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Tag Archives: vein

need help with vein graft balloon angio only

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PROCEDURES
1. Coronary angiogram
2. Left heart catheterization
3. Graft angiogram
4. Percutaneous intervention and balloon angioplasty of vein graft to OM1.
5. Right iliofemoral angiogram

PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in a sterile fashion. Patient was premedicated with 1.5 mg Versed and 100 mcg fentanyl IV. After injecting 2% lidocaine, right common femoral artery was accessed with the help of micropuncture with some difficulty due to previous scarring and 6 French femoral sheath was inserted. 6 French diagnostic catheters were used to cannulate left and right coronary artery. 6 French FR 4 catheter was also used to cannulate the vein grafts. Patient was proceeded with intervention of the vein graft of obtuse marginal branch. Overall patient tolerated procedure well. Right iliofemoral angiogram was performed and femoral sheath was pulled and manual pressure was applied for 20 minutes with good hemostasis. FemoStop was applied at Bell pressure for persistent hemostasis.
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LEFT HEART CATHETERIZATION
Left ventricular end diastole pressure was 18 mmHg. No significant gradient across aortic valve.

CORONARY ANGIOGRAM
1. Left main was calcified with 70-80% distal stenosis.

2. Left anterior descending artery had severe diffuse disease proximally before it was 100% occluded for previous stents

3. Left circumflex artery was 100% occluded proximally

4. Right coronary artery was under percent occluded at the origin.
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GRAFT ANGIOGRAM
1. Vein graft to LAD was under percent occluded (chronic)
2. Vein graft to RCA was patent. Stent was noted in the mid body of the graft which was patent with 80% in-stent restenosis. 50-60% stenosis noted in distal RCA after anastomosis before the bifurcation of PDA and PLV branches. PDA branch was patent with no significant disease given collaterals to distal LAD. PLV branch was patent.
3. Vein graft to obtuse marginal branch was patent with TIMI II antegrade flow. Stent at the ostium had 99% in-stent restenosis. There was also 80-90% stenosis of mid part of the body of the graft within the previous stent. Distal part of the vein graft was patent.
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PERCUTANEOUS INTERVENTION OF VEIN GRAFT OBTUSE MARGINAL BRANCH
6 French JR4 guide catheter was used to cannulate the vein graft to OM 1. Heparin was used for anticoagulation. Initially filter wire was attempted for distal protection which was unsuccessful to advance due to significant ostial stenosis. 0.014 BMW guidewire was advanced and vein graft to OM stenosis was successfully crossed without difficulty. 2.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft was predilated at 16 followed by 18 atm. Nitroglycerin intracoronary was given. Subsequent angiogram revealed TIMI-3 antegrade flow and distal part of the body of the graft but still residual significant stenosis at the ostium. 3.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft were dilated at 16 atm couple of times. Adenosine followed by nitroglycerin were given through guide catheter. Subsequent angiogram revealed wide-open vein graft to OM with TIMI-3 antegrade flow and no evidence of dissection or perforation. No evidence of distal embolization. Patient was hemodynamically stable and asymptomatic at the end of procedure.

RIGHT ILIOFEMORAL ANGIOGRAM
Right common femoral artery was patent. Sheath insertion was just below the origin of the inferior epigastric artery..

IMPRESSION
1. Severe native 3 vessels coronary artery disease.
2. Patent vein graft to OM1 with 99% ostial stenosis within the stent as well as 80% instent restenosis within the mid body of the graft. (Likely culprit)
3. Patent vein graft to RCA with 80% in-stent restenosis.

RECOMMENDATIONS
Patient has complex coronary disease as described above. He had multiple intervention of vein graft in the past including 3 intervention in vein graft to OM last year. He has significant instent restenosis of drug-eluting stents. Recommend evaluation by cardiac surgery for possible redo CABG. Continue aggressive medical treatment.
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should I do 93459,92937 -lc since this is vein graft balloon angio or 92920? I bill for hospital
thanks in advance

Medical Billing and Coding Forum

Varicose Vein education????

Posted on by
Hello all,

I am curious to see if y’all know of any education courses/books/ANYTHING that could help me with varicose vein coding? I can’t find any specialty courses or anything that have to do with lower extremity varicose vein management coding. PLEASE ANY ADVICE IS HELPFUL!!!

Thanks in advance!

MacKenzie M.
email: [email protected]

Medical Billing and Coding Forum

36000 – Introduction of needle or intracatheter, vein?

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Please help! I work in a primary care/urgent care setting.

I have a provider wanting to use 36000 when we cannot bill for actual hydration or an infusion. I’m thinking this would also be when we are sending patients our via ambulance. Medicare and Tricare will not cover this code, but some commercial payers will. My other concern is that KVO is not separately reportable, and maybe this scenario falls under that category.

Also, 96365 states "up to 1 hour" but doesn’t specify a minimum like the other codes do. Is it ok to bill this code for less than 30 minutes when we are infusing an antibiotic?

Any help would be appreciated!!

Medical Billing and Coding Forum

Left femoral artery and vein cutdown for cardiopulmonary bypass.

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Physician a femoral artery and vein cutdown for cardiopulmonary bypass during minimally invasive valve repairs. What is the correct billable CPT code for the femoral artery and vein cutdown? 34714 is the suggested the problem is we are not creating a conduit a member on our team suggested (34812 ).

This is the part of the providers note. Our attention was turned towards the left groin where femoral artery and vein cutdown were performed, 5000 units of heparin were given and using a Seldinger technique and echocardiographic guidance, a left femoral arterial cannula 18-French was placed and a 25-French femoral venous cannula was placed. The femoral venous cannula was advanced so that the tip was in the superior vena cava right atrial junction.

thank you!

Medical Billing and Coding Forum

FB (hypodermic needle) removal from antecubital vein

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My provider removed a syringe needle from a patients vein. I need help finding the correct CPT code. I feel he did more than CPT 10120. See the Op note below.

PREOPERATIVE DIAGNOSIS: Foreign body in the left upper extremity.

POSTOPERATIVE DIAGNOSIS: Syringe needle in the left upper extremity.

NAME OF PROCEDURE: Removal of left upper extremity foreign body with fluoroscopic guidance.

ANESTHESIA: General.

FINDINGS: There was a TB needle stuck within the superficial vein in the left antecubital area. Fluoroscopy was used to confirm there were no other pieces of metal in that area following removal. There was a very cord-like vein underneath the vein that had the needle stuck in it.

TECHNIQUE: The patient was taken to the operating room and placed supine on the operating table. The left upper extremity was prepped and draped in a standard surgical fashion. Local anesthetic was injected over the area where the needle could be felt. A small incision was made at this location. Scissors were used to dissect down to the vein containing the needle. The vein was looped proximally and distally with a 2-0 silk suture. The vein was opened up with the scissors, and the hypodermic needle was removed with a hemostat. The 2 previously placed loop sutures were tied. There was no bleeding. Fluoroscopy was then used to confirm that no other metal objects could be seen in the antecubital space. The incision was then reapproximated with a running 4-0 Vicryl subcuticular stitch. The wound was cleaned and dried, and Steri-Strips were applied. The patient tolerated the procedure well.[/COLOR]

Medical Billing and Coding Forum

Foreign body removal vs. removal of scarred vein

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This one has me stumped & I would appreciate any assistance I can get. Here are pertinent sections from the chartnote:
1) "Patient complains of a foreign body in her right hand following having an IV that malfunctioned. It has been there for several weeks and is beginning to cause more pain. The patient believes that it is an IV that was left in and she insists that I remove it." 2) "Right hand has a palpable mass that is long and thin over the dorsum of the thenar space, about 2.5cm x 1mm, it is stiff, but flexible. There is some discoloration of the skin overlying." 3) "I discussed the risks of attempting to remove a foreign body here in the clinic, and recommended to her that I refer her to a surgeon. She refused and wants me to do it here. The consent having been signed, I attempted the removal in the office. The area was prepped and draped in a sterile fashion. Anesthesia was achieved with approximately 1.5 cc of lidocaine with epinephrine. An incision of about 2cm was made over the palpable abnormality. A blunt dissection was carried out down to the vein and then it was incised. There was old blood and clot expressed. An attempt was made to find a foreign body, a section of thickened and scarred vein was removed. (I clarified this with the provider; the vein had basically dead-ended due to the clot & there was no blood flow) The wound was closed with 4.0 nylon with 3 simple interrupted sutures with good cosmesis and hemostasis. Total blood loss estimated at 1cc. It is unclear if there was a foreign body that was not found, or if the palpable abnormality was clot and scarred vein." (When patient returned for follow up, there was no evidence of a mass or foreign body)
Does anyone have suggestions on how to code this? Provider gave me M79.5 as a dx, which is what he thought before he did the procedure. Neither of us thinks it really fits. I can’t find a CPT code that really applies either. Thanks!

J. Beck, CPC

Medical Billing and Coding Forum

Multiple Veins vs. Multiple Branches of same vein

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Patient had an endovenous radiofrequency ablation of the anterior and posterior branch of the right greater saphenous vein. It is the same vein just two different branches off the vein.

After informed consent was obtained, the right leg was prepped and draped in usual fashion. Using Seldinger technique, access was obtained in the anterior branch of the greater saphenous vein in the mid to distal thigh. A 7-French sheath was placed over the wire and the radiofrequency catheter was inserted through the sheath and confirmed on ultrasound to be approximately 3 cm distal to saphenofemoral junction. After this, the access obtained to the posterior branch of the right greater saphenous vein and a wire was left into place. Next using 0.1% lidocaine with lactated Ringers, the area about the anterior and posterior branch of the right greater saphenous vein were anesthetized. Next using 15 cycles of radiofrequency energy, 20 cm anterior branch of the right greater saphenous vein was ablated. Pressure was held at this location and the 7-French sheath was re-loaded and reinserted back over the wire into the posterior branch. The radiofrequency catheter was then inserted through the sheath and confirmed on ultrasound to be greater than 3 cm distal to saphenofemoral junction. Next using 6 cycles of radiofrequency energy with a 3 cm catheter, 9 cm posterior branch of the right greater saphenous vein was ablated. The patient tolerated the procedure well. Restrictions and expectations as well as pain and discomfort, discoloration, and hardening were discussed as possibilities. The leg was wrapped and the patient ambulated prior to discharge.

Should I code 36475 RT and 36476 RT?

CPT Code 36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

CPT Code 36476 Subsequent vein(s) treated in a single extremity, each through separate access sites(list separately in addition to code for primary procedure)

Medical Billing and Coding Forum

vein harvest

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I need help coding this procedure. I am going to bill 35500 but am needing help with the primary procedure

PROCEDURE PERFORMED: Open harvest of the left greater saphenous vein with
bridge incisions.

a history
of a known left internal carotid artery aneurysm supraclinoid measuring 1.2 x
1.1 cm. I was consulted intraoperatively for greater saphenous vein harvest
from the left lower extremity. Patient had a prior left radial artery
harvest. When I arrived, patient was prepped and draped. Consent had been
Obtained. The distal portion of the saphenous vein had been harvested from the ankle to mid-shin.
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DESCRIPTION OF PROCEDURE: A transverse incision was made below the knee and
the greater saphenous vein was dissected out. Using bridge incisions and
tunneling technique, the greater saphenous vein was harvested with side
branches clipped and divided. The distal portion of the vein had already been
harvested from the ankle upwards. The vein was ligated at the
proximal portion just below the knee with clips, brought through the tunnels,
and the distal end was ligated with clips as well. The distal end was marked.
A vein cannula wasinserted. Then, small branches were clipped. Two small areas of leak were
repaired with 7-0 Prolene figure-of-eight sutures. The vein dilated nicely.
The wound beds were hemostatic and will be closed by the neurosurgery service.

Medical Billing and Coding Forum

Pcmk change out with “serial dilation veoplasty to the left subclavian vein”

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EP physician- changing out a pt’s pcmk & adding a biv lead.
He dictated this:
Pre-op diagnosis: ischemic cardiomyopathy, EF37-44 %, 2nd AV block, subclavian stenosis
Procedure:

#1 left subclavian venography demonstration in the presence of tight 90% stenosis of the left subclavian vein
#2 serial dilation venoplasty to the left subclavian vein
#3 coronary sinus catheterization and angiography
#4 Balloon PTA to the posterolateral branch of the coronary sinus

He wrote the code 35476 which is deleted. I am questioning if he can bill for any of the above? He used theses techniques to get to & add the leads.

Thanks,

EP

Medical Billing and Coding Forum