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  #1  
Old 07-16-2010, 05:08 AM
prabha prabha is offline
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Default brachial artery angioplasty

Kindly confirm my codes,

35475
36120
75962-26
75710-2659
Left Upper Extremity Arteriogram:
Clinical History: 77-year-old male with end-stage renal disease on
hemodialysis with a left upper extremity brachiocephalic
hemodialysis AV fistula with steal syndrome status post AV
fistulagraphy and left upper extremity arteriography demonstrating
stenoses within the axillary artery and the brachial artery just
beyond the AV anastomosis with percutaneous angioplasty of the
axillary artery stenosis on 06/28/2010.
patient presents for left upper extremity arteriography
and percutaneous angioplasty of the brachial artery stenosis.

Procedure and Findings:
The left upper extremity was prepped and draped in the usual
sterile fashion. After the administration of local anesthesia and
under ultrasound guidance, access into the mid upper arm brachial
artery was obtained with a 21-gauge micropuncture set in a
retrograde fashion. A Bentson wire was advanced through the
transition dilator which was exchanged for a 4-French vascular
sheath.

A 4-French Berenstein catheter was then advanced over the wire and
position within the brachial artery just central to the AV
anastomosis of the brachiocephalic AV fistula. A gentle injection
of contrast was then performed confirming good positioning of the
catheter just central to the AV anastomosis and demonstrating the
brachial artery distal to the AV anastomosis.

A straight glide wire was advanced through the Berenstein catheter
and the catheter and Glidewire were used to gently cross the known
high grade stenosis within the mid brachial artery just beyond the
level of the AV anastomosis. A gentle injection of contrast
confirmed good positioning of the distal tip of the catheter
within the distal brachial artery beyond the AV anastomosis and a
focal stenosis.

An 014 wire was advanced through the catheter and down the ulnar
artery.

A pullback arteriogram with compression of the AV fistula outflow
vein was then performed which demonstrated the focal high-grade
stenosis of the mid brachial artery just distal to the AV
anastomosis. The Berenstein catheter was then readvanced over the
wire and positioned within the distal brachial artery.

A distal left upper extremity arteriogram, utilizing digital
subtraction angiography, was then performed.
This demonstrated a focal, a mild, stenosis within the distal
brachial artery likely related to spasm. The distal brachial
artery was otherwise widely patent. The inter-osseous artery was
widely patent. The ulnar artery was widely patent to the level of
the wrist. The radial artery was not identified. The deep and
superficial palmar arch were widely patent. The metacarpal
digital arteries, the common digital arteries, the proper digital
arteries, the radialis indicis artery appeared widely patent. The
princeps pollicis artery was not identified.

The indwelling Berenstein catheter was then removed over the 014
wire. 30 mg of intra-arterial papaverine and 1 mL of normal
saline was then administered via the indwelling sheath.

Serial dilatation of the focal, high-grade, stenosis within the
mid brachial artery was then performed with a 4 mm x 4 cm
angioplasty balloon.

The angioplasty balloon was then exchanged for the 4-French
Berenstein catheter which was positioned within the brachial
artery just central to the AV anastomosis.

A post intervention left upper extremity arteriogram, utilizing
digital angiography, was then performed via the indwelling
catheter. This demonstrated a good result with white luminal
patency of the mid brachial artery. A focal, moderate on the
stenosis in the distal brachial artery was identified likely
secondary to spasm.

The Berenstein catheter was then advanced beyond the AV
anastomosis into the mid brachial artery. An additional 30 mg of
intra-arterial papaverine in 1 mL of normal saline was
administered through the indwelling catheter. The indwelling
catheter was then removed.

Percutaneous submaximal balloon inflation angioplasty of the focal
area of spasm within the distal brachial artery was then performed
with a 4 mm x 4 cm angioplasty balloon. The angioplasty balloon
was then removed and exchanged for the Berenstein catheter which
was positioned within the brachial artery just central to the AV
anastomosis of the AV fistula.

A repeat left upper extremity arteriogram, with compression of the
outflow vein of the AV fistula, was then performed via the
indwelling catheter. This demonstrated a good result with white
luminal patency of the mid and distal brachial artery. The
angioplasty the focal high-grade stenosis within the mid brachial
artery just beyond the AV anastomosis appeared widely patent. The
focal area of spasm within the distal brachial artery appear
widely patent.

A final post-intervention left upper extremity arteriogram,
utilizing digital subtraction angiography, was then performed.

This demonstrated wide luminal patency of the mid and distal
brachial artery. A high origin the radial artery was identified
just central to the AV anastomosis and appear grossly patent. The
ulnar artery and interosseous artery appeared widely patent with
no filling defects identified to suggest distal embolization.

The deep and superficial palmar arches and the digital arteries of
the hand appeared widely patent with no filling defects to suggest
distal embolization. The princeps pollicis artery is now
identified and is widely patent. Reflux retrograde flow up the
widely patent radial artery is identified.

The catheter was then removed. After normalization of coagulation
parameters the sheath was removed and hemostasis was obtained with
direct manual compression.
Impression:
Left upper extremity arteriography demonstrating a focal
high-grade stenosis within the mid brachial artery just distal to
the AV anastomosis of the brachiocephalic fistula as described
above. High origin of the radial artery originating from the
brachial artery just central to the AV fistula AV anastomosis as
described above.

Successful treatment of the above described brachial artery
stenosis with percutaneous angioplasty up to 4 mm as described
above.
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Prabha CPC
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  #2  
Old 07-29-2010, 04:08 AM
HNISHA HNISHA is offline
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Default

I would prefer the same set of codes....

Thanks,
Abdul Saleem CPC
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  #3  
Old 07-29-2010, 07:58 AM
dpeoples dpeoples is offline
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Default

Quote:
Originally Posted by prabha View Post
Kindly confirm my codes,

35475
36120
75962-26
75710-2659
Left Upper Extremity Arteriogram:
Clinical History: 77-year-old male with end-stage renal disease on
hemodialysis with a left upper extremity brachiocephalic
hemodialysis AV fistula with steal syndrome status post AV
fistulagraphy and left upper extremity arteriography demonstrating
stenoses within the axillary artery and the brachial artery just
beyond the AV anastomosis with percutaneous angioplasty of the
axillary artery stenosis on 06/28/2010.
patient presents for left upper extremity arteriography
and percutaneous angioplasty of the brachial artery stenosis.

Procedure and Findings:
The left upper extremity was prepped and draped in the usual
sterile fashion. After the administration of local anesthesia and
under ultrasound guidance, access into the mid upper arm brachial
artery was obtained with a 21-gauge micropuncture set in a
retrograde fashion. A Bentson wire was advanced through the
transition dilator which was exchanged for a 4-French vascular
sheath.

A 4-French Berenstein catheter was then advanced over the wire and
position within the brachial artery just central to the AV
anastomosis of the brachiocephalic AV fistula. A gentle injection
of contrast was then performed confirming good positioning of the
catheter just central to the AV anastomosis and demonstrating the
brachial artery distal to the AV anastomosis.

A straight glide wire was advanced through the Berenstein catheter
and the catheter and Glidewire were used to gently cross the known
high grade stenosis within the mid brachial artery just beyond the
level of the AV anastomosis. A gentle injection of contrast
confirmed good positioning of the distal tip of the catheter
within the distal brachial artery beyond the AV anastomosis and a
focal stenosis.

An 014 wire was advanced through the catheter and down the ulnar
artery.

A pullback arteriogram with compression of the AV fistula outflow
vein was then performed which demonstrated the focal high-grade
stenosis of the mid brachial artery just distal to the AV
anastomosis. The Berenstein catheter was then readvanced over the
wire and positioned within the distal brachial artery.

A distal left upper extremity arteriogram, utilizing digital
subtraction angiography, was then performed.
This demonstrated a focal, a mild, stenosis within the distal
brachial artery likely related to spasm. The distal brachial
artery was otherwise widely patent. The inter-osseous artery was
widely patent. The ulnar artery was widely patent to the level of
the wrist. The radial artery was not identified. The deep and
superficial palmar arch were widely patent. The metacarpal
digital arteries, the common digital arteries, the proper digital
arteries, the radialis indicis artery appeared widely patent. The
princeps pollicis artery was not identified.

The indwelling Berenstein catheter was then removed over the 014
wire. 30 mg of intra-arterial papaverine and 1 mL of normal
saline was then administered via the indwelling sheath.

Serial dilatation of the focal, high-grade, stenosis within the
mid brachial artery was then performed with a 4 mm x 4 cm
angioplasty balloon.

The angioplasty balloon was then exchanged for the 4-French
Berenstein catheter which was positioned within the brachial
artery just central to the AV anastomosis.

A post intervention left upper extremity arteriogram, utilizing
digital angiography, was then performed via the indwelling
catheter. This demonstrated a good result with white luminal
patency of the mid brachial artery. A focal, moderate on the
stenosis in the distal brachial artery was identified likely
secondary to spasm.

The Berenstein catheter was then advanced beyond the AV
anastomosis into the mid brachial artery. An additional 30 mg of
intra-arterial papaverine in 1 mL of normal saline was
administered through the indwelling catheter. The indwelling
catheter was then removed.

Percutaneous submaximal balloon inflation angioplasty of the focal
area of spasm within the distal brachial artery was then performed
with a 4 mm x 4 cm angioplasty balloon. The angioplasty balloon
was then removed and exchanged for the Berenstein catheter which
was positioned within the brachial artery just central to the AV
anastomosis of the AV fistula.

A repeat left upper extremity arteriogram, with compression of the
outflow vein of the AV fistula, was then performed via the
indwelling catheter. This demonstrated a good result with white
luminal patency of the mid and distal brachial artery. The
angioplasty the focal high-grade stenosis within the mid brachial
artery just beyond the AV anastomosis appeared widely patent. The
focal area of spasm within the distal brachial artery appear
widely patent.

A final post-intervention left upper extremity arteriogram,
utilizing digital subtraction angiography, was then performed.

This demonstrated wide luminal patency of the mid and distal
brachial artery. A high origin the radial artery was identified
just central to the AV anastomosis and appear grossly patent. The
ulnar artery and interosseous artery appeared widely patent with
no filling defects identified to suggest distal embolization.

The deep and superficial palmar arches and the digital arteries of
the hand appeared widely patent with no filling defects to suggest
distal embolization. The princeps pollicis artery is now
identified and is widely patent. Reflux retrograde flow up the
widely patent radial artery is identified.

The catheter was then removed. After normalization of coagulation
parameters the sheath was removed and hemostasis was obtained with
direct manual compression.
Impression:
Left upper extremity arteriography demonstrating a focal
high-grade stenosis within the mid brachial artery just distal to
the AV anastomosis of the brachiocephalic fistula as described
above. High origin of the radial artery originating from the
brachial artery just central to the AV fistula AV anastomosis as
described above.

Successful treatment of the above described brachial artery
stenosis with percutaneous angioplasty up to 4 mm as described
above.
IMO, this is an AV fistulogram with angioplasty. I would code:
35475/75962
36147

HTH
__________________
Danny L. Peoples
CIRCC,CPC
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