A patient presents for treatment of an ulcerated bleeding brachiocephalic arteriovenous (AV) fistula. At surgery, stenosis of previously placed innominate vein stent and cephalic arch stenosis were discovered. A balloon was inflated within the stent and angioplasty was performed on the innominate vein stent as well as the cephalic arch. Following angioplasty, a clot formed within the fistula. Open thrombectomies of the AV fistula were performed. Repeat fistulogram revealed inadequate flow through the innominate vein stent. A stent graft was then positioned, overlapping the previously placed innominate vein stent and extending up into the cephalic arch. Following placement of the stent graft, excellent flow was achieved through the central veins into the right atrium and completely resolved the cephalic arch stenosis. What is the correct root operation for the placement of the stent graft within the innominate vein stent, Revision or Dilation? How is the body part value determined for the thrombectomy portion of the procedure? Surgeons rarely identify vein or an artery. Additionally, since an AV fistula is a direct anastomosis, is it considered a device in ICD-10-PCS terms?
Assign the following procedure codes:
05733DZ Dilation of right innominate vein with intraluminal device, percutaneous approach, for the balloon angioplasty and stent in the innominate vein;
03C70ZZ Extirpation of matter from right brachial artery, open approach; and
05CD0ZZ Extirpation of matter from right cephalic vein, open approach, for the open thrombectomies of the two sides of the AV fistula.
In this case, the original brachiocephalic fistula was formed by a direct anastomosis between the patient’s brachial artery and cephalic vein. When the original bypass procedure to create an AV fistula uses a direct anastomosis between a native artery and vein to form the arterial and venous limbs of the fistula, then the site of the procedure does not include any material that is classified as a device in ICD-10-PCS. The previously placed stent in the innominate vein is not part of the AV fistula, and in this case, the root operation Dilation is more accurate than Revision, because in the operative report the surgeon noted “significant edge stenosis at the peripheral edge of the stent” and the new stent graft was “positioned overlapping with the innominate vein stent and extending up into the cephalic arch.”