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HELP! Carotid angio 1st order/2nd order

Best answers
Need major help coding this. I am not familiar with coding the carotid first and second orders. Can someone please help me?

Patient was referred for cardiac catheterization to assess the coronary anatomy . Indications for the procedure include: Recurrent chest pain suggestive of angina and abnormal CTA of coronaries suggesting severe Cx stenosis w occlusion of all SVG. S/p CABG several years ago.chest pain, and positive stress test. Pt also had suggestion of severe L ICA stenosis and is awaiting clearance for CEA. I recommended carotid angiography to assess the severity of the carotid stenosis.

Procedure Details
The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient and/or family concurred with the proposed plan, giving informed consent. Patient was brought to the cath lab after IV hydration was begun and oral premedication was given. Patient was further sedated with fentanyl and versed. Patient was prepped and draped in the usual manner. Using the modified Seldinger access technique, a 6 French sheath was placed in the femoral artery. A left heart catheterization was done. Right and Left Coronary Angiograms were also done. SVG and LIMA angiography were performed w JR4 catheter. Aortic arch angiograpgy was then performed followed by selective carotid and cerebral angiography using JB2 and VTK catheters (for Right and Left Carotids respectively).

Interventions: no Intervention.

After the procedure was completed, sedation was stopped and the sheaths and catheters were all removed. Hemostasis was achieved with Mynx.


Hemodynamics LVEDP= 20
Left Main Patent with no angiographically significant disease.
LAD Severe disease involving the mid LAD
RCA 100% mid vessel.
Circ Patent with no angiographically significant disease. Widely patent stent!
L-R collaterals
SVG(s) All occluded. (SVG to OM1, OM2 and RCA all occluded!
LIMA to distal LAD widely patent.
LV LV angiogram was done and revealed normal wall motion and normal contractility. Ejection fraction is more than 55%.
Aortic arch angio Type B aortic arch with L carotid taking off from the right innominate
Left Carotid Selective angiography--> <=60% stnosis of L ICA. Cerebral Angio: Patent cerebral vessels w no aneurysms or AV malformaton,
Right Carotid Selective angiography--> mild disease involving theo rigin of the right internal cartotid artery.Cerebral Angio: Patent cerebral vessels w no aneurysms or AV malformaton,

Vessel Dominance Right
Closure Device Mynx
Complications None

Estimated Blood Loss: less than 20 mL

Complications: None; patient tolerated the procedure well.

Disposition: PACU - hemodynamically stable

Condition: stable

Treatment: Continue current medical therapy and follow up in the office in one week. No indication for L CEA!


Best answers
Hello, please take a look at code 36223 since the catheter placement in both the right and left carotids was selective plus angiography was done. This code includes the intracranial (cerebral) carotid circulation, the extracranial carotid and cervicocerebral arch, when performed. Modifier 50 can be used since it was bilateral.

I hope this helps on the carotid portion of your procedure.

Jean Kayser CPC CIRCC