Ok, let's continue with our discussion of
Chapter 4, the Cardiovascular System
Part 2. The next exercise is 4.23
#6. An open revision of an AV
fistula with thrombectomy, patient
receiving dialysis. In a purple bolded
font, I have highlighted those terms that
will come into play when choosing this
code. When I began looking for my main
terms for the index, i started with
"revision". That did not work so then went
to "fistula" and under fistula "repair".
I went to an arteriovenous and that took
me to arteriovenous fistula. When I went
there, I found arteriovenous fistula,
revision, with thrombectomy. I'm not sure
why I have it down twice there. I must
have really liked it. My final code is
arterial venous fistula revision with
thrombectomy and here is in the code
book 36833. You see that there was
a family of codes. You see my circle with
the arrows at the top, that is referring
me back to the previous column where the
parent code for 36833 lives. I've
written in pencil here "revision open AV
fistula". That's the part of the parent
code that I want to keep and then I've
chosen this code because it says "with
thrombectomy" and that's what we are
coding. Also notice I've highlighted a
few things in the notes under the code
to help me remember some things. As I
mentioned in previous podcasts, I will
continue to mention to you
the thing about CPT that's a challenge
to me is all the reading. You really have
to read it. There's just no getting
around it. What makes a good coder is
someone who enjoys that kind of detail.
I hope that you will at least enjoy
it enough to get through this class.
Okay, complications of AV fistulas and
graphs- venous anastomotic stenosis.
I just bring this to your attention
because of balloon angioplasties are
performed quite a bit and they are to
restore the patency and the flow of
blood through these grafts or these
fistulas. One that's mentioned
36902 is a new code. It was another one
of those that I had to do some reading
but once you make that mistake once, you
don't continue to make that mistake. You
go back and read those new codes. A
transluminal balloon angioplasty
percutaneous venous comes under 36902.
Now when we talk about vascular families,
i'm just going to review some things
here. I'm not going to spend a lot of
time coding a vascular family. Just so
you understand the complexity of it. An
arterial vascular family is a group of
arteries that's fed by a primary branch
of the aorta or primary branch of the
vessel that's punctured. Most of the time,
that's going to be the left common iliac
artery, the innominate artery and the
right renal artery. I encourage you to look
in your code book at illustrations for
these different arteries and veins in
the body so you have some idea of where
these vessels are. A venous vascular
family is a group of veins that flows
into a primary branch of the vena cava
or a primary branch of the vessel
punctured and that can be the left iliac
vein, the right renal vein, or the left
brachiocephalic vein. Angiography tells
us in our coding guidelines that codes
have to be assigned for both the
catheter placement, which is considered
the surgical component of the code and
the imaging and that imaging
falls under supervision and
interpretation of the images. Selective
or non selective? When you read about
this a non-selective catheter is one in
which the vessel, the catheter is left in
the vessel that is punctured and not gone any
further or it just goes into the aorta
and sits in the aorta.
A selective catheter placement- you
puncture a vessel to get into the body
and then you select where that catheter
is going to go within the order of
vessels. That's where that Appendix L
comes into play. This is the type of
detail that the interventional
radiologist and the cardiovascular coders
get paid the big bucks for. Because
they understand this. Each vascular
family that is catheterized is coded
separately. You assign a code to the
highest order within the vascular family
and there is a guideline that tells us
not to code for a non-selective catheter
placement in addition to a code from
selected catheter placement unless there
are multiple punctures. It's usually
going to be either selective or non
selective catheter placement. More
guidelines -the supervision and imaging
which is abbreviated as "S and I" codes
are used to describe the imaging
component of the procedure and those
codes are based on the vessels imaged,
not the vessels that are catheterized.
Two different things. To make it more
interesting, some CPT codes include both
the catheter placement and the
supervision and imaging and some don't.
You really have to read your code
descriptions very carefully and the
guidelines around those codes to be sure
you don't trip up. A vascular injection
procedure can be either intra-arterial
or intravenous. In the intra-arterial
injections, there's a selective arterial
catheterization which is when the
catheter is placed where you want it to
be somewhere in the arterial system
other than the aorta or the vessel that
you punctured. In other words, you are
choosing where it goes once you get into
the vessels. The non-selective
catheterization- you just place it
directly into an artery and it
only goes there. It can go into the
thoracic or the abdominal aorta but not
anywhere else.
When it comes to vascular injection
procedures for intravenous injection, I
have it there, the language right out
of your textbook. Suffice it to say that
the Selective is when you are choosing
from your puncture where you go in the
order of families; a non-selective you're
just going where the needle is punctured.
Central venous access procedures are
used to administer different medications
or treatments. The CPT code assignment is
based on the type and the use of the
catheter. Only catheters... only
catheters inserted by physicians are
coded, not catheters inserted by nursing
personnel. Central venous access devices,
which are also called CVADs, are used
for the administration of meds, like
antibiotics or chemotherapy. The administration
of fluids or nutritional compounds like
hyperalimentation for someone who is
needing additional help for nutrition,
transfusing blood products or if someone
just has to have so many blood draws for
diagnostic testing, that it is just easier to
put in a central line. The categories of
venous access procedures are insertion,
repair, partial replacement, complete
replacement and removal. Definitions of
each one of these procedures is
available in the CPT code book. Coders
are instructed not to code removal of a
non-tunneled central venous catheter.
There's a decision tree in the 2017 CPT
textbook (Figure 4.17) that may be
helpful showing you what we're
talking about. For insertion of CVADs,
you have to decide if it is a central or
peripheral insertion? If its central, it is
either going into the jugular, subclavian,
the femoral or the inferior vena cava.
That's often referred to as a central
line.
A peripheral line or a PICC line is
placed in usually the basilic or the
cephalic vein of the arm and then it's
advanced from there into the larger
subclavian vein. It's not going into a
central vein, like the inferior (vena cava) or the
superior vena cava. The word "tunneled"
means the entrance site is at a distance
from where the surgeon has entered the vascular
system. So tunneled CVADs are usually for
long-term use. In the textbook exercise
4.22 Operative Report #2 is
the removal of a venous access port.
I have here the index pathway and the
code 36590. Here it is in the code
book. You see there's only a few codes
under removal of CVAD and this one is a
tunneled central venous catheter without
a port or a pump.
The term "endovascular surgery" is very
common now. It means inside the blood
vessels and typically a procedure begins
with an introduction of a catheter
that's inserted percutaneously into a
large blood vessel. The guidelines around
these codes are with the individual
family of codes. Just be sure you read
those notes above and below your codes.
The endovascular revascularization, also
called open or percutaneous or
transcatheter, I have here a screenshot
of those guidelines. My highlights, just
to emphasize again, the importance of
reading the guidelines. Balloon
angioplasty and stenting improves
arterial perfusion in lower extremities
so it's quite common for that to be used. As
you can see, there are a lot of
guidelines that precede the code 37222.
Exercise 4.23 #4 A patient seen
for surgical treatment of an occlusion
of the superficial femoral artery, left.
Percutaneously, under guidance, the
surgeon inserts a catheter to perform an
atherectomy which is a lower extremity
revascularization. I highlighted in purple
font all the key terms and the word
that I would use for the main term for
the index would be the "revascularization"
which is what an atherectomy is. You
go there, look up "revascularization,
artery. femoral" because that's what
occluded is your femoral artery.
There is your code. Be sure and use your
modifier because we do have left and
right femoral arteries because we have
left and right lower extremities.
Here is the family of codes in the code
book. I purposely did not blow it up (increase size). I
want you to be able to see the entire
family of codes, my circle around them, my
differentiation with the purple
highlighter and the 37225 -LT is
what correctly describes our diagnosis.
Here's an angioplasty that is a homework
exercise , not in your textbook.
not in your textbook. A surgeon
performs a percutaneous transluminal
angioplasty on the left femoral/
popliteal artery for a patient with
peripheral artery disease. Transluminal
just means "in the vessel". Angioplasty,
popliteal artery, intra-operative. You
also could have used femoral artery and
revascularization as your main term.
There is our code with the modifier -LT
and here it is in the code book. Same
class of codes as a previous slide, just
a different code, same family. I should
say same family of codes, different code
within the family. Ligation, division, and the
stripping of the saphenous vein. As we've
mentioned back when we're talking
about CABGs, the saphenous vein is
used for the grafting procedure and
CABG. Ligation and division, the
surgeon actually ties off all the
tributaries that are coming from the
saphenous vein. He ties it off and then
he divides the vessel between where he's
tied it, the ligatures. Stripping involves
completely removing the saphenous vein
from the leg. Because of all the blood
flow to the legs, it does not affect
circulation in the leg to remove the
saphenous vein. That's why it's a
great vessel to use for the CABG. It is
easy to get to and it doesn't harm the
body when you take it away. In our
homework is a creation of AV fistula.
I want to go through this creation of a
fistula. We have not done that. In this
particular patient, it says the doctor
created an anastomosis. The words he
directly connected the
radial artery and the cephalic vein. I
I first looked under "creation" and "AV
fistula". It wasn't obvious what it was,
but then there is a main term
"anastomosis." When we go there and look at
"arteriovenous fistula, direct" that takes
us to the correct code. There is an
illustration in your CPT code book as
well. Here is the code 36821. You see
I have entire family of codes circled.
The parent code 36818 is the code
that describes what we are doing, the
direct method is all the way down to 36821.
Tthat's all I have for the
Cardiovascular section of the code book.
It is a bit more challenging. If you have
any questions, please post them in
Discussion Board and provide me with the
path that you've tried to use to find
your codes and I will attempt to answer
your questions. Thank you so much and
have a nice evening.