Looking for advise. Has anybody found a circumstance in which they would bill 36224-50, 36226-50, 75716-26? Have providers who insist that 75716-26 should be billed for every diagnostic angiogram. Please see below note;
DIAGNOSTIC CEREBRAL ANGIOGRAM
DATE OF SERVICE: August 12, 2022
PREPROCEDURE DIAGNOSIS: Basilar stenosis, ACom aneurysm
POSTPROCEDURE DIAGNOSIS: See below
OPERATOR:
CLINICAL INDICATION: 71yo male hx renal CA post kidney transplant with flow limiting basilar stenosis and left filling ACom
aneurysm. The patient underwent treatment of the left ACom aneurysm Feb 2022 with Surpass Evolve flow diverter. The
patient now presents for routine follow up cerebral angiography.
ANESTHESIA: Local only
ARTERIAL ACCESS SITE: Right femoral artery
SUPPLIES:
5-French JB-1 glide catheter
5-French Simmons 2 glide catheter
0.035 glidewire
5F Mynx Device
MEDICATIONS: 1% Lidocaine.
CONSENT:
The technical aspects of the procedure as well as its potential risks, benefits, and alternatives were reviewed with the patient.
These risks include but were not limited to allergic reaction, damage to organs/vital structures, non-diagnostic procedure,
stroke, intracranial hemorrhage, aneurysm rupture, worsening neurological symptoms, vascular damage, possible emergent
vascular surgery, groin hematoma, infection, radiation injury, and the catastrophic outcomes of heart attack, coma, and
death. All questions raised by the patient and family were addressed. With an understanding of these risks, informed
consent was obtained from patient, which was placed in the patient's chart.
APPROACH:
After obtaining an informed consent, the patient was brought to the AngioSuite and placed on the angiography table in the
supine position. At this point the Timeout protocol was undertaken to conform the patient identification, indication and
side/site of the procedure. The groin areas were prepped and draped in the usual sterile fashion.
The procedure was performed under local anesthesia and monitored by the in-suite nurse and Dr. Lin.
The right common femoral artery was accessed with a micropuncture needle. A 5 French 10 cm vascular sheath was placed
into the right common femoral artery over a guidewire utilizing Seldinger technique.
HEPARIN: 1000 units total.
CONTRAST: Isovue 300, total of 45 cc
FLUOROSCOPY TIME: 6.4 combined AP and lateral minutes.
RADIATION DOSE: 393 mGy
VESSELS CATHETERIZED:
Right femoral artery
Right common carotid artery
Right internal carotid artery
Right subclavian artery
Right vertebral artery
Left common carotid artery
Left internal carotid artery
Left subclavian artery
Left vertebral artery
ANGIOGRAM PERFORMED:
Right common carotid artery angiogram - cervical view: AP and lateral
Right internal carotid artery angiogram - cerebral view: AP, lateral, obliques
Right upper extremity angiogram: AP
Right vertebral artery angiogram - cervical and cerebral view: AP, lateral
Left common carotid artery angiogram - cervical view: AP and lateral
Left internal carotid artery angiogram - cerebral view: AP, lateral, obliques
Left upper extremity angiogram: AP
Left vertebral artery angiogram - cerebral view: AP, lateral
VESSELS TREATED: None, except for 5F Mynx device deployment on the common femoral artery.
PROCEDURAL NARRATIVE:
Under fluoroscopic guidance a 5 French JB-1 diagnostic catheter was then navigated over a 0.035 glidewire into the aortic
arch followed by innominate and right common carotid artery. Cervical angiography was performed. Under direct fluoroscopic
guidance, the right internal carotid artery was then selected and cerebral angiography was performed. The catheter was then
withdrawn into the innominate artery and the right subclavian artery was selected. Right upper extremity angiogram was
performed. The catheter was then withdrawn into the aortic arch and the left common carotid artery was selected. Cervical
angiography was performed. Under direct fluoroscopic guidance, the left internal carotid artery was then selected and
cerebral angiography was performed. The catheter was then withdrawn into the aortic arch and the left subclavian artery was
selected. The left upper extremity angiogram was performed. The left vertebral artery was then selected and cerebral
angiography was performed.
After the above diagnostic angiography, the catheter was completely withdrawn from the arterial system without incident, and
decision was made to complete the procedure.
INTERPRETATION:
Right common carotid: cervical:
The carotid bifurcation is unremarkable. The post bifurcation internal carotid artery diameter measures approximately 5-6mm.
There is no significant stenosis, occlusion, aneurysm or plaque visualized on this injection.
Right internal carotid: cerebral:
Injection reveals the presence of a widely patent ICA, M1 segments and their branches. There is no significant stenosis,
occlusion, aneurysm or high flow vascular malformation visualized. The parenchymal and venous phases are normal. The
venous sinuses are widely patent.
Right upper extremity: Normal subclavian vessel. Right vertebral artery occlusion at the origin.
Right vertebral: cervical and cerebral
Right vertebral artery fills retrograde via left vertebral artery without evidence of significant stenosis.
Left common carotid: cervical:
The carotid bifurcation is unremarkable. The post bifurcation internal carotid artery diameter measures approximately 5-6mm.
There is no significant stenosis, occlusion, aneurysm or plaque visualized on this injection.
Left internal carotid: cerebral:
Injection reveals the presence of a widely patent ICA, A1, and M1 segments and their branches. Large left PCom with
opacification of the basilar apex and bilateral PCAs. There is brisk filling across the ACom with opacification of the
contralateral ACA territory. Persistent filling and stable appearance of left A1-2 medially directing 3mm wide-neck aneurysm
post treatment with Surpass Evolve flow diverter Feb 2022. The device is widely patent without evidence of in-stent stenosis.
There is no significant stenosis, occlusion, or high flow vascular malformation visualized. The parenchymal and venous
phases are normal. The venous sinuses are widely patent.
Left upper extremity: Normal subclavian vessel. Left vertebral artery not visualized secondary to aortic arch origin.
Left vertebral: cerebral:
Injection reveals the presence of a widely patent left vertebral artery. There is retrograde filling into the right vertebral artery.
There is flow limiting severe stenosis of the mid basilar artery without filling of the basilar apex.
DISPOSITION:
Upon completion of the study, the vascular sheath was removed and 5F Mynx was applied to obtain complete hemostasis.
Good proximal and distal lower extremity pulses were documented upon achievement of hemostasis.
The patient was monitored by a designated radiology nurse and was hemodynamically stable throughout the procedure.
There was no neurological deficit identified after the procedure. The patient was brought back to the post-procedure unit in
stable condition.
DIAGNOSTIC CEREBRAL ANGIOGRAM
DATE OF SERVICE: August 12, 2022
PREPROCEDURE DIAGNOSIS: Basilar stenosis, ACom aneurysm
POSTPROCEDURE DIAGNOSIS: See below
OPERATOR:
CLINICAL INDICATION: 71yo male hx renal CA post kidney transplant with flow limiting basilar stenosis and left filling ACom
aneurysm. The patient underwent treatment of the left ACom aneurysm Feb 2022 with Surpass Evolve flow diverter. The
patient now presents for routine follow up cerebral angiography.
ANESTHESIA: Local only
ARTERIAL ACCESS SITE: Right femoral artery
SUPPLIES:
5-French JB-1 glide catheter
5-French Simmons 2 glide catheter
0.035 glidewire
5F Mynx Device
MEDICATIONS: 1% Lidocaine.
CONSENT:
The technical aspects of the procedure as well as its potential risks, benefits, and alternatives were reviewed with the patient.
These risks include but were not limited to allergic reaction, damage to organs/vital structures, non-diagnostic procedure,
stroke, intracranial hemorrhage, aneurysm rupture, worsening neurological symptoms, vascular damage, possible emergent
vascular surgery, groin hematoma, infection, radiation injury, and the catastrophic outcomes of heart attack, coma, and
death. All questions raised by the patient and family were addressed. With an understanding of these risks, informed
consent was obtained from patient, which was placed in the patient's chart.
APPROACH:
After obtaining an informed consent, the patient was brought to the AngioSuite and placed on the angiography table in the
supine position. At this point the Timeout protocol was undertaken to conform the patient identification, indication and
side/site of the procedure. The groin areas were prepped and draped in the usual sterile fashion.
The procedure was performed under local anesthesia and monitored by the in-suite nurse and Dr. Lin.
The right common femoral artery was accessed with a micropuncture needle. A 5 French 10 cm vascular sheath was placed
into the right common femoral artery over a guidewire utilizing Seldinger technique.
HEPARIN: 1000 units total.
CONTRAST: Isovue 300, total of 45 cc
FLUOROSCOPY TIME: 6.4 combined AP and lateral minutes.
RADIATION DOSE: 393 mGy
VESSELS CATHETERIZED:
Right femoral artery
Right common carotid artery
Right internal carotid artery
Right subclavian artery
Right vertebral artery
Left common carotid artery
Left internal carotid artery
Left subclavian artery
Left vertebral artery
ANGIOGRAM PERFORMED:
Right common carotid artery angiogram - cervical view: AP and lateral
Right internal carotid artery angiogram - cerebral view: AP, lateral, obliques
Right upper extremity angiogram: AP
Right vertebral artery angiogram - cervical and cerebral view: AP, lateral
Left common carotid artery angiogram - cervical view: AP and lateral
Left internal carotid artery angiogram - cerebral view: AP, lateral, obliques
Left upper extremity angiogram: AP
Left vertebral artery angiogram - cerebral view: AP, lateral
VESSELS TREATED: None, except for 5F Mynx device deployment on the common femoral artery.
PROCEDURAL NARRATIVE:
Under fluoroscopic guidance a 5 French JB-1 diagnostic catheter was then navigated over a 0.035 glidewire into the aortic
arch followed by innominate and right common carotid artery. Cervical angiography was performed. Under direct fluoroscopic
guidance, the right internal carotid artery was then selected and cerebral angiography was performed. The catheter was then
withdrawn into the innominate artery and the right subclavian artery was selected. Right upper extremity angiogram was
performed. The catheter was then withdrawn into the aortic arch and the left common carotid artery was selected. Cervical
angiography was performed. Under direct fluoroscopic guidance, the left internal carotid artery was then selected and
cerebral angiography was performed. The catheter was then withdrawn into the aortic arch and the left subclavian artery was
selected. The left upper extremity angiogram was performed. The left vertebral artery was then selected and cerebral
angiography was performed.
After the above diagnostic angiography, the catheter was completely withdrawn from the arterial system without incident, and
decision was made to complete the procedure.
INTERPRETATION:
Right common carotid: cervical:
The carotid bifurcation is unremarkable. The post bifurcation internal carotid artery diameter measures approximately 5-6mm.
There is no significant stenosis, occlusion, aneurysm or plaque visualized on this injection.
Right internal carotid: cerebral:
Injection reveals the presence of a widely patent ICA, M1 segments and their branches. There is no significant stenosis,
occlusion, aneurysm or high flow vascular malformation visualized. The parenchymal and venous phases are normal. The
venous sinuses are widely patent.
Right upper extremity: Normal subclavian vessel. Right vertebral artery occlusion at the origin.
Right vertebral: cervical and cerebral
Right vertebral artery fills retrograde via left vertebral artery without evidence of significant stenosis.
Left common carotid: cervical:
The carotid bifurcation is unremarkable. The post bifurcation internal carotid artery diameter measures approximately 5-6mm.
There is no significant stenosis, occlusion, aneurysm or plaque visualized on this injection.
Left internal carotid: cerebral:
Injection reveals the presence of a widely patent ICA, A1, and M1 segments and their branches. Large left PCom with
opacification of the basilar apex and bilateral PCAs. There is brisk filling across the ACom with opacification of the
contralateral ACA territory. Persistent filling and stable appearance of left A1-2 medially directing 3mm wide-neck aneurysm
post treatment with Surpass Evolve flow diverter Feb 2022. The device is widely patent without evidence of in-stent stenosis.
There is no significant stenosis, occlusion, or high flow vascular malformation visualized. The parenchymal and venous
phases are normal. The venous sinuses are widely patent.
Left upper extremity: Normal subclavian vessel. Left vertebral artery not visualized secondary to aortic arch origin.
Left vertebral: cerebral:
Injection reveals the presence of a widely patent left vertebral artery. There is retrograde filling into the right vertebral artery.
There is flow limiting severe stenosis of the mid basilar artery without filling of the basilar apex.
DISPOSITION:
Upon completion of the study, the vascular sheath was removed and 5F Mynx was applied to obtain complete hemostasis.
Good proximal and distal lower extremity pulses were documented upon achievement of hemostasis.
The patient was monitored by a designated radiology nurse and was hemodynamically stable throughout the procedure.
There was no neurological deficit identified after the procedure. The patient was brought back to the post-procedure unit in
stable condition.