I'm barely getting use to this but I got so confused on this report... provider is capturing cath codes but not the stent, or am I missing something.. HELP someone please! Where should I be targeting first..
Codes:
36222
36225
37222
75710
75625
99152
76937
PROCEDURE PERFORMED:
1. Carotid angiography, selective.
2. Carotid stent placement with the 7.0 x 19 mm Omnilink Elite stent at nominal
atmospheres. Postdilated with 8.0 Evercross balloon up to 8 atmospheres.
3. Modifier 22 for complex case at the level of the common carotid artery.
4. Distal embolic protection device was not used given complexity of the
procedure with difficulty with maintaining a 0.014 inch wire in the carotid
artery. 5. Ultrasound for vascular access.
6. Supervision and interpretation of above.
INDICATION:
The patient is a 71-year-old Caucasian female, recent carotid angioplasty with
distal embolic protection, referred back for Omnilink stent placement in the
proximal left common carotid artery. Informed and witnessed signed consent
placed in the patient's medical record. The patient understood the risks,
benefits, and alternatives of the procedure including but not limited to
stroke, myocardial infarction, renal failure, bleeding, limb loss, and death,
and wished to proceed with procedure.
DESCRIPTION OF PROCEDURE:
The patient was brought to the cardiac catheterization laboratory in the
fasting state. The modified Seldinger technique micropuncture and ultrasound
for vascular access. A 6-French side-arm sheath successfully placed in right
femoral artery. I had used a Glidewire for advancement given the tortuosity
and calcification noted in the right iliac artery.
I was able to advance a JR4 initially with a Glidewire into the left common
carotid artery. However, there was some difficulty with maintaining the JR4 in
the ostial left common carotid artery. Therefore, the system was exchanged
out. The shuttle sheath had been placed already into the arch of the aorta
with the 6-French side-arm sheath removed.
With the same JR4, I was able to use the Advantage wire and was able to probe
into the left common carotid artery for better support.
Because the prior JR4 with the shuttle sheath was not able to stay in the left
common carotid artery due to tortuosity, even with a super core wire, I
realized that distal embolic protection device would not work with a 0.014 inch
system despite a bare metal wire that showed firmer support for the NAV6 distal
embolic protection device. Therefore, I proceeded with using roadmap feature
as well as direct stent placement with an Omnilink 7.0 x 19 mm stent using
roadmap feature, as well as measuring with the computer system for exact
specifications given the poststenotic dilatation. Balloon angioplasty last
time had improved flow.
The stent was deployed at nominal atmospheres and 8.0 Evercross Medtronic
Covidien balloon was used post at 8 atmospheres. The distal edge of the stent
into the carotid dilatation. Final angiography with and without wire done for
excellent flow. No evidence of edge dissection or distal thrombus in the MCA
or ACA arteries.
RESULTS:
1. Hemodynamics: Aortic pressure is 180/100 mmHg. Heart rate is 70 beats per
minute.
2. Carotid angiography: Carotid angiography demonstrates a 50% lesion post
balloon angioplasty last time.
3. Internal carotid artery otherwise has mild luminal irregularities.
4. Cerebral angiography: Cerebral angiography demonstrates widely patent
anterior cerebral artery and middle cerebral artery post procedure.
INTERVENTION:
Diameter of stenosis pre was 50%, post was 0%. Stent placed was Omnilink 7.0 x
19 mm up to nominal atmospheres. Postdilated with 8.0 Evercross balloon up to
8 atmospheres.
IMPRESSION:
Successful stent placement with a 7.0 x 19 mm Omnilink, postdilated with a 8.0
Evercross balloon up to 8 atmospheres.
RECOMMENDATIONS:
Continue aspirin and Plavix daily. The patient was given an additional 300 mg
Plavix despite being on Plavix, as well as aspirin 325 mg. She will continue
on aspirin 81 mg daily and Plavix 75 mg daily. We will watch her for the next
2 days given that this is a carotid stent procedure with neuro checks in the
next 24 hours as well. Sheath was sutured in place given that she has a 90%
lesion noted in the right common femoral artery as well.
Codes:
36222
36225
37222
75710
75625
99152
76937
PROCEDURE PERFORMED:
1. Carotid angiography, selective.
2. Carotid stent placement with the 7.0 x 19 mm Omnilink Elite stent at nominal
atmospheres. Postdilated with 8.0 Evercross balloon up to 8 atmospheres.
3. Modifier 22 for complex case at the level of the common carotid artery.
4. Distal embolic protection device was not used given complexity of the
procedure with difficulty with maintaining a 0.014 inch wire in the carotid
artery. 5. Ultrasound for vascular access.
6. Supervision and interpretation of above.
INDICATION:
The patient is a 71-year-old Caucasian female, recent carotid angioplasty with
distal embolic protection, referred back for Omnilink stent placement in the
proximal left common carotid artery. Informed and witnessed signed consent
placed in the patient's medical record. The patient understood the risks,
benefits, and alternatives of the procedure including but not limited to
stroke, myocardial infarction, renal failure, bleeding, limb loss, and death,
and wished to proceed with procedure.
DESCRIPTION OF PROCEDURE:
The patient was brought to the cardiac catheterization laboratory in the
fasting state. The modified Seldinger technique micropuncture and ultrasound
for vascular access. A 6-French side-arm sheath successfully placed in right
femoral artery. I had used a Glidewire for advancement given the tortuosity
and calcification noted in the right iliac artery.
I was able to advance a JR4 initially with a Glidewire into the left common
carotid artery. However, there was some difficulty with maintaining the JR4 in
the ostial left common carotid artery. Therefore, the system was exchanged
out. The shuttle sheath had been placed already into the arch of the aorta
with the 6-French side-arm sheath removed.
With the same JR4, I was able to use the Advantage wire and was able to probe
into the left common carotid artery for better support.
Because the prior JR4 with the shuttle sheath was not able to stay in the left
common carotid artery due to tortuosity, even with a super core wire, I
realized that distal embolic protection device would not work with a 0.014 inch
system despite a bare metal wire that showed firmer support for the NAV6 distal
embolic protection device. Therefore, I proceeded with using roadmap feature
as well as direct stent placement with an Omnilink 7.0 x 19 mm stent using
roadmap feature, as well as measuring with the computer system for exact
specifications given the poststenotic dilatation. Balloon angioplasty last
time had improved flow.
The stent was deployed at nominal atmospheres and 8.0 Evercross Medtronic
Covidien balloon was used post at 8 atmospheres. The distal edge of the stent
into the carotid dilatation. Final angiography with and without wire done for
excellent flow. No evidence of edge dissection or distal thrombus in the MCA
or ACA arteries.
RESULTS:
1. Hemodynamics: Aortic pressure is 180/100 mmHg. Heart rate is 70 beats per
minute.
2. Carotid angiography: Carotid angiography demonstrates a 50% lesion post
balloon angioplasty last time.
3. Internal carotid artery otherwise has mild luminal irregularities.
4. Cerebral angiography: Cerebral angiography demonstrates widely patent
anterior cerebral artery and middle cerebral artery post procedure.
INTERVENTION:
Diameter of stenosis pre was 50%, post was 0%. Stent placed was Omnilink 7.0 x
19 mm up to nominal atmospheres. Postdilated with 8.0 Evercross balloon up to
8 atmospheres.
IMPRESSION:
Successful stent placement with a 7.0 x 19 mm Omnilink, postdilated with a 8.0
Evercross balloon up to 8 atmospheres.
RECOMMENDATIONS:
Continue aspirin and Plavix daily. The patient was given an additional 300 mg
Plavix despite being on Plavix, as well as aspirin 325 mg. She will continue
on aspirin 81 mg daily and Plavix 75 mg daily. We will watch her for the next
2 days given that this is a carotid stent procedure with neuro checks in the
next 24 hours as well. Sheath was sutured in place given that she has a 90%
lesion noted in the right common femoral artery as well.