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If you could help me confirm appropriate codes, my doctors seem to still be lacking in documentation and makes it very hard to code what I believe should be coded. Doctor marked that he did 36200 aorta, 36245 iliac placement, and 75625, and 75716. Below is the procedure as noted in chart. I feel because it doesn't state selective placement of iliac that maybe it would be 36200, 36140-59, 75625, 75716. Any help is appreciated:
[B]Procedure: The risks and alternatives of the procedures and conscious sedation were explained to the patient
and informed consent was obtained. The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile fashion. ASA rating of 2. Cardiac
catheterization performed electively. Coronary intervention performed electively. Peripheral catheterization
performed electively.
1. Right femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was
advanced over the wire into the vessel.
2. Left femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was
advanced over the wire into the vessel.
3. Left brachial artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a catheter
was advanced over the wire into the vessel.
4. Abdominal aortogram with Angio Extremity Bilateral Lower.[/B]
[B]Procedure: The risks and alternatives of the procedures and conscious sedation were explained to the patient
and informed consent was obtained. The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile fashion. ASA rating of 2. Cardiac
catheterization performed electively. Coronary intervention performed electively. Peripheral catheterization
performed electively.
1. Right femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was
advanced over the wire into the vessel.
2. Left femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was
advanced over the wire into the vessel.
3. Left brachial artery access. The puncture site was infiltrated with local anesthetic. The vessel was
accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a catheter
was advanced over the wire into the vessel.
4. Abdominal aortogram with Angio Extremity Bilateral Lower.[/B]