Arteriovenous (AV) Graft Study and Recanalization

This is first in the series of interventional radiology coding created by Coding Gurukul http://coding-gurukul.blogspot.com/ team.

An AV graft is a surgically implanted synthetic blood vessel, usually in the upper arm, which connects a major artery and vein in patients with renal failure, requiring hemodialysis. The purpose of the graft is that when needles are inserted to perform hemodialysis 2 to 3 times a week, the real blood vessels do not have to be punctured but instead, the synthetic graft is used.
As in blood vessels, grafts get clogged and the flow through them becomes restricted.
Initially, a graft study has to be performed to determine whether there are areas of blockage. This is coded as:

1. Introduction of needle into AV Graft: 36145 (can use twice per session, use mod -59)
2. Graft study (includes extremity venogram, subclavian venogram, brachicephalic venogram): 75790 (coded once per session)


AV Graft Recanalization:
After the areas of blockage are determined , several treatments may be undertaken to clear these blockages and make the graft patent. Listed below are the typical steps followed to treat the graft. In most cases all the steps will apply but there may be instances when one or two of them may not be performed. Following are the steps:


1 Graft Study

Introduction of needle into Graft: 36145
Graft Angiography: 75790 (includes study of arm and chest)
(Note: Can code 75710 extremity arteriogram, if arteriogram is performed after crossing the arterial anastomosis of the graft)

2 Infusion Therapy for more than 1 hour
Transcatheter Infusion (TPA): 37201
Radiological (S&I): 75896
(Note: do not use this code if infusion is run for a while before or after mechanical thrombectomy) TPA is tissue plasminogen activator which is a naturally occurring thrombolytic serine protease that catalyzes the conversion of plasminogen to plasmin. Plasminogen promotes thrombosis.

3 Mechanical Thrombectomy
AV Graft Thrombectomy (not vein/artery): 36870
Radiological (S&I): 75790
Includes aspiration of thrombus and thrombectomy and dislodging of arterial plug using Fogarty balloon. (Note: Do not code 75790 for mechanical thrombectomy, if it has already been coded as part of AV graft study.)

4 Percutaneous Transluminal Angioplasty (PTA) of Venous Anastomosis
Venous Angioplasty: 35476
PTA Radiological (S&I): 75978
(Note: This code includes PTA of graft as well as PTA of the extremity veins up till the level of the axillary vein. PTAs of the subclavian vein, brachiocephalic vein, IVC can be coded separately.)

5 PTA of Arterial Anastomosis
Arterial Angioplasty: 35475
PTA Radiological (S&I): 75962
(Note: Use this code pair only when the PTA is performed in the actual extremity artery after traversing the AV graft and crossing the arterial anastomosis)

The procedure report will indicate which of the above steps were actually performed.

Important Note: The most commonly used diagnosis for graft stenosis is 996.73 with 585.6 and is widely accepted by insurances.

Sample report:

History: ESRD on HD with thrombosed left arm AVG for declot. Procedure: Left arm AVG thrombectomy and angioplasty The risks and benefits of the procedure were explained to the patient, and written consent was obtained. The risks discussed included but were not limited to bleeding, infection and blood vessel injury. The total procedure length was 1 hr(s) and 9.3 minutes of fluoroscopy time was used. The patient received IV Versed and Fentanyl for conscious sedation, and was monitored by the interventional radiology nursing staff. The left arm was prepped and draped in sterile fashion and 1% lidocaine was used as local anesthetic. A 21g needle was used to puncture both the arterial and venous limbs of the graft. A 4 Fr tapered dilator was placed over each wire, and exchanged for 6 Fr sheaths. Approximately 100 cc of iodinated contrast was used in total. Findings and intervention: Using a 4 Fr Berenstein catheter in the subclavian vein angiography of the proximal arm and central veins demonstrated patency. A pulled back venogram was performed demonstrating stenosis within the venous anastomosis at the antecubitus. The patient received 3000 units of heparin IV. An Arrow thrombectomy device was placed within the venous limb of the graft and retracted slowly.The device was used repeatedly in both the Venous and arterial limbs in similar fashion. Contrast injection within the graft demonstrates several segments of intra graft stenosis.The arterial plug was removed with a 4 Fr fogarty balloon. Angioplasty was performed with an 8 x 40 mm Conquest balloon. Percutaneous transluminal angioplasty was performed within the graft with an 8 x 40 mm balloon with good angiographic result. Repeat angiogiography demonstrated residual stenosis at the venous anastomosis. Reflux of contrast into the arterial anastamosis was unremarkable. A good thrill was present, and the sheaths were pulled with manual compression for hemostasis. The patient tolerated the procedure well and there were no complications. Impression: Thrombosed left arm AVG with a severe stenosis at the venous anastomosis and segments of intra graft stenosis. Declot and angioplasty was performed with residual stenosis at the venous anastomosis. If pulsatility returns in the graft a repeat study should be performed with the possibility of using a cutting balloon for angioplasty.

Try to code above report.

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