GENERAL SURGERY NOTE:
PREOPERATIVE DIAGNOSIS: Enterovesicular fistula. N32.1

POSTOPERATIVE DIAGNOSIS: Enterovesicular fistula.

PROCEDURE:
1. Exploratory laparotomy. BUNDLES
2. Lysis of adhesions. APPEND -22 TO PRIMARY PX
3. Ileocecectomy. 44160
4. Ileocolic anastomosis. BUNDLES TO ILEOCECECTOMY
5. Urachal remnant/ peritoneal flap creation. 49905???

Urologist
— cystoscopy
— performed a cystogram
–Following his cystogram, we replaced the cystoscope and cauterized several small mucosal tears as a result of slightly overfilling his bladder
— placed ureteral catheters,

General surgeon
–They mobilized the bowel and remove the portion of small bowel
adherent to the posterior wall of the bladder.
–They had excellent exposure of the bladder and retracted the bowel cranially so we could fully visualize the fistula.

Urologist
–We mobilized the peritoneum on either side and covered this fistula with interrupted Vicryl sutures.
–We then mobilized the omentum with the base off of the right
gastroepiploic artery for interposition flap.
— we performed another cystogram using methylene blue and noted no extravasation of methylene blue.
** We then turned the rest of the case over to our general surgery colleagues who would later place the omental interposition graft following their bowel resection.

General surgeon
— urachal remnant that had been taken down from the umbilicus at the beginning of the case was then packed over this area of repair as an extra added layer and a omental pedicle flap was created by urology

— attention to creating the bowel anastomosis.
— bowel was isolated per our colorectal protocol and a stapled anastomosis was created

Medical Billing and Coding Forum

mucous fistula creation

Patient is a 11 day old patient that had a tunneled central line placement , av small bowel resection , Meckel’s Diverticulectomy, ileostomy, and a mucous fistula creation , so far I have

36558- catheter
77001-26
44120 -small bowel resection
44800- Meckel’s Diverticulectomy
Ileostomy and Mucous Fistula Creation ??????? , I am not sure of , can someone point me in the right direction ?

Thank you

Medical Billing and Coding Forum

Help coding excision elbow bursal cutaneous fistula

Hi Everyone,

This is my first time posting! I am in need of help with coding the excision of elbow bursal cutaneous fistula. The op note reads…

An elliptical incision was marked around the small bursal cutaneous tract and this was after the ellipse was marked out to excise this. Then,
10 mL of 1% lidocaine with epinephrine was infiltrated into the skin and subcutaneous tissues. At this point, full-thickness ellipse of skin was resected down to the olecranon bursa. Olecranon bursa showed some steroid white chalky deposits that were noted, some of these were excised as
well and a small portion of the bursa was also excised. The fistula tract appeared to come with the skin and this was excised as well. The bursal area was then thoroughly irrigated and closed using interrupted 3-0 nylon sutures and a sterile dressing was applied with a compression dressing.

I am at a loss on this one. Thanks for your help, Lisa

Medical Billing and Coding Forum