Our doctor gave a code of L97.322 Ulcer Ankle Left w∕ Fat Exposed which requires the underlying condition to be coded first. He also gave us I87.8 which is Venous Stasis. Per what I read in the ICD 10 book, venous stasis does not fit the criteria to be used an underlying condition for this ulcer code. We have a difference of opinion at my job. Can I87.8 be used as the underlying condition to the Ulcer code or no? Thanks!
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Tag Archives: Venous
CPT code for excision of subQ venous malformation in forearm?
One of my providers had a patient w/ a lump on her forearm that was tender, blue, and had gone from compressible to non-compressible. His differential dx was "cyst vs. vericosity with thrombus". The decision was made for excision. Here is the procedure note:
"After discussion of the treatment options the patient wishes to proceed with
excision. The area is prepped and draped, anesthesia provided with 2cc lidocaine
with epi. A longitudinal incision of 2cm is made and disection carried out down
to the level of the mass, which is identified as veinous in nature. It is ligated
with multiple ties of 4.0 vicryl. The wound is then closed with 3.0 Nylon, with
simple interupted sutures #7. A sterile bandage is placed and wound care
instructions given."
I did verify with the doctor that the mass was located at the subcutaneous level. Can anyone give me some guidance? I found 26115, which does refer to vascular malformations in the section for soft tissue tumor removals of the fingers & hand; would the same apply to 25075 – soft tissue tumor removal of the forearm?
Thanks in advance!!
venous access
Is there a code to use when an patient, IV drug user, has no usable veins, or the veins are so compromised as to make attempts at IV access almost impossible? Something like "IV access complicated by history of drug use"?
central venous catheter
I have a report where the physician injects contrast in an existing permcath(tunelled cath), and then makes a replacement with a new permcath.
My question is, can we code 36598 along with 36581 or is it part of the procedure?
Any help would be great..
Venous duplex
We have been having all of our venous duplex claims come back as not medically necessary. We I look up the LCD with Medicare the only codes listed are varicose vein codes. We are unable to file with swelling of limb, pain in limb, DVT, pre-op surgery, which are the main reasons for this tests. Has anyone heard anything about this?
36556 nun-tunneled central venous catheter billed twice by different specialty Doctor
Need your help, please! 36556 billed twice on the same day by two different specialty Doctors, denied as duplicate, do you think a modifier is needed?
Adding venous thromboembolism to the CDI checklist at your facility
By Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
The annual incidence of an initial venous thromboembolism (VTE) event, either a pulmonary embolus (PE) or a deep vein thrombosis (DVT), is approximately 0.1% in the United States, with the highest incidence among the elderly and a recurrence rate of about 7% at six months. At the same time, thrombotic stroke is the third leading cause of death in the United States. Virchow’s triad theory suggests that VTE occurs due to three factors:
- Altered blood flow
- Vascular endothelial injury
- Alterations in the blood constituents, or hypercoagulable state
A patient with an abnormally increased tendency toward coagulation may be said to experience a hypercoagulable state. Hypercoagulable states can be further specified as primary or secondary. Primary hypercoagulable states are inherited thrombophilia conditions caused by deficiencies or defects of the physiologic anticoagulants or increased coagulation factors, according to the journal Cardiovascular Medicine (2007). The major causes of inherited thrombophilia include factor V Leiden mutation, antithrombin deficiency, protein S and protein C deficiency, and prothrombin gene mutation.
Secondary, or acquired, hypercoagulable states are a varied group of disorders with an associated elevated risk for developing thromboses. Many conditions can effect changes in the coagulation system, resulting in a hypercoagulable state. Secondary hypercoagulable state, when documented in the medical record, is a comorbidity that can increase reimbursement, impact length of stay, and reflect a higher severity of illness and risk of mortality, but it is often underdocumented and underreported.
Many clinicians easily recognize that patients may present a higher risk of thrombosis with evidence of a previous thrombus, recent major surgery, new trauma, malignancy, pregnancy, the use of oral contraception, antiphospholipid syndrome, or the use of a central venous catheter.
Patients undergoing surgery who have not received VTE prophylaxis experience a rate of DVT from 15% to 30%, and fatal PEs from 0.2% to 0.9%, according to a 2007 article in the journal Circulation. Trauma patients run almost a 60% risk of VTE. Among cancer patients, at least 50% are found to have a VTE at autopsy.
Increases in blood viscosity, fibrinogen, and factor VIII during pregnancy increase the risk of VTE in pregnant women six times higher than that of nonpregnant women. The prevalence of VTE in pregnancy is 1:600, and PE causes 9% of all deaths during pregnancy. In one study, currently available oral contraceptives increased the risk of VTE to five times that of a non-user.
The risk increases within four months of the start of therapy and remains unchanged, regardless of duration of use, until three months after the end of therapy.
However, additional conditions seen among the inpatient population also may increase the risk of developing VTE. Diabetic patients are at higher risk of thrombosis; 80% of Type 2 diabetic deaths may be attributed to thrombi. The risk of stroke and myocardial infarction is significantly higher in the diabetic population.
Researchers have found modifications in the coagulation pathway in diabetic patients, including abnormal coagulation screening tests and altered clotting factor levels. Enhanced platelet aggregation and activation, along with an inhibited fibrinolytic system associated with insulin resistance, can suggest a hypercoagulable prothrombotic state that increases risk of a cardiovascular event.
In metabolic syndrome, in which we find obesity, chronic inflammation, and insulin resistance, we also find a hypercoagulable state associated with increased clotting factors and an inhibited fibrinolytic pathway. Elevated cholesterol levels can impact platelet aggregation and clot formation. Smoking causes damage to the endothelium, adhesion of platelets, release of growth factor, and reduced tPA production that can result in a prothrombotic state. Immobility associated with travel can triple the risk of thrombosis, particularly in obese patients. Heart failure, chronic renal failure, thyroid disease, and sepsis can also result in a prothrombotic state.
Documentation of secondary hypercoagulable state must, as with all secondary diagnoses, meet the definition of a secondary diagnosis, to include at least one of the following:
- Clinical evaluation
- Therapeutic treatment
- Diagnostic procedures
- Extended length of stay
- Increased nursing care and/or monitoring
In all physician documentation, the diagnosis to the correct degree of specificity, the supporting clinical indicators, and the treatment plan must always be in alignment.
While encouraging physicians to capture this comorbidity when clinically warranted, we must also emphasize that documentation of secondary hypercoagulable state is incomplete without referencing the indicators that support the diagnosis, as well as how it is being evaluated, treated, or diagnosed.
Documentation of anticoagulant therapy in patients at risk for VTE should not only be associated with meeting core measures requirements, but should also be linked to the secondary hypercoagulable state and the underlying conditions that put the patient at risk.
The goal of any clinical documentation program is to paint the full clinical picture, so consider adding secondary hypercoagulable state to the paintbox.
Editor’s note: Brown is the director of CDI for Tanner Health System, Carrollton, Georgia. She has experience in critical care, nursing education, case management, long-term care, and, of course, CDI. She thinks the only thing better than writing for the Association for Clinical Documentation Improvement Specialists is snuggling with her cat Thomas. Contact Brown at [email protected]. Email your questions to editor Steven Andrews at [email protected].
Mechanical thrombectomy (venous)
Patient has EKOS cathetet follow-up found a little more thrombus and they ended up doing mechanical thrombectomy (venous) and then they removed the EKOS catheter. These two codes 37214 and 37187 bundle. Are these two codes often billed together? I’m not sure I would use the 59 modifier in this situation because both removal of EKOS catheter was from the femoral vein and mechanical thrombectomy was of the same vessel.
Thanks,
LUE intravascular U/S & Angioplasty LUE AV graft venous anastomosis
I think I’m short &/or incorrect on my codes. Please! I really use some help because it’s been awhile for vascular. I’m putting this under Cardiovascular.
35476
37252
36005
75978/75820
PROCEDURES:
1. Left upper extremity intravascular ultrasound.
2. Cutting balloon angioplasty of the left upper extremity AV graft
venous anastomosis.
DESCRIPTION OF PROCEDURE:
After informed consent was obtained, the patient was taken to the
operating room, placed in supine position on the operating table.
Anesthesia was local with sedation. The left upper extremity was
prepped and draped in the usual sterile fashion. Because of the
patient’s severe allergy to contrast, no contrast was given and we
used intravascular ultrasound to navigate as our guide to perform
upper extremity venogram. The AV graft was accessed under ultrasound
guidance with a micropuncture needle. Micropuncture wire was advanced
into the AV graft and exchanged for a 0.035 guidewire. A short 6-
French dialysis access sheath was placed. At that point, using
fluoroscopy, an angled Glidewire and a Kumpe catheter navigated
through the distal venous anastomotic obstruction and placed the wire
into the left innominate vein. We then exchanged for a 0.018
guidewire and placed the intravascular ultrasound. The intravascular
ultrasound was taken to the central veins. There was no evidence of
any significant stenosis based on intravascular ultrasound from the
innominate vein back to the proximal axillary vein. We did notice a
high-grade stenosis at the distal anastomosis of the Acuseal graft to
the axillary vein. The location of the anastomotic stenosis was
marked on the screen. We then used a 7 mm x 4 cm AngioSculpt cutting
balloon for angioplasty of the stenotic portion. There was an obvious
waist on the balloon upon initial inflation. We did 2 inflations at
this site. We then placed a 7 x 2 standard angioplasty balloon to
iron out the site. Upon completion, we then replaced the IVUS
catheter and the anastomotic stenosis was essentially resolved. There
was excellent flow through the distal anastomosis into the central
veins.
With that completed, we then removed our catheter and wires and with
the sheath and held pressure until hemostasis was achieved. The
patient tolerated the procedure well. There were no complications.
The patient was sent to the recovery room in stable condition. He can
resume dialysis on his usual schedule.
Attempted Venous Decompression
I am having difficulty finding anything that can be billed in the scenario below. Please advise. Thank you in advance.
BSA: 1.89
Contrast: Low Osmolar Visipaque 320-1mL
Heparin given: 3000 units
Procedure: Attempted Venous Decompression
We attempted to gain access via patients right saphenofemoral vein and the left saphenofemoral vein. We were able to gain access, but it was difficult placing the sheaths, and then sheath access was lost on the right, and we were unable to place sheath access on the left. Subsequently, the procedure was terminated. We are going to get better assistance in ultrasound to attempt this procedure.