american academy of professional coders

American Academy of Professional American Academy of Professional Coders Coders New Haven Chapter MeetingNew Haven Chapter MeetingSeptember 17, 2009September 17, 2009

Jeffrey S. Pollak, M.D.Yale University School of MedicineVascular & Interventional Radiology

Vascular & Interventional RadiologyVascular & Interventional Radiology

• Minimally invasive, image-guided diagnostic and therapeutic procedures– fluoroscopy– ultrasound– CT– MRI (future)

• Compared to open procedures, typically– less pain– less risk– shorter recovery

Vascular & Interventional RadiologyVascular & Interventional Radiology

• Rapid growth

• Originated and based in diagnostic radiology but now expanded patient responsibilities– outpatient clinic– admission service still perform traditional service procedures

Vascular & Interventional RadiologyVascular & Interventional RadiologyThree Patient ScenariosThree Patient Scenarios

• Uterine fibroid disease– ICD-9: 218.9, uterine leiomyoma, unspecified– Procedure: Uterine fibroid embolization

• Hepatocellular carcinoma– ICD-9: 155.0, primary malign neoplasm of liver– Procedures: Chemoembolization & RFA

• Lower extremity varicose veins– ICD-9: 454.8, varicose veins of LEs with other

complications (edema, pain, swelling)– Procedures: Ablation and sclerotherapy

#1: Uterine Fibroid Disease (218.9), #1: Uterine Fibroid Disease (218.9), EmbolizationEmbolization

• 7/2008: 47 year old woman with hypertension and uterine fibroid disease who presented with heavy menstrual bleeding, discomfort, and urinary frequency

History of Present IllnessHistory of Present Illness

• Known fibroids for years, with heavy menstrual blding

• ~2004 D&C: helped ~2 y, then recurrent heavy bleeding

• Periods last 4-5 days, 1st day particularly heavy– this has persisted despite hysteroscopy & D&C

in 5/2008 Pathology: benign endocervical polyp &

fragment of leiomyoma

HPI (cont’d)HPI (cont’d)

• No intermenstrual bleeding & cycles regular

• Fatigue & told of anemia (takes iron pills)

• No significant menstrual cramps

• Other symptoms– RLQ discomfort (difficult to sleep on R side)– occasional bloating– urinary frequency (2-3 times per night)

• No perimenopausal symptoms – no hot flashes, night sweats, or mood swings.

HPI, cont’dHPI, cont’d

• MRI earlier on day of first visit– somewhat limited by motion artifact– enlarged uterus

17 x 10 x 12 cm (calculated volume 1068 ml)– innumerable fibroids

predominantly intramural but broad-based subserosal ones as large as 6 and 5 cm and submucosal ones up to 3.1 cm

all fibroids enhanced, few w central degeneration– neither ovary confidently identified– 2 cm cystic structure near the external cervical

os – probably a large nabothian cyst.

MRI

T2, coronal Post contrast, coronal

Past Medical HistoryPast Medical History

• Uterine fibroid disease

• Hypertension

• Prior borderline diabetes – resolved with dietary change & exercise

Other Medical HistoryOther Medical History

• Medications– diuretic daily (actual one given in real note)

• Allergies– Sulfa drugs – hives

• Social History– Work: (given in the real note)– Tobacco: None – Alcohol: Rare– Single


• Family History– Mother: 60s, healthy– Father: 60s, hypertension, treated prostate

cancer– Children: None– Other: hypertension, lupus

Review of SymptomsReview of Symptoms

• Constitutional: Appetite & energy level fine. Weight stable

• Cardiac: No chest pain or pressure

• Hypertension: Yes

• Respiratory: No dyspnea or asthma, wheezing, coughing.

• No claudication. No swelling. No varicose veins.

• Hem/lymph: No easy bleeding or bruising

• GI: No reflux/heart burn, diarrhea, constipation, ulcers, liver disease.

• Urinary: No dysuria

• Metabolic/endocrine: No diabetes or thyroid problems.

• Neurolog.: No headaches, strokes, seizures.

• Psych: No depression.

• Eyes: Wears glasses. No glaucoma or other problems.

• ENT: No hearing difficulty. No nosebleeds. No sinus pain.

• MSK: No arthritis.

• Skin: No growths or rashes.

• Reprod.: Pap smear 1/2008, D&C w neg path 5/2008, gravida/para history given in real note.

Physical ExaminationPhysical Examination

• GA: Healthy appearing woman in no acute distress.

• Vitals: P, BP, RR, Wgt all normal, actual values in real note.

• Neuro: Alert and oriented.

• HEENT: Sclerae anicteric. No thyroid masses or lymphadenopathy.

• Chest: Breathing comfortably. Clear to auscult.

Physical Examination, cont’dPhysical Examination, cont’d

• Back: No spinal or costovertebral angle tenderness.

• Heart: PMI within mid clavicular line. Regular rhythm and rate. No murmurs.

• Abdomen: Normal bowel sounds. Faintly felt mass arising from the pelvis, extending 15.5 cm above the pubic symphysis and 4.5 cm below the umbilicus. No tenderness.


• Extremities: No clubbing, cyanosis, or edema.

• Vascular Pulses: Femoral DP PT Radial Brachial

Right 2+ 2+ 1+ 2+ 2+

Left 2+ 2+ ± 2+ 2+

Impression/PlanImpression/Plan

• 47 yo woman w htn & uterine fibroid disease who has menorrhagia, lower abdominopelvic discomfort, occasional bloating, & urinary frequency. She has numerous fibroids that are predominantly viable on MRI & is a good candidate for embolotherapy. This treatment option was thoroughly reviewed with her and she is interested in proceeding.

• Plan – Uterine fibroid embolization– Laboratory values needed before this

BillingBilling

• 99203-25– E&M for initial outpatient office visit, level 3

• 72197– Pelvic MRI without and with contrast

Admission & ProcedureAdmission & Procedure11/200811/2008

• History, physical, laboratory values, and impression/plan

• Procedure– right common femoral artery puncture– infrarenal abdominal aortogram– left uterine artery selective catheterization &

embolization– right uterine artery selective catheterization &

embolization– final abdominal aortogram

Abdominal aortogram

Left uterine artery catheterization

SP left uterine artery embolization

Right uterine artery catheterization

SP right uterine artery embolization

Abdominal aortogram after bilateral UAE

Inpatient follow-upInpatient follow-up

• Discharged one day after procedure– hospital visit– prescriptions– discharge instructions – discharge dictation

BillingBilling

• 37210– Uterine fibroid embolization procedure

• 99238– Hospital discharge day management, 30 minutes

or less

First Follow-up VisitFirst Follow-up Visit12/200812/2008

• 6 weeks SP UFE

• History– summary of UFE procedure– post-procedure course

mild pain at home, did not need narcotics nocturnal discomfort for two weeks no fevers brown discharge off & on 3-4 weeks until period period: Started 9 days ago lasted ~8 days

just spotting during the last few dayslighter that prior periods but still with some clots

First Follow-up Visit, cont’dFirst Follow-up Visit, cont’d

– post-procedure course, cont’d bloating and discomfort resolved nighttime urinary frequency reduced from 2-3

times to only one time no hot flashes or night sweats returned to work 9 days after the procedure

• PMH, medications, allergies: no change


• Physical examination – directed– GA– Vitals– Abdomen: Faintly felt mass arising from the

pelvis, extending 12 cm above the pubic symphysis and 6.5 cm below the umbilicus. No tenderness.

– Extremities: Right groin clean, no hematoma. No change in 2+ right femoral and dorsalis pedis pulses and 1+ right posterior tibial pulse.


• Impression/Plan– tolerated uterine embolization procedure well – resolution of her bloating and discomfort– improvement in nighttime urinary frequency and

menorrhagia. Further improvement in the latter may yet be seen over the next month. She is pleased with her outcome so far.

– Plan: Follow-up in approximately 5 months: CBC, pelvic MRI, and office visit.


• The patient was seen by Drs. “trainee’s name” (Vasc/Interv Rad Fellow) & Pollak. I, Dr. Pollak, personally reviewed with the patient his/her medical history, performed a relevant physical examination, & reviewed the treatment plan.

BillingBilling

• 99212– E&M for established patient office visit, level 2

Second Follow-up VisitSecond Follow-up Visit6/2009 6/2009

• 7 months SP UFE

• History– further improvement in menorrhagia such that

periods are basically no longer heavy will bleed for 3 days and then spot for 4-5 days

– slight brown spotting for 1-2 d’s before periods– still gets up to urinate as much as 2 times per

night, although drinks fair amount water at night and on a diuretic

– cycles regular and has no perimenopausal symptoms

Second Follow-up Visit, cont’dSecond Follow-up Visit, cont’d

• History, cont’d– MRI

decreased uterine size to 11.5 x 8.1 x 8.9 cm, volume 414 ml compared to preembolization volume 1065 ml

innumerable fibroids, mostly intramural but some submucosal and subserosal

fibroids decreased in size and all but one no longer enhancedresidual partially viable one 2.5 cm anterior

subserosal fibroid, decreased from 4.2 cm

MRI

T2, coronal Post contrast, coronal



• Physical examination – directed– GA– Vitals– Abdomen: No mass palpable anymore. No

tenderness.


• Impression/Plan– excellent response to embolization – resolution

of all symptoms but some degree residual urinary frequency, which could have other causes. Her uterine volume has decreased by over 60% on MRI and nearly all her fibroids are infracted, with only one now smaller subserosal fibroid having partial viability. She is happy with her outcome. No routine further follow-up is needed.

BillingBilling

• 99212-25– E&M for established patient outpatient office

visit, level 2

• 72197– Pelvic MRI without and with contrast

#2: Hepatocellular Carcinoma #2: Hepatocellular Carcinoma (155.0), Chemoembolization & RFA(155.0), Chemoembolization & RFA

• 4/2007: 82 year old man with coronary artery disease, hypertension, diabetes, chronic renal insufficiency, respiratory insufficiency (restrictive and obstructive), and a medial left lobe hepatocellular carcinoma


• Cholecystectomy 2/2007 → abnormal liver → biopsy → hepatocellular carcinoma

• Past heavy ethanol use, stopped 15-20 y ago– possible cirrhosis

• Symptoms– occasional RUQ pain radiating to right back– prior weight loss, now stable & normal appetite– no fevers or sweats– lower extremity swelling 2-3 y, no abd swelling– no confusion


• LFTs normal

• AFP elevated, 70

• CT scan 2/2007– vague enhancing area

in mid liver– left adrenal mass,

prob myelolipoma– some perihepatic ascites


• MRI 3/2007– 4.1 x 3.7 cm arterial enhancing mass in mid

liver with rapid washout compatible with hepatocellular carcinoma


• Hepatocellular carcinoma

• Questionable cirrhosis – past alcohol use– hepatitis B immune– hepatitis C negative

• Coronary artery disease – infreq angina now– past MI, coronary art stent – details in real note

• Hypertension

• Diabetes

• Chronic renal insufficiency

PMH, cont’dPMH, cont’d

• Respiratory – restrict’v dis & obstr’v sleep apnea– home nasal oxygen (prob 3 liters/min) & BiPAP– additional details in real note

• Peripheral art disease – SP BPG 1980, 2003

• Left adrenal mass – benign myelolipoma

• Past GI ulcer

• Past orthopedic surgery – details in real note

• Left retinal hemorrhage & cataract surgery


• Medications – 17 prescription & OTC items– listed in real note

• Allergies – penicillin – swelling – hydrochlorothiazide – unknown react

• Social History– Work: Given in the real note.– Tobacco: Stopped ~1970 – Alcohol: Stopped 1980s/early 1990s, prev heavy– Married


• Family – parents, children, & other illnesses listed

• ROS– Constitutional: appetite fine, energy level

decreased, lost 10-15 lbs in past 2 y’s.– Cardiac: Infrequent episodes substernal pain – Hypertension: Yes– Respiratory: As above. Exertional dyspnea at 4

steps of stairs. He sleeps on 4 pillows– Urinary: Difficult flow– Easy bruising– 9 other items basically negative


• GA: Elderly, frail, chronically ill appearing man with tachypnea and significant respiratory exertion at rest but in no acute distress. He is not currently using his oxygen.

• Vitals: P, BP, RR, & Wgt listed

• Neuro: Alert and oriented. Mild tremor but no definite asterixis.

• HEENT: Sclerae anicteric. No thyroid masses or lymphadenopathy.


• Chest: Breathing comfortably. Clear to auscultation.

• Back: No spinal or costovertebral angle tenderness.

• Heart: PMI within mid clavicular line. Regular rhythm and rate except for rare ectopic beats. 1/6 systolic murmur.


• Abdomen: Slightly promin ven pattern. Healed R subcostal, vertical midline, & lower abdom paramedian scars & bilat groin scars. Normal bowel sounds. Soft. No masses or tenderness.

• Extremities: 2-3+ bilat pitting pretibial edema.

• Vascular Pulses: Femoral DP PT Radial Brachial

Right 2+ ± 2+ 2+ 2+

Left 2+ ± ± 2+ 2+

AdditionalAdditional

• Laboratory values– given in real note

• Limited liver ultrasound during the visit– hypoechoic mid liver mass, 5.2 x 3.7 x 4.5 cm

(tr, AP, CC). No ascites seen about the liver, in Morrison’s pouch, or in the pelvis.

– no recorded images

ImpressionImpression

• 82 yo man w coronary artery disease, htn, DM, chronic renal insufficiency, respiratory insufficiency (restrictive & obstructive), & a mid liver hepatocellular carcinoma.

• Size of liver lesion indicates that best treatment modality would be chemoembolization with possible adjunctive radiofrequency ablation. – liver reserve good, so should tolerate these well– major concern relates to his co-morbidities– this thoroughly reviewed w patient and his son

PlanPlan

• Chemoembolization followed one day later by radiofrequency ablation– cisplatin will not be used due to renal

insufficiency

• He will need a gated nuclear cardiac scan

• Periprocedural management– hydration, Benadryl, allopurinol, antibiotics

(Cipro, Flagyl), steroids, Zofran, Mucomyst.– he should bring his own BiPAP machine.

First visit, cont’dFirst visit, cont’d


BillingBilling

• 99204-GC– E&M for initial outpatient office visit, level 4

Admission & ProceduresAdmission & Procedures5/20075/2007

• History, physical, laboratory values, and impression/plan

Chemoembolization ProcedureChemoembolization Procedure

• R common fem art punct– mod sedation time: 2 hours

• Superior mesenteric artery angiogram– unremark, patent portal vns

• Celiac, then common hepatic art angiography– replaced LHA to LGA– mod large mid liver mass w

C staining in late art phase

Chemoembolization Procedure, Chemoembolization Procedure, cont’dcont’d

• Selective LHA off proper HA– supplied L side of tumor– chemoemb & postemb angio

• Select superior segmental RHA– supplied R side of tumor– chemoemb & postemb angio

• Select inferior segmental RHA– no tumor supply, not chemoemb

• Final proper HA angiogram• Performed with trainee, attending present

Radiofrequency Ablation ProcedureRadiofrequency Ablation Procedure1 day later1 day later

• Ultrasound: mixed echogenic lesion in mid liver

• Radiotherapeutics 4.0 cm RFA probe into lesion under ultrasound guidance– RF-generated thermal energy & device removed

• Final US – region ↑ed echog corresp treated zone

• Recorded US images obtained

• Moderate sedation time: 45 minutes

• Performed with trainee, attending present

Inpatient follow-upInpatient follow-up

• Discharged one day after RFA procedure– hospital visit– prescriptions– discharge instructions – discharge dictation

BillingBilling

• 37204– Transcatheter embolization

• 36245– Selective arterial catheter placement, each first

order abdominal, pelvic, or lower extremity

• 36247– Initial 3rd order or more selective abdom artery

• 36248 x 2– Additional 2nd, 3rd, order or greater abdom art

BillingBilling

• 75726 x 2– Angiography, visceral selective, radiolog S&I

• 75774 x 2– Angiography, selective, each additional vessel

after basic one, radiolog S&I

• 75894– Transcatheter therapy, embolization, rad S&I

• 75898– Angiography through exist cath, fu for emboliz

BillingBilling

• 96420– Chemotherapy intra-arterial push administration

• 99144– Moderate sedation, > 5 yo, 1st 30 minutes

• 99145– Moderate sedation each additional 15 minutes

BillingBilling

• 47382– Ablation, 1 or more liver tumor(s), percut, RF

• 76940– US guidance, parenchymal tissue ablation



BillingBilling

• 99238– Hospital discharge day management, 30 minutes

or less

First Follow-up VisitFirst Follow-up Visit6/20076/2007

• 6 weeks after HCC interventional therapies

• History– summary of procedures– post-procedure course

some decrease in appetite after procedures, resolved

no change in chronic RUQ pain or respiratory-related limitations

– AFP ↓ to normal range, 4.48 (previously 70)– CT (not MRI given CRI. Mucomyst &

bicarbonate hydration used)

CT 6/2007

5.3 x 3.7 mid liver mass with dense chemoembolic material

within it that did not enhance. No other lesions seen.



• Physical examination– GA, vitals, neuro, HEENT, abdomen,

extremities, directed vascular in real note (all unchanged)

• Laboratory values– given in real note


• Impression/Plan– tolerated interventional procedures for mid liver

hepatocellular carcinoma quite well. Alpha fetoprotein level normalized & today’s CT scan showed no evidence for viable tumor

– cause of RUQ pain not clear & he has been placed on narcotics for this.

– continued morbidity from other med problems– Plan: Follow-up visit in 3 months, with three-

phase liver CT scan (using Mucomyst and bicarbonate hydration) and laboratory values

BillingBilling

• 99212-25– E&M for established patient outpatient office

visit, level 2

• 74170– CT abdomen without and with contrast

Second Follow-up VisitSecond Follow-up Visit10/200710/2007

• 4 months after HCC interventional therapies

• History– increase in strength over the past few months– appears to have been given epoetin for anemia– wearing compression stockings for leg swelling,

with improvement– AFP remains normal– CT (with Mucomyst & bircarbonate hydration)

↓ size mid liver mass with no enhancement 2 small foci art enhance in dome nonspecific

follow-up recommended.


• PMH: no change

• Physical examination – GA, vitals, neuro, HEENT, abd, extremities in real note, all unchang

• Laboratory values – given in real note

• Impression/Plan– no evidence of viable HCC now over 4 months

after treatment. Cont’d surveillance is indicated.– Plan: FU visit in 3 months, w 3-phase liver CT

(Mucomyst & bicarb hydration) & lab values

BillingBilling

• 99212-25-GC– E&M for established patient outpatient office

visit, level 2

• 74170– CT abdomen without and with contrast

Further Follow-upFurther Follow-up

• Additional visits performed every 3-6 months

#3: Lower Extremity Varicose Veins #3: Lower Extremity Varicose Veins (454.8), Ablation & Sclerotherapy(454.8), Ablation & Sclerotherapy

• 7/2007: 40 year old woman with right worse than left lower extremity varicose veins.


• Noticed LE vv during 1st pregnancy, 13 years ago, which have progressively worsened.

• Largest & most symptomatic varices located in lower R posteromedial thigh and leg

• Pain – 8/10 R side, 7/10 over L post leg vv

• Other symptoms– bilat: aching, throbbing, easy tiredness,

heaviness– R LE: warmth, occ itching & nocturnal cramps


• Symptoms worse with prolonged standing and before periods

• No swelling or history of phlebitis, bleding ulceration, or DVT

• Wore compression stocking for ~3 months in 2005 and in 2006 with no help

• No other therapy for her varicose veins.


• R worse than L LE varicose veins.

• Multiple liver masses compatible with focal nodular hyperplasia

• Pneumonia in past

• Anemia in the past– treated with iron pills

• Arthritis


• Medications – ibuprofren or Tylenol as needed

• Allergies – none

• Social History– Work: (given in the real note)– Tobacco: None – Alcohol: Rare– Married

• Family – for parents & children, in real note

• ROS – over 12 items listed in real note


• GA: Healthy appear woman, no acute distress

• Vitals: P, BP, & RR listed

• Neuro: Alert and oriented.

• HEENT: Scler anict, no thyr masses or LAD

• Chest: Breathing comfortably. Clear.

• Back: No spinal or costovert angle tenderness.

• Heart: PMI within MCL. RRR. No murmurs.

• Abd: Norm bowel sounds, soft, no mass or tender


• Extremities– no clubbing, cyanosis, or edema– Right lower extremity

Moderate sized varicose veins in the medial lower thigh, zone 4, extending inferiorly across the knee and into the medial leg, with somewhat greater concentration in medial zone 7. Few varices in anterior leg. Few scattered reticular veins. No definite corona phlebectasia.


• Extremities (cont’d)– Lef lower extremity

Moderate sized varicose vein in posteromedial mid leg, zone 6.5, & smaller ones elsewhere in the leg. Few scattered reticular veins. No definite corona phlebectasia.

• Vascular Pulses: Femoral DP PT Radial Brachial Right 2+ 2+ 2+ 2+ 2+ Left 2+ 2+ 2+ 2+ 2+

Ultrasound During VisitUltrasound During Visit

• Grey scale and color flow Doppler performed of superficial venous systems of both lower extremities and limited views of deep venous systems at levels of groins and popliteal fossae. Augmentation used to help assess veins.

US: Right Lower ExtremityUS: Right Lower Extremity

• Variably enlarged, refluxing great saphenous vein from saphenofemoral junction to lower leg, zone 7, with significant tortuosity btween zones 6.5 & 7. Refluxing posterior tributaries in zone 6 & 7 and incompetent perforat in zone 7.

• Right small saphenous vein competent

• Right common femoral and popliteal veins widely patent, completely compressible, and nonrefluxing

US: Left Lower ExtremityUS: Left Lower Extremity

• Moderately enlarged refluxing great saphenous vein from the saphenofemoral junction to zone 5.5, where a posterior refluxing tributary was present.

• Left small saphenous vein competent

• Left common femoral and popliteal veins widely patent, completely compressible, and nonrefluxing

ImpressionImpression

• 40 yo woman w R > L LE varicose veins who has pain, aching, throbbing, easy tiredness, heaviness, & R sided warmth. R varices due to refluxing GSV from SFJ to zone 7 but w signif tortuosity btwn zone 6.5 & 7. Reflux post tribut’s in zones 6 & 7 and incompet perfor in zone 7. L varices from reflux GSV from SFJ to zone 5.5, where poster reflux tributary present.

• Ablation & sclerotherapy benefits, side effects, risks reviewed with patient

PlanPlan

• Patient will call when ready for treatment

• Right lower extremity to be treated first– R GSV ablation, SFJ to zone 6.5 (above tortuos)

& sclerother of it below that as well as of vv.

• L lower extremity to be treated afterwards– L GSV from SFJ to zone 5.5 and vv sclerother

• Sclero of resid vv may be needed during fu

• Graduated compress stockings in meantime– although this did not help her in the past

BillingBilling

• 99203-25– E&M for initial outpatient office visit, level 3

• 93970– Duplex scan of extremity veins, including

response to compression and other maneuvers, complete bilateral study

Second VisitSecond Visit7/20087/2008

• Continued symptoms from R worse than L LE varicose veins– no change in symptoms, again listed in real note– no help from compression stockings again, worn

after 7/2007 visit


• Physical examination– GA, vitals, chest heart, abdomen, extremities,

vascular in real note (all unchanged, including appearance of vv)

Second Visit, cont’dSecond Visit, cont’d

• Bilateral LE venous ultrasound (superficial veins, limited view of deep veins)– findings listed, with no change from first US

• Impression– continued R > L LE pain, aching, throbbing,

easy tiredness, heaviness, & right sided warmth– R varices due to refluxing, mod enlrg GSV from

SFJ to zone 7. Also, reflux posterior tributaries zone 6.5 & incompetent perforator in zone 7.

– L varices due to reflux mild & mod enlrg GSV from SFJ to zone 5.5, where post reflux tribut

Second Visit, cont’dSecond Visit, cont’d

• Plan– Right lower extremity treated first

ablation of right GSV from SFJ to zone 7 and sclerotherapy of varicose veins

– Left lower extremity to be treated afterwards ablation of left GSV from SFJ to zone 5.5 and

sclerotherapy of varicose veins– Supplementary sclerotherapy of residual

varicose veins may be needed during follow-up

BillingBilling

• 99213-25– E&M for established patient office visit, level 3


response to compression and other maneuvers, complete bilateral study

First Procedure (Outpatient)First Procedure (Outpatient)9/20089/2008

• R GSV puncture in lower leg– ultrasound guidance, recorded

• Laser fiber introduced, tip inferior to SFJ

• Tumescent anesthesia along length of GSV

• Laser ablation of GSV to near entry site

• Sclerotherapy of varicose veins– sodium tetradecyl sulfate formed into a foam– ultrasound guidance, 3 injections into varicose

veins in medial leg, with recorded US images

First Procedure, cont’dFirst Procedure, cont’d


• Performed with a trainee– attending present for entire procedure

BillingBilling

• 36478– Percut endoven laser ablat incompet extrem vn,,

inclusive all imaging guid & monitor, 1st vn Rx

• 36471– Injection of sclerosing solution, multiple veins,

same leg



Third VisitThird Visit10/200810/2008

• 1 month after R LE varicose vein treatment

• History– summary of procedure– developed pain & redness in upper medial R

thigh shortly afterwards & later in medial knee– required narcotics for short time for pain, now

resolved, except mild tenderness in medial knee– baseline R LE symptoms significantly improved– untreated L LE remains symptomatic


Third Visit, cont’dThird Visit, cont’d

• Physicial examination– GA, vitals– Extremities

R: Line of discolor in medial thigh & leg, over treated GSV, w some erythema in lower thigh & knee. GSV & prior vv in medial thigh (no longer visible) all firm. Mild tenderness over GSV in medial knee.

L: Persist mod vv’s post-med upper & mid leg & smaller ones elsewhere in leg. Few scattered reticular veins.

Third Visit, cont’dThird Visit, cont’d

• Right LE venous ultrasound (superficial veins, limited view of deep veins)– appropriately occluded R great saphenous vein

from zone 7 to near R saphenofemoral junction. Small portion patent at SFJ, but did not reflux.

– occluded varicose veins in medial right leg

• Impression/Plan– had R LE post-procedure pain, improved– R lower extremity baseline symptoms improved– appropriate occlusion of treated veins on US– ready for L LE treatment

BillingBilling



response to compression and other maneuvers, unilateral or limited study

Second Procedure (Outpatient)Second Procedure (Outpatient)10/200810/2008

• Left LE post tribut below knee punctured & catheter subsequently advanced into GSV– ultrasound guidance, recorded

• Laser system introduced, tip inferior to SFJ

• Tumescent anesth: GSV & upper post trib

• Laser ablation GSV & upper post tributary

• US-guided STS foam sclerother varicose vns– 3 injections given into vv in medial left leg– recorded US images

Second Procedure, cont’dSecond Procedure, cont’d


• Performed with a trainee– attending present for entire procedure

BillingBilling

• 36478– Percut endoven laser ablat incompet extrem vn,,

inclusive all imaging guid & monitor, 1st vn Rx

• 36471– Injection of sclerosing solution, multiple veins,

same leg



Fourth VisitFourth Visit12/200812/2008

• Returns 3 months SP treatment of right LE vv & 1.5 months after treatment of left side

• History– summary of procedures– initial symptoms of pain, easy tiredness, &

heaviness all resolved– after standing long time → mild pressure

sensation in legs over old varicose veins. – some numbness in medial lower R leg, related to

laser ablation

Fourth Visit, cont’dFourth Visit, cont’d

• Physical examination– GA, vitals– Extremities

R: Marked reduction in discoloration in medial thigh and leg over treated great saphenous vein. No residual varicose veins visible.

L: Resolution of varicose veins.

• Left LE superficial vn US (limited deep vns)– appropriately occluded L GSV from few mm

below SFJ inferiorly to below knee & occluded posterior tributary below knee & varicose veins

Fourth Visit, cont’dFourth Visit, cont’d

• Impression– resolution of baseline symptoms– quite happy with outcome– mild pressure sensation in legs after prolonged

standing may be related to occluded varicosities, which should continue to recede with time.

• Plan– Follow-up visit in 4-6 months

Fourth visit, cont’dFourth visit, cont’d


BillingBilling




Fifth VisitFifth Visit6/20096/2009

• Returns 9.5 months after treatment of right LE vv & 8 months after treatment of left side

• History– pain, easy tiredness, & heaviness all much better– will now only have pain along inside of both

knees if stands quite a long time– varicose veins are much improved visually

• Physical examination– GA, vitals– Extemities: No signif resid large vv bilaterally

Beforetreatment

Aftertreatment

Beforetreatment

Aftertreatment

Fifth Visit, cont’dFifth Visit, cont’d

• Bilat LE superficial vn US (limited deep vns)– Both GSVs appropriately occluded, not

visualized 1 cm below nonrefluxing SFJs– patent SSVs & CFVs & pop vns

• Impression/Plan– basically resolution of baseline symptoms &

lack of visible vv or ultrasound abnormalities– happy with outcome – no further specific follow-up is needed.

BillingBilling




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