Original Coding Alert from 12/27/2016 is attached for reference.

Q:  

In regard to the Coding Alert from 12/27/16 on moderate sedation claims, can you tell me if this has been corrected and if I should go ahead and rebill or appeal these sedation codes? I called Medicare today (4/12) and they didn’t seem to know anything about this. 

A:  The new NCCI procedure to procedure edits did come out April 1 so it makes sense to resubmit claims, though carriers sometimes lag behind. Apparently, some intermediaries have been able to make corrections internally and are paying the codes for sedations.  Other intermediaries are not able to make the corrections internally and are having to wait until Medicare makes them.   For this reason, some are now paying and some are not.  Probably will be some variability in local carriers for a while.

I had had an interesting PD case today that I thought I would share, as this is the 

first time I have seen this.

I was sent a patient with a laparoscopically placed right sided double cuffed

coilec PD  cather with midline infra-umbilical approach about 5 weeks prior with

intra-Peritoneal fixation. He was sent for complete outflow failure and 

inflow with some resistance.

We initially flushed and aspirated a few fibrin plugs from the 

catheter - we did not manipulate the PD catheter with wire or 

styler. On PD gram I see what I think is encasemrnt of the coil

and I think separation of the catheter with injection. (Video link included)

my suspicion is that the catheter might have torn perhaps by 

coming in contact with the staples then completly separated on 

contact injection.

the pt will see the surgeon for Laparoendoscopic replacement.

i am interested in knowing if others have seen this and their thoughts.

Raj.

This patient presented to us for an AVF creation. He was getting hemodialysis through a temporary jugular catheter ( which was there in position for a month and a half !!). We were planning for a tunnelled line placement followed by an AVF creation. As per our protocol we did a venogram before creating the AVF. There was stasis of dye around the central venous area. Contrast injected through the temporary catheter as a part of the venogram showed an ? SVC thrombus surrounding the catheter. ECHO ruled out any RA thrombus.

Now i don't know if

     a) I have to remove the catheter or to keep it insitu

     b) Convert this temporary line to a tunnelled line ( with a possible risk of embolization during the procedure)

     c) Create an AVF ( with a possible risk of immaturity/failure secondary to a compromised central vasculature)

I don't know how much of my fears are real..expecting inputs from the experts..

 Please use the youtube link above for the video.

Dr Venkatesh Rajkumar,

Chennai,

India.

Recently I have had several patients with a fairly new catheter (1-2months old) who presented with fairly sudden onset of pain and redness extending up the neck over the internal jugular vein. they had no fever or infectious symptoms and the catheter was functioning well. The catheter tunnel and exit site were normal. We drew blood cultures and gave empiric antibiotics - and then the blood cultures returned negative. I think the symptoms are a result of thrombophlebitis because of the relatively acute thrombosis. The symptoms improve with 3-5 days of NSAID.

My question is whether anticoagulation is required or appropriate in this setting? Would you use Lovenox and/or Warfarin? For how long?

Thanks,

Tim Pflederer

*Image to follow

An issue I've come across a few times but honestly have only relied on standard and drug-coated balloons for my intervention has been the refractory anastomotic stenoses at a terminal artery.  By this, I mean either a Radial-Cephalic AVF where the Radial Artery distal to the AVF is completely occluded (and thus all flow to the hand is via the Ulnar Artery, with the Radial Artery essentially merely supporting flow to the AVF itself), or in an upper arm AVF where the surgeon inadvertently vs intentionally used a High-Takeoff Radial Artery for the inflow and again the artery distal to the anastomosis becomes quite atretic, thereby leaving the Brachial/Ulnar to supply the forearm/hand.  I have not seen lasting (and honestly nor did I expect) results from either standard/DCB's of the arterial anastomosis.

Today was another such example.  Aside from sending the patient back to surgery to move the arterial anastomosis more proximal, have any of you simply stented this region into the artery itself since the atretic segment of the artery distal to the anastomosis is essentially non-functional anyway (provided you have first documented adequate flow to the Palmar Arch via another vessel)?

As you can see from the (soon to be uploaded) picture, I'd hate to lose such an otherwise nice AVF during a proximalization of the arterial anastomosis.  However, we're also talking about already small vessels here, so would a 5mm Viabahn vs other stent actually provide enough increased vascular lumen to make a difference?

Regards,

Kevin Harned, MD

The new coding manual mentions  sedation codes 99152 and 99153. ( p22)   These sedation codes are column 2 codes for all our  column 1 codes (36901-9  )   and therefore are not allowed.   

Still learning the new rules of the game.

Jeff Hoggard MD

I have been meaning to present this case for a while. This case taught me many different lessons. Firstly, never trust what anyone says (even yourself) about what can and cannot be done. Secondly, always have a plan B, and, hopefully, a plan C.

This was a patient that I had known for years. At the time he was 49 years old. He had had multiple attempts at a permanent dialysis access with each failing early after creation or within a few months to years. This was in spite of mapping and aggressive maturation procedures as well as active surveillance/monitoring. Part of the issue was non-compliance on his part, but, also, he seemed to stenose quickly and easily despite even stenting. He had accrued multiple medical conditions in his young life, including: coronary artery disease and peripheral vascular disease in addition to diabetes, obesity, and hypertension. He was poor surgical candidate for anything extremely invasive.

Interestingly, he had also developed SVC syndrome that was symptomatic (he had a swollen head). At the University, a CT of the chest showed the SVC occlusion. The local expert in central vein stenoses said "there was nothing to do".

I had seen him multiple times for access issues, but, for some reason, after his last graft had failed, he went to the local hospital where a surgeon placed the tesio catheters. Yes, there is a RIJ vein tesio with a cephalad venotomy site and a left SCV tesio. He was sent to me due to poor function of the tesios.

I was able to cut down to the RIJ vein tesio after an angiogram showed no blood flow to the right atrium. Using a 180-cm stiff straight Glidewire and guiding Berenstein catheter, I was able to pass the guidewire through the occlusion (after removing the internal portion of the tesio and cleaning the guidewire). Amazingly, the guidewire passed through the right heart and into the IVC. I, then, dilated the SVC with a 12mm Conquest catheter with 80-90% residual due to elasticity. So, I decided to stent the SVC. I deployed a 14mm by 4cm Luminexx stent, that although I allowed time for it to expand and with the occlusion in the middle of the stent, the stent traveled forward and dropped into the right atrium. Thankfully, the stent was still on the guidewire. Now, I was in a dilemma. I was in an outpatient center with a patient who would likely not survive open heart surgery. If the stent embolized, he would likely die as well. I could not grab the stent with anything. A 14mm by 4cm Atlas catheter passed right through the stent. Additionally, the IVC appeared to come off the right atrium somewhat anteriorly which kept the stent from passing out of the heart. The one image shows the stent in the right atrium, but it is somewhat faint. Finally (after trying multiple ideas), I was able to grab the stent with an 18mm by 4cm Atlas catheter and pass it through the right atrium and park it in the IVC. I performed an angiogram that showed successful placement in the IVC.

Now, I still had the occluded SVC. The blood flow was through the azygous system. Therefore, I deployed a second 14mm by 4cm Luminexx stent in basically the same fashion as the first one (but, making certain that it did not travel even the slightest). It was placed across the occlusion and seated with the 14mm by 4cm Atlas catheter. There was about 20% residual stenosis, but blood flowed into the right atrium.

To make matters worse, the surgeon had placed the RIJ vein tesio with a cephalad venotomy site as the RIJ vein was occluded at the clavicle. Therefore, I cannulated an 8mm by 4cm Vaccess catheter at the clavicle that been used to dilate the RIJ vein and right innominate veins using the 180-cm stiff straight Glidewire that was already in place. I used this new venotomy site to place a RIJ vein tunneled dialysis catheter. I collapsed the balloon around the micro-wire after inserting it into the balloon using the 21 gauge needle. I had cannulated the balloon with this needle using ultrasound guidance just cephalad to the clavicle. Remember, this patient was obese and had a short neck which made this cannulation difficult. The micro-wire and balloon were passed centrally giving me a venotomy site just cephalad to the clavicle to keep the catheter from kinking. With a nicely functioning RIJ vein tunneled dialysis catheter, I also removed the left SCV tesio.

Therefore, like I said. Never trust anyone, even yourself. Sometimes, we just need to try a case and find out if there is nothing left to do. And, always have a Plan B and a Plan C (if you can).