Jane5711
Networker
I'm just getting back into cardiology coding and need some guidance on the below procedure. I'm thinking 36223-50 but unsure whether to code the 75625. Any guidance/help would be appreciated. TIA 
TECHNIQUE: Vascular access obtained with micropuncture kit, and modified Seldinger technique to the right common femoral artery, and 5 French sheath introduced. We encountered difficulty crossing with the wire into the distal aorta, for that reason the HH 1 catheter was placed to the distal aorta, and angiogram obtained in AP projection with manual injection of 7 cc of contrast. Then with the use of 150 cm angled Glidewire 5French HH1 catheter was used for selective engagement of ostium right common carotid artery, ostial left common carotid artery, orthogonal views were used for cervical carotid angiogram, lateral and Towne's views were used for intracranial carotid angiogram. Manual management of access site was provided. Patient received heparin 2000 units IV upon sheath insertion to prevent thrombotic complications. Under my direct supervision, intravenous moderate sedation was administered during the course of this procedure, with continuous monitoring of hemodynamic parameters. Total time of sedation was 33 minutes. The patient was given conscious sedation by a registered nurse with me in attendance. The agents used were fentanyl and Versed. There was continuous monitoring of EKG, blood pressure and pulse oximetry. Moderate sedation was achieved with Versed (0.5mg) and Fentanyl (25mcg). Monitoring of the patient's vital signs and respiratory status was provided by trained nursing staff during the entire course of the procedures and under my supervision and recoded in the patient’s medical record. Local anesthesia to the left groin with 2% lidocaine -15 cc. Blood loss was negligible, blood samples were not taken. There were no immediate complications.
Contrast use: Optiray 350 - 28mL. Fluoro time - 5.9 minutes HEMODYNAMICS: Aortic pressure was 200/90mm Hg. Labetalol 10 mg IV was given twice during the procedure, Hydralazine 10 mg IV was given, closing blood pressure was 150/80 mm Hg.
ABDOMINAL AORTOGRAM: There is distal abdominal aortic aneurysm with lumen measuring 3.8 cm, no evidence of extravasation, no obstructive plaque, There is 50% stenosis of the proximal right common iliac artery There is 60-70% stenosis of the proximal left common iliac artery
RIGHT CAROTID ANGIOGRAM, INCLUDING CRANIAL VIEWS: Common carotid artery is a large vessel, originated from innominate artery, it has no stenosis, but it is extremely tortuous vessel, making two 180 degree loops in its proximal and midportion. Internal carotid artery is a large vessel, which has significant 80-85% ostial stenosis, followed by 50% stenosis of entire proximal portion, the rest of the cervical internal carotid artery has no significant stenosis. Intracranial internal carotid artery has nonobstructive 40-50% stenosis, no aneurysm, and gives rise to medium-size patent right anterior cerebral artery, and mid cerebral artery. Mid cerebral artery has 40% stenosis in M2 portion, nonobstructive .Anterior communicating artery is patent. Venous phase is normal. External carotid artery is a large size patent vessel without significant stenosis.
LEFT CAROTID ANGIOGRAM, INCLUDING CRANIAL VIEWS: Common carotid artery is a large vessel, without significant stenosis. Internal carotid artery is status post carotid endarterectomy, and no evidence of restenosis. Intracranial internal carotid artery has mild luminal irregularities, but no evidence of stenosis, no aneurysm, and gives rise to medium-size patent left anterior cerebral artery, and mid cerebral artery. Mid cerebral artery has 50% M2 portion stenosis, nonobstructive.
Venous phase is normal. External carotid artery is a large size patent vessel without significant stenosis
.CONCLUSIONS:1. Severe stenosis of the ostial-proximal right internal carotid artery 80-85%, with severe tortuosity of proximal-mid right common carotid artery, precluding stent procedure from peripheral approach.2. Nonobstructive intracranial carotid disease.3. Recommend evaluation by vascular surgery for either carotid endarterectomy, or TCAR of the right carotid artery.4. Continue with aggressive medical management of hypertension.
TECHNIQUE: Vascular access obtained with micropuncture kit, and modified Seldinger technique to the right common femoral artery, and 5 French sheath introduced. We encountered difficulty crossing with the wire into the distal aorta, for that reason the HH 1 catheter was placed to the distal aorta, and angiogram obtained in AP projection with manual injection of 7 cc of contrast. Then with the use of 150 cm angled Glidewire 5French HH1 catheter was used for selective engagement of ostium right common carotid artery, ostial left common carotid artery, orthogonal views were used for cervical carotid angiogram, lateral and Towne's views were used for intracranial carotid angiogram. Manual management of access site was provided. Patient received heparin 2000 units IV upon sheath insertion to prevent thrombotic complications. Under my direct supervision, intravenous moderate sedation was administered during the course of this procedure, with continuous monitoring of hemodynamic parameters. Total time of sedation was 33 minutes. The patient was given conscious sedation by a registered nurse with me in attendance. The agents used were fentanyl and Versed. There was continuous monitoring of EKG, blood pressure and pulse oximetry. Moderate sedation was achieved with Versed (0.5mg) and Fentanyl (25mcg). Monitoring of the patient's vital signs and respiratory status was provided by trained nursing staff during the entire course of the procedures and under my supervision and recoded in the patient’s medical record. Local anesthesia to the left groin with 2% lidocaine -15 cc. Blood loss was negligible, blood samples were not taken. There were no immediate complications.
Contrast use: Optiray 350 - 28mL. Fluoro time - 5.9 minutes HEMODYNAMICS: Aortic pressure was 200/90mm Hg. Labetalol 10 mg IV was given twice during the procedure, Hydralazine 10 mg IV was given, closing blood pressure was 150/80 mm Hg.
ABDOMINAL AORTOGRAM: There is distal abdominal aortic aneurysm with lumen measuring 3.8 cm, no evidence of extravasation, no obstructive plaque, There is 50% stenosis of the proximal right common iliac artery There is 60-70% stenosis of the proximal left common iliac artery
RIGHT CAROTID ANGIOGRAM, INCLUDING CRANIAL VIEWS: Common carotid artery is a large vessel, originated from innominate artery, it has no stenosis, but it is extremely tortuous vessel, making two 180 degree loops in its proximal and midportion. Internal carotid artery is a large vessel, which has significant 80-85% ostial stenosis, followed by 50% stenosis of entire proximal portion, the rest of the cervical internal carotid artery has no significant stenosis. Intracranial internal carotid artery has nonobstructive 40-50% stenosis, no aneurysm, and gives rise to medium-size patent right anterior cerebral artery, and mid cerebral artery. Mid cerebral artery has 40% stenosis in M2 portion, nonobstructive .Anterior communicating artery is patent. Venous phase is normal. External carotid artery is a large size patent vessel without significant stenosis.
LEFT CAROTID ANGIOGRAM, INCLUDING CRANIAL VIEWS: Common carotid artery is a large vessel, without significant stenosis. Internal carotid artery is status post carotid endarterectomy, and no evidence of restenosis. Intracranial internal carotid artery has mild luminal irregularities, but no evidence of stenosis, no aneurysm, and gives rise to medium-size patent left anterior cerebral artery, and mid cerebral artery. Mid cerebral artery has 50% M2 portion stenosis, nonobstructive.
Venous phase is normal. External carotid artery is a large size patent vessel without significant stenosis
.CONCLUSIONS:1. Severe stenosis of the ostial-proximal right internal carotid artery 80-85%, with severe tortuosity of proximal-mid right common carotid artery, precluding stent procedure from peripheral approach.2. Nonobstructive intracranial carotid disease.3. Recommend evaluation by vascular surgery for either carotid endarterectomy, or TCAR of the right carotid artery.4. Continue with aggressive medical management of hypertension.