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Tag Archives: Placement

Endarterectomy with patch angioplasty, selective cath, stent placement — pls review

Posted on by
Hello – We would love someone to review our codes and provide feedback. Also, specifically, it’s our understanding that we code for both access sites, hence the use of 36140-XS-RT. Yes/No – Circumstantial? We are specifically being asked why we want to use this code.

These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625

Many thanks. Kristi

Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN

Post-op Diagnosis: same

Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA
4. R EIA PTA, stent placement, 8 x 60mm

Anesthesia: General

Estimated Blood Loss: 200 mL

CONTRAST: 50 cc

Drain: none

Total IV Fluids: see anesthesia log

Specimens:
ID Type Source Tests Collected by Time Destination
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY

Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No.
Used
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL
STERILE – SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC – A
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1
mynx N/A CARDINAL HEALTH INC F1805704 Left 1

Complications: none

Findings: R EIA occlusion with bulky calcified plaque extending into R
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde
approach therefore L CFA access was obtained and lesion was crossed from
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good
result. Palpable pedal pulses upon completion.

Disposition: awakened from anesthesia, extubated and taken to the recovery
room in a stable condition, having suffered no apparent untoward event.

Condition: doing well without problems

Technique:
After informed consent was obtained the patient was taken to the operating
room. Placed in the supine position. General endotracheal anesthesia was
administered. The abdomen and bilateral groins were prepped and draped
usual sterile fashion.

We began by making an incision in the inguinal
right area right groin midline between a cyst in the pubic tubercle in
vertical fashion. We dissected through the skin subcutaneous tissue
Scarpa’s fascia until we encountered the femoral sheath. Any veins that
were seen were tied off and suture ligated. Then got into the femoral
sheath identified our inguinal ligament and then our right common femoral
artery. It was noted to be calcified with some posterior plaque and some
inflammation noted. We dissected systemic fashion inferiorly identifying a
few branches and putting small Vesseloops around. We then identified the
SFA and profunda. Placed vessel loops around them. We then continued our
dissection more proximally we had to divide part of the inguinal ligament
to get more proximal control.

At this point, we began our endarterectomy
we heparinized the patient and obtained ACTs every 30 min to remain
therapeutic. Once the patient was therapeutic we got control with vessel
loops and then performed an arteriotomy with an 11 blade and extended it
with Potts scissors. The common femoral artery had noted hemorrhagic
calcified plaque. We then perform an endarterectomy between the median
intima with a Freer elevator and piecemeal off the plaque in the common
femoral artery. We then made our endpoint at the distal common femoral
artery. There was noted to be calcified posterior plaque on the proximal
aspect of our endarterectomy site with a chronic occlusion.

We attempted
to access through the open endarterectomy vessel the right external iliac
artery with a Glidewire 035 as well as a 5 French sheath. When we
advanced the wire and there was mild resistance proximally we advance into
what we thought was the abdominal aorta we then performed an angiogram
which demonstrated a dissection plane at this point we then stopped access
from this area. We removed the sheath and the wire and then gain access on
the opposite groin. At this point we then gain access to the left groin
under palpation using Seldinger technique.

We accessed the left common
femoral artery and then we upgraded to a 5 French sheath. We then
advanced a Glidewire and a VCF catheter and performed a angiogram with
minimal contrast. This demonstrated extensive infrarenal calcification in
bilateral patent common iliac arteries. The left hypogastric appeared to
be occluded. The left external iliac had multilevel disease but nothing
hemodynamically significant. The right common iliac artery appeared to be
patent the external had a flush occlusion about 1 cm after the takeoff.
The left hypogastric artery appeared to be patent with an ostial lesion.
There was extensive pelvic collaterals and reconstitution at the femoral
head of the common femoral artery. At this point we then upgraded to a 6
French up-Andover sheath and advanced it over the bifurcation into the
right common iliac artery. We then used a support Seeker catheter within
and a stiff 035 glidewire and was able to go through the chronic occlusion
of the left external iliac artery into our endarterectomy site in the
right common femoral artery. We then switched snared the Glidewire
through the right common femoral artery endarterectomy site. At this point
we then placed a 6 French sheath through the Glidewire in the right groin
and then we used a 8 x 60 mustang balloon used to measure the length of
our occlusion. At this point we then decided to use a 8 x 60 self
expanding stent. We deployed the stent in standard fashion at the takeoff
of the hypogastric artery with the endpoint proximal to the femoral head.
We then post dilated with a 8 x 60 mustang balloon. Postop angiogram
demonstrated good apposition of the stent with no hemodynamic significant
stenosis noted. We then at that point, performed a patch angioplasty with
a pericardial patch with 6 0 Prolene in standard fashion. Before
completing the patch angioplasty we forward flushed and backflushed the
common femoral artery. Before completing the full angioplasty, we left
the wire in place and then performed a angiogram which demonstrated
patency of the right common iliac artery as well as external iliac artery
and common femoral artery with no hemodynamic significant stenosis. The
right groin shot demonstrated patency of the profundus as well as the SFA.

At that point we then finished our patch angioplasty and endarterectomy
site. Everything was noted to be hemostatic and mildly oozy. We reversed
the patient with protamine. We dried out any bleeding points with Bovie
electrocautery and clips. We then closed the right groin in layers of
Vicryl multiple. We closed that the subdermal with 3 0 Vicryl pop offs
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was
then applied.

On the left groin we downsized to a 6 French sheath over the
wire under fluoroscopic guidance. We then used a 6 French Mynx closure
device and closed the left common femoral artery at the access site. In
standard fashion. Sterile dressing was then applied. At completion of the
procedure the patient had a palpable right pedal pulses. Patient tolerated
the procedure well was extubated transferred to the PACU in stable
condition.

Medical Billing and Coding Forum

Powerport Placement with arterial cannulization

Posted on by
Hello all! I have seen some great advice given on the forums and wanted to throw this challenge out there. The coders at our facility are all scratching their heads at the best way to approach this one. We are an acute care hospital and this patient was seen as an outpatient surgery case. There are several op notes, so I’m just going to summarize to avoid a several page long query. Any help would be greatly appreciated and thanks in advance!

Diagnosis: Non- small cell lung cancer needing vascular access due to peripheral venous insufficiency for startup of chemotherapy

First surgery
1. Left subclavian single lumen PowerPort placement
Surgeon accessed left subclavian with guidewire, followed by peel-away sheath and internal dilator along appropriate course. Guidewire and dilator were removed and substantial bleeding occurred which prompted surgeon to perform an ABG for possible arterial access instead of venous. ABG came back with elevated pO2 so a co-surgeon was brought in for consult which both evaluated flouro images and decided to proceed as a venous cannulization. Case was finished with insertion of tunneled central venous catheter to superior vena cava. Pocket was created on the chest and port was inserted. Catheter was mated to the port and closure of sites occurred. Patient was taken to PACU for postoperative imaging to determine if arterial cannulization had occurred.

Second surgery
1. Removal of left-sided arterial port.
2. Repair of subclavian artery
3. Right internal jugular vein single lumen PowerPort placement
Patient brought back to OR after subclavian artery identified as the cannulization point. Surgeon cut-down to level of pectoralis muscle, divided muscle and identified catheter access into subclavian artery. Vascular co-surgeon placed a pursestring suture in the subclavian artery and the catheter was slowly withdrawn. Pursestring suture was pulled tight after catheter was removed and hemostasis was maintained. Muscle and fascia were reapproximated. Original port and remaining catheter were also removed and sites were closed. Surgeon moved to right side of body, accessed the internal jugular vein and performed catheter insertion down into the vena cava. Pocket was created on right side of chest and port was placed. Catheter was tunneled and mated to port. Incision sites were closed.

So I am trying to figure out diagnoses and CPT for this one. Since the patient left the OR and was in recovery after the original surgery, we would assign a complication code for the arterial access right? Would it be considered an intraoperative complication since it happened during the procedure instead of a postoperative? Would a misadventure code need to be assigned since the surgeon messed up? Below is what we have.

Diagnoses
C34.91, I87.2, I97.88, Y65.51? (would it be a wrong operation on correct patient), Y92.530

CPT
36561 (Initial VAD insertion), 35201-78-XP (Subclavian artery repair with unplanned return to OR performed by vascular surgeon, or should this not be coded as vascular repair is included in the insertion/removal of VAD), 36590-78 (Removal of initial VAD with unplanned return to OR), 36561-76 (Insertion of second VAD with same procedure repeated by same physician)

Medical Billing and Coding Forum

us for intravenous line placement can ED doc bill that ? What CPT code ?

Posted on by
Complete, Entered, Signed in Full, General

Language Services Used or Declined: Not Applicable – Interpreter Services not required.

Event Note:
· .
Consulted by Dr Silver from pediatric hematology to assist with vascular access in this 17 year old male with epidermolysis bullosa and chronic iron defiency anemia for planned labwork and iv iron infusion. patient registered at hematology infusion center and transported to ED for ultrasound guided phlebotomy and IV placement.

patient accompanied by mother, home nurse and Dr Silverman from peds hematology

Procedure Note:
Procedure: intravenous line placement
Indication: chronic difficult vascular access, chronic iron defiency anemia, for scheduled phlebotomy and IV access to assist with iron infusion
22 gauge 1.5 inch needle placed under sonographic guidance in LUE vein
good blood return, flushed easily with normal saline with sonographic confirmation into vein – no resistance. Secured with gauze and paper tape as pre patient’s skin care protocol.

Labs and clinical care handed off to Dr Silver to transport patient back to infusion center for his iron infusion.

Time Spent: 90 minutes

dr Fox MD

What CPT code would you use ? Thanks

Medical Billing and Coding Forum

ERCP w/ stent removal and stent placement not in same areas

Posted on by
I would like insight into how you would code the following stent removal not in the same area as subsequent placement(s) – 1 stent removed from biliary tree, 1 stent placed into left hepatic duct, 1 stent placed into right hepatic duct.

One stent was removed from the biliary tree using a snare. The stent was found to be occluded via the water column test. A short 0.035 inch Soft Jagwire was passed into the biliary tree into the right intrahepatic ducts. The short-nosed traction sphincterotome was passed over the guidewire and the bile duct was then deeply cannulated….The upper third of the main bile duct, hepatic duct bifurcation and left and right hepatic ducts separately (Bismuth II) contained a single segmental stenosis 15 mm in length. A short 0.035 inch Soft Jagwire passed successfully into the left intrahepatic branches. The hepatic duct bifurcation and the left main hepatic duct were successfully dilated with an 8 mm balloon dilator. One 10 mm by 8 cm transpapillary uncovered metal stent was placed 7 cm into the left hepatic duct. Bile flowed through the stent. The stent was in good position. One 10 mm by 8 cm transpapillary uncovered metal stent was placed 6.5 cm into the right hepatic duct. Bile flowed through the stent. The stent was in good position.

73274,73274.59, but what for the stent removal? 43275 can’t be billed with 73274. 43276 then I can’t use 73274 for 2nd stent placement. Thoughts?

Medical Billing and Coding Forum

Revision of Uterus along with Recanalization of Cervix with Cervical Stent Placement

Posted on by
Does anyone know the correct CPT code to use for the following procedure?

PROCEDURE IN DETAIL: Patient was taken to the operating room and was placed in dorsal lithotomy position and was prepped and draped in standard surgical fashion.
*
Intra-abdominal entry was not made in this patient. The patient was examined under anesthesia. It appeared that patient had a rather aggressive LEEP in the past. Her cervix was virtually absent. When we placed the duck billed speculum in the vagina we could not find a cervix or a cervical opening.
*
Intraoperative ultrasound was then performed which demonstrated a large collection of blood within the uterus with complete occlusion of the presumed cervical endocervical canal.
*
Patient wanted to have kids and therefore a recanalization procedure along with division of the uterus was needed.
*
Subsequently, multiple lacrimal duct probes were taken and a tentative cervical canal was formed with lacrimal duct probe and under ultrasound guidance an opening into the uterus was made in a transvaginal fashion. As soon as we entered the uterus, old hematometra was evacuated, evacuating approximately 200 mL of blood under ultrasound guidance. This blood was old and altered. Subsequently, we needed to suture the upper vagina to the endocervical canal with multiple interrupted stitches and the minimal cervical tissue that was found was subsequently sutured onto itself with a cervical stent. A red rubber Foley catheter was subsequently inserted into the uterus and was passed through the vagina to keep the newly created endocervical canal open.
*
The red rubber Foley catheter was basted to the right thigh of a patient. Multiple intraoperative pictures with ultrasound guidance were taken and were uploaded to the patient’s chart.

I have NO idea. My surgeon wants me to use 58540 but that does not seem correct to me.

Any help is greatly appreciated!! 😮

Medical Billing and Coding Forum

Can I charge mod sedation for placement of nerve blocks

Posted on by
Hi,
If anyone can help me it would be greatly appreciated.
I am coding for a hospital; The anesthesiologist is using moderate sedation to place nerve blocks before a surgery. The surgery anesthesia is MAC and I know I can’t charge for the nerve block, but was wondering if I could charge for a facility charge for the mod sedation? I was thinking it’s like when you charge for us guidance used with a nerve block even when you can’t charge for the nerve block.

Any thoughts……

Medical Billing and Coding Forum

Denial issues: No ROS and PEG tube placement

Posted on by
Good morning!

I have a claim I am struggling with.

This claim was initially billed to UHC as:
02/05/17 99223
02/06/17 99233 – 57
02/07/17 31600
02/07/17 43246 – 59

I have several issues with this claim/denial:

1. Line 02/05/17 99223 was denied for level of service. We sent the medical records, but they didn’t deem them sufficient for this level of service. I am having a hard time determining the level due to the information provided. Here is what I was given:

HPI:
The HPI that was listed on the intake form is:
67F presented to X Facility on 01/28 after found down by husband at home. She was AO with left sided weakness on arrival but progressively worsened. She became less responsive, GCS 8 and was unable to protect her airway. She was remained intubated since that time. She was found to have a ICH due to a small AVM. No neurosurgical intervention is planned at this time. Off of all sedation she is only able to follow simple commands and oopens eyes to pain. General surgery has been consulted for trach and peg.

History:
Med history: GERD, hyperlipidemia, hypertension, Osteoarthritis
Surg history: appendectomy, hysterectomy
Social history: lives with family, married
Family history: Father – Diabetes

ROS: Unable to obtain due to ventilator; ams

It also states under the Diagnosis, Assessment & Plan:
– Will plan for trach and PEG this week
– Procedure explained and all questions answered with husband and daughter

2. Line 02/06/17 99233 – 57 was denied for improper use of modifier.

The decision for surgery was made on 02/05/17 so this mod doesn’t apply. I think it needs to be removed, my co-worker disagrees.

3. Line 02/07/17 43246 – 59 was denied for Medical Record does not support code.

The lines from the Op Report that pertain to this are as follows:

The guidewire was passed. It was snared and brought out through the oropharynx with the EGD scope. A PEG was then placed through the guidewire and brought back down though the oropharynx into the stomach through the abdominal wall. It was secured at 3.5 at the skin incision and placed a 2-0 nylon the around bumper and to the skin.

Is that sufficient enough info to bill the 43246?

I know this is a lot to take in. I am new to this practice and not familiar with these types of surgeries just yet. I would appreciate any help and/or suggestions with the above listed three problems.

Medical Billing and Coding Forum