Documentation Dissection - AAPC

Documentation Dissection

Preoperative Diagnosis: Surgical arteriovenous fistula graft failure to mature.

Postoperative Diagnosis: Surgical arteriovenous fistula graft failure to mature |1|.

Procedure Performed: Arteriovenous fistulogram, angioplasty, and coil embolization of branch vein for right forearm radiocephalic vein fistula |2|.

Indication for Procedure: Failure of fistula to develop more proximally, making proximal cannulation difficult |3|.

History: The patient is a 68-year-old lady with end-stage renal disease, on hemodialysis |4|. She has a right forearm radiocephalic vein fistula being used for dialysis. Her access flows have been in the 600 range. The nurses are concerned that they are unable to get her access cannulated more proximally, and they repeatedly have to stick her in the most distal aspect of the fistula in order to cannulate her. Because of this and some difficulty getting her to a higher blood pump speed with the larger bore needles |5|, we have been asked by the patient's nephrologist to perform a fistulogram. Prior to this procedure the patient was interviewed and examined, and informed consent was obtained by me.

Description of the Procedure: The patient was taken to the operating room in satisfactory condition. The patient was given 2 mg of Versed for conscious sedation.

Her right arm was prepped and draped in the usual fashion. The midportion of the fistula was locally infiltrated with lidocaine and cannulated in retrograde fashion using an 18-gauge Angiocath. Contrast was injected to illustrate the feeding artery, body of fistula, and runoff vein. This showed the feeding artery to be the smooth and patent radial artery. The arteriovenous anastomosis appeared to be adequately patent |6|. The juxta-anastomotic segment was mildly narrowed, about 6 mm in diameter in places. The cephalic vein of the fistula was widely patent or dilated to 8, if not 9 mm in diameter. There was, in fact, a branch vein that began at about 10 cm from the anastomosis, which would be proximal to the areas where she is able to be cannulated. As mentioned, the nurses would like to be able to cannulate more proximal than that on her forearm. This branch vein was about 6 mm in diameter |7|.

There was integrated filling of the branch vein, so I decided to go ahead and coil that off. I advanced the Glidewire to the balloon-tip catheter, removed the balloon-tip catheter, and traded it out for a Berenstein catheter. Using a fair amount of catheter and wire manipulation I was able to maneuver the wire and the Berenstein catheter into the branch vein. I positioned it so that it was seated about 2 cm into the branch vein, and then obtained an 8 mm x 7 cm Nestor coil. I advanced the Nester coil into the branch vein, coiled well within the branch vein, and seated well |8|. Post-coil angiogram showed a very good result with minimal flow of contrast across the coil |9|.

At this point the procedure was concluded, the catheter was removed, and Tip-Stop was applied. The patient was taken to the recovery room in satisfactory condition.

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|1| Postoperative diagnosis is surgical AV (arteriovenous) fistula with failure to mature, which is inadequate for hemodialysis for this patient.

|2| Planned procedures are arteriovenous fistulogram, with coil embolization of a branch vein for radiocephalic vein fistula. Verify procedures in the body of the operative report.

|3| Verification of the postoperative diagnosis.

|4| Secondary diagnosis identifying the need for an AV fistula.

|5| Explanation of the current AV fistula complication.

|6| The fistulogram was performed in the radial artery.

|7| This identifies a branch vein near the anastomosis that may be used for dialysis.

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|8| A Nestor coil was placed in the branch vein. |9| After the coil was inserted, an angiogram was performed. _____________________________________________________________ What CPT? and ICD-10-CM codes are reported? CPT? Codes: 36901, 36909 ICD-10-CM Codes: T82.898A, N18.6, Z99.2 Rationales: CPT?: The first procedure performed is arteriovenous fistulogram. Look in the CPT? Index for Dialysis/Introduction/Dialysis Circuit referring you to 36901-36903. Report 36901. This code includes the introduction of the angiocath, and all necessary imaging for the fistulogram. Next report the coil embolization of the branch vein. In the CPT? Index look for Embolization/ Vascular/Venous referring you to 37241. The notes for Vascular Embolization and Occlusion indicate that this code is not used for hemodialysis access and to report 36909. In the CPT? Index look for Dialysis/with Vascular Embolization/Occlusion referring you to 36909. The notes below 36909 instruct us to code 36909 in conjunction with 36901, 36902, 36903, 36904, 36905, 36906. ICD-10-CM: The postoperative diagnosis is a surgical arteriovenous fistula graft with failure to mature. Since the arteriovenous fistula has been created surgically and it has failed to mature enough to be used for dialysis procedures, this is considered a complication of surgery. Documentation identifies the type of complication but a code is not available for failure to mature. In the ICD-10-CM Alphabetic Index look for Complication/arteriovenous/fistula, surgically created /specified type NEC directing you to T82.898. Verification in the Tabular List identifies T82.898 as the correct code. Assign the seventh character A for episode of care. Assign the ICD-10-CM code of T82.898A for this procedure. A secondary diagnosis code is reported for the end stage renal disease. In the Alphabetic Index look for Disease/renal/end stage (failure) referring you to N18.6. Verification in the Tabular List identifies N18.6 as the correct code. There is a note that states, "Use Additional code to identify dialysis status (Z99.2)." Report code Z99.2 for dependence on renal dialysis, as an additional code.

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