Cpt Code For Vein Patch Angioplasty
In our last article, we discussed how to code percutaneous procedures in arteriovenous (AV) fistulas and grafts. If you haven’t had a chance to read part 1 of this article, I encourage you to do so first to gain the most benefit from the information below:.Today, we are going to take a look at procedures that are performed in AV fistulas and grafts through an. We will also look at hybrid procedures (cases where part of the procedure is performed through an open approach and part through a percutaneous approach).
These procedures present unique challenges due to guidelines that bundle some of the percutaneous procedure codes to the open procedure codes – more on that in a moment.Open Approach CodesLet’s start by looking at the three key procedure codes for open approach to procedures in an AV fistula/graft:CPT 36831 is reported for open thrombectomy of an arteriovenous fistula or graft. This procedure involves making an incision over the AV fistula/graft, creating an opening into that fistula or graft (often referred to as a fistulotomy or graftotomy respectively), and removing thrombus from the graft. Thrombus may be removed directly by grasping thrombus with tools such as forceps or even by “finger extracting” (freeing thrombus that is located right at the opening into the fistula/graft with the surgeon’s finger). Alternatively, thrombus may be removed further from the opening into the fistula/graft by passing catheters such as Fogarty catheters to remove the thrombus. When the physician has removed all of the thrombus he/she is able to remove, they close the opening in the graft and then close the incision.CPT 36832 is reported for open revision of an arteriovenous fistula or graft without thrombectomy. A revision of an AV fistula/graft is a repair that allows blood to flow through the AV fistula/graft more effectively. There are many different complications that can occur in an AV fistula/graft including but not limited to, a. Taking down the existing connection between the artery and vein (known as the anastomosis) and recreating a new connection between the artery and vein.
Cutting out an area of stenosis in the graft/fistula and replacing that area with a piece of graft harvested from the body or a synthetic graft (graft that is not from the patient’s body). This procedure is sometimes referred to as an “interposition graft.”. Creating an open incision over accessory veins that are drawing blood flow away from the AV fistula/graft and causing poor blood flow then banding (i.e., narrowing) those veins to allow more blood flow into the AV fistula/graft. Making a graftotomy and inserting a catheter with a balloon to open up an area of stenosis.
Making an incision to open the anastomosis then placing a patch such as vein or synthetic material to cause the vessels forming the anastomosis to remain wide open. This procedure is sometimes called a “patch angioplasty.”CPT 36833 is reported for open revision of an arteriovenous fistula or graft with thrombectomy. To put it simply, this procedure involves the work of CPT 36831 and 36832 combined.Coding ExamplesNow that we’ve looked at some key definitions and the open approach codes, let’s look at some examples of procedures and the appropriate coding for each example.Example #1: After sterile prep and drape, an incision was made over the l eft arm AV graft. A graftotomy was created a few centimeters from the arterial anastomosis.
Cpt Code For Patch Angioplasty
A Fogarty catheter was threaded through the graft towards the venous side and a long string of thrombus was retrieved. After retrieval, the flow in the graft significantly improved. A few more passes of the Fogarty were made throughout the entire venous outflow to the level of the axillary vein.
Some additional short strings of thrombus were retrieved from the graft. Graftotomy was then closed followed by layered closure of the left arm incision. Patient tolerated the procedure well.Answer example #1: In the note above, the phrases highlighted in bold help us to understand the approach to the procedure, the phrases underlined let us know where the surgeon was working, and the phrases in italics let us know what procedures were performed once the surgeon has entered the graft.
Beginning with the the approach, we first see that an “incision was made” and “a graftotomy (again an opening into the graft) was made.” This confirms our open approach. From there, I have underlined the phrase “left arm AV graft” to make it clear the surgeon is accessing an arteriovenous graft in the left arm through this open approach. In the next sentence, the surgeon “uses a Fogarty catheter” to enter the graft and threads it “through the graft” towards the venous side (the end of the the graft where it connects to the vein forming the arteriovenous graft). He then “retrieves (aka removes) a long string of thrombus.” You may see surgeons use this word “string” to refer to thrombus. This term means that there are multiple areas of thrombus all clotted and connected together. By telling us whether the string is short or long, the surgeon is giving us a picture of how much thrombus is being pulled out of the graft.
The surgeon notes the flow in the graft has improved after pulling out that initial string of thrombus, but decides to keep going with the procedure to ensure he’s cleared the graft of all clot. So he makes “a few more passes with the Fogarty catheter” and threads the catheter this time up through the entire venous outflow to the level of the axillary vein. I talk about venous outflow and the extent of the peripheral segment of an AV fistula or graft in part 1 of this article so feel free to go back to that article for a refresher on these terms if need be.
He removes “some additional short strings of thrombus” with the additional passes of the Fogarty catheter. He then concludes the procedure is complete and closes the graftotomy and then the arm incision.This documentation supports CPT 36831.Example #2: After sterile prep and drape, an incision was made exposing the right arm AV fistula. A fistulotomy was created at the anastomosis. I extended my incision longitudinally until the entire anastomosis was widely opened. Through a separate incision, I harvested a small piece of saphenous vein for use as a vein angioplasty. I then sutured this patch in place at the arteriovenous anastomosis. Good flow was observed, confirming a successful procedure and a widely patent anastomosis.
Vein Used For Patch Angioplasty Cpt Code
The incision was closed in layers.Answer example #2: Again in the note above, the phrases highlighted in bold help us to understand the approach to the procedure, the phrases underlined let us know where the surgeon was working, and the phrases in italics let us know what procedures were performed once the surgeon entered the fistula. Beginning with the approach, we first see that an incision was made and a fistulotomy (again an opening into a fistula) was made. This confirms our open approach. From there, I have underlined the phrase “right arm AV fistula” to make it clear the surgeon is accessing an arteriovenous fistula in the right arm through this open approach. In the next sentence, the surgeon “extends the incision longitudinally (or lengthwise) until the entire anastomosis was widely opened.” He then describes harvesting a piece of the saphenous vein (a superficial vein in the leg often used for patches or bypass grafts during vascular procedures).
Hoping you might provide assistance in regards the following: Specifically it concerns an AV graft, in which percutaneous thrombectomy (36870) is performed. After intervention, collateral vein in mid-fistula is determined to be stealing 50% of flow from AV graft and ligation is performed. Based on 2012 SVS recommendation, code 36832 would be appropriate for the ligation of collateral, as we are revising the flow of graft. However, the physician performed percutaneous thrombectomy during the same session.
Codes 36870 and 36832 represent an NCCI coding conflict with no modifier override. Would you recommend reporting code 36833 despite having not performed open thrombectomy? Or report the ligation with unlisted code 37799?.Date: March 13, 2013.