Bilateral Arteriogram

amym

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I need HELP! coding this!

PROTOCOL: The patient underwent chemistry evaluation, which revealed a
creatinine of 4.2. Two weeks ago when the patient was admitted his
creatinine was 3.7, which was treated to a lower level of 2.0 upon
discharge on July 1, 2011. Now his creatinine is back up to 4.2. Give
the need for the procedure we went ahead and proceeded with the
procedure after discussion with Dr. Bhamani.

Based on these findings the patient underwent selective imaging without
the use of bolus chase method and total contrast used was 31 mL of
Visipaque. The access was obtained via right femoral artery with single
stick and subsequently J-wire was advanced and 5-French OmniFlush
catheter was advanced into the left iliac artery using exchange
glidewire and the catheter tip was placed at the level of the common
femoral artery. Imaging was obtained at the external iliac artery and
imaging was obtained with selective small contrast injections. The
entire extremity on the left side was imaged and on the right side
imaging of the iliac vessel, femoral, and trifurcation was performed.
No complications occurred. A probe light was used for cautery device
and the patient was sent to the recovery room.

FINDINGS:
1. The left lower extremity was visualized well and demonstrates the
external iliac artery shows mild disease.
2. The left common femoral artery is patent with mild to moderate
plaque.
3. The left common femoral artery/superficial femoral artery stent is
widely patent. This is an IDEV stent with excellent flow through it.
4. The mid superficial femoral artery percutaneous transluminal
angioplasty site is widely patent with less than 40% narrowing.
5. The distal superficial femoral artery/popliteal percutaneous
transluminal angioplasty site is widely patent. This used to be a
chronic occlusion, but excellent flow is noted through this vessel and
flow into the popliteal artery is well preserved.
6. The trifurcation shows occlusion of the anterior tibial artery, which
is chronic.
7. The 50% disease noted in the posterior tibial take off and the
peroneal artery is a large vessel, which goes all the way to the distal
foot above the ankle. There is three vessel runoff in the foot with
posterior tibial/anterior tibial reconstituting above the ankle and the
peroneal artery.
8. The right lower extremity was visualized only in the iliac and
femoral vessels and appears to be intact. There appears to be total
occlusion of the distal superficial femoral artery, which is chronic and
the trifurcation is diseased as previously reported.

Based on these findings the patient has adequate flow and the previous
stent and percutaneous transluminal angioplasty sites are widely patent.
Therefore, the patient will continue with wound care as previously and
followup with his podiatrist. In addition, he will followup with his
renal physician tomorrow for further recheck and evaluation. The
patient is advised to continue to encourage fluid PO intake.
 

dpeoples

True Blue
Messages
889
Location
Birmingham, Alabama
Best answers
0
I need HELP! coding this!

PROTOCOL: The patient underwent chemistry evaluation, which revealed a
creatinine of 4.2. Two weeks ago when the patient was admitted his
creatinine was 3.7, which was treated to a lower level of 2.0 upon
discharge on July 1, 2011. Now his creatinine is back up to 4.2. Give
the need for the procedure we went ahead and proceeded with the
procedure after discussion with Dr. Bhamani.

Based on these findings the patient underwent selective imaging without
the use of bolus chase method and total contrast used was 31 mL of
Visipaque. The access was obtained via right femoral artery with single
stick and subsequently J-wire was advanced and 5-French OmniFlush
catheter was advanced into the left iliac artery using exchange
glidewire and the catheter tip was placed at the level of the common
femoral artery. Imaging was obtained at the external iliac artery and
imaging was obtained with selective small contrast injections. The
entire extremity on the left side was imaged and on the right side
imaging of the iliac vessel, femoral, and trifurcation was performed.
No complications occurred. A probe light was used for cautery device
and the patient was sent to the recovery room.

FINDINGS:
1. The left lower extremity was visualized well and demonstrates the
external iliac artery shows mild disease.
2. The left common femoral artery is patent with mild to moderate
plaque.
3. The left common femoral artery/superficial femoral artery stent is
widely patent. This is an IDEV stent with excellent flow through it.
4. The mid superficial femoral artery percutaneous transluminal
angioplasty site is widely patent with less than 40% narrowing.
5. The distal superficial femoral artery/popliteal percutaneous
transluminal angioplasty site is widely patent. This used to be a
chronic occlusion, but excellent flow is noted through this vessel and
flow into the popliteal artery is well preserved.
6. The trifurcation shows occlusion of the anterior tibial artery, which
is chronic.
7. The 50% disease noted in the posterior tibial take off and the
peroneal artery is a large vessel, which goes all the way to the distal
foot above the ankle. There is three vessel runoff in the foot with
posterior tibial/anterior tibial reconstituting above the ankle and the
peroneal artery.
8. The right lower extremity was visualized only in the iliac and
femoral vessels and appears to be intact. There appears to be total
occlusion of the distal superficial femoral artery, which is chronic and
the trifurcation is diseased as previously reported.

Based on these findings the patient has adequate flow and the previous
stent and percutaneous transluminal angioplasty sites are widely patent.
Therefore, the patient will continue with wound care as previously and
followup with his podiatrist. In addition, he will followup with his
renal physician tomorrow for further recheck and evaluation. The
patient is advised to continue to encourage fluid PO intake.
I see:
36245
75716

HTH :)
 
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