Hello All !!!
Can we code the below procedure with
CLINICAL INDICATION: Possible vasculitis with pacemaker precluding
performance of MRI. Recent possible right cerebral subacute infarction.
After obtaining informed consent, the patient was placed in the supine
position and the right groin prepped and draped in a sterile fashion.
The skin was anesthetized with 1% lidocaine. An 18 gauge single-wall
needle was used to access right groin/right common femoral artery. Using
Seldinger technique, a Fr vascular sheath was placed.
Via a 5 Fr sheath, a 5 Fr pigtail catheter was placed at the level of the
ascending thoracic aorta and a thoracic aortogram performed in the LAO
projection. This revealed normal origins to the great vessels. Minimal
narrowing was identified involving the left vertebral artery
approximately 5 cm distal to its origin, extending for a length of 1 cm.
The left vertebral artery appears slightly dominant to the right
Each of the cerebral arteries was selectively catheterized with a 5 Fr
Davis catheter. Digital subtraction arteriography in multiple projections
The patient tolerated the procedure well and there was no hematoma or
change in the distal vascular examination. The patient was transported
to her room in stable condition.
Thoracic aortogram as described above reveals normal origins to the great
vessels. There is minimal narrowing involving the left vertebral artery
which was likely injected and revealed only a minimal approximately 20%
smooth narrowing for a length of 1 cm.
The vessels have normal caliber without stenosis, acute cut-off, filling
defect, beading, or aneurysm.
Normal four vessel cerebral arteriogram.
Normal origins means 3 vessels arising from the aortic arch; the brachiocephalic, left common carotid and left subclavian. So...
all you really have documented is 36215 (X), and 75650 for the arch angiography and 75685 for the left vertebral angiography.
See comments in the above note for more specifics.
Danny L. Peoples