I've never coded a procedure. Any help would be appreciated.
OPERATION PERFORMED:
1. Aortogram with lower extremity bolus chase.
2. Angioplasty of right common iliac.
3. Stenting of right common iliac lesion.
REFERRING PHYSICIANS:
1. Dr.
2. Dr.
INDICATION FOR PROCEDURE:
Severe lifestyle-limiting claudication.
HISTORY:
A 58-year-old female with known coronary artery disease, hypertension, dyslipidemia, who presents with lifestyle-limiting bilateral lower extremity claudication. She had an ABI which showed 0.71 on the right lower extremity and 0.68 on the left lower extremity. Subsequent duplex showed possible bilateral aortoiliac disease and bilateral SFA occlusion with distal reconstitution at the popliteals. Given her lifestyle-limiting claudication, she was scheduled for angiogram of the lower extremity to further delineate her lower extremity arterial vasculature and consider for possible revascularization.
PROCEDURE NOTE:
Informed consent was obtained. Risks, benefits, alternatives, complications including, but not limited to, vascular injury, needing emergent surgery, limb loss, amputation, death were explained to patient and son in detail. They agreed to the procedure, understood the complications involved, and is willing to proceed.
Both groins were prepped and draped in the usual sterile fashion. Lidocaine 2% was used for local anesthesia. Next, using a modified Seldinger technique and a micropuncture needle, 4-French arterial sheath was inserted in the right common femoral artery. We then used a pigtail catheter to obtain aortogram and lower extremity bolus chase. We then proceeded to the intervention as outlined below.
At the end of the procedure, the wires and catheters were removed and hemostasis will be obtained with manual compression once ACT is acceptable.
Medications given during the procedure were Versed and fentanyl per protocol, 5000 of intravenous heparin. She will be loaded with Plavix. She is already on aspirin.
INTERVENTION REPORT:
1. Abdominal aorta had mild to moderate atherosclerosis.
2. The right common iliac had an eccentric 70% to 80% stenosis with greater than 35-mm gradient across the stenosis. The left common iliac had mild irregularities.
3. The bilateral external iliacs had mild disease. The internal iliacs were patent.
4. Bilateral common femoral had mild luminal irregularities.
5. The right SFA was proximally 100% occluded. The right SFA reconstituted at the adductor hiatus through collaterals from the profunda. The left SFA was occluded at its origin. It also reconstituted through dense collaterals from the profunda at the adductor hiatus.
6. Bilateral popliteal arteries had mild disease.
7. The right infrapopliteal vessels were poorly seen as the filling was through collaterals and there was hardware in the right lower extremity which obstructed the view. However, it appears to have at least 2-vessel runoff from the peroneal and the anterior tibial. The posterior tibial was not well-visualized proximally but was seen distally. At the ankle of the right leg, there is runoff from the peroneal, the posterior tibial reconstitutes, and the anterior tibial was seen very faintly.
8. The left lower extremity had 3-vessel runoff which again was not very well-visualized given flow through collaterals.
INTERVENTION REPORT:
We accessed the left common femoral artery with a 4-French sheath using a micropuncture technique. A pigtail catheter was placed on the abdominal aorta to visualize the right common iliac stenosis. We up-sized the right groin sheath for a 6-French long 23-cm sheath. This right common iliac lesion was first pre-dilated with a 6 x 20-mm balloon at normal inflations. We then stented this with a 7 x 27-mm balloon. We then post-dilated with an 8 x 20-mm balloon. At the end of the procedure, there was no residual stenosis and no significant gradient across this lesion. The left common iliac ostium looks pristine.
IMPRESSION:
1. Severe right common iliac stenosis which was successfully angioplastied and stented with bare metal stent.
2. Bilateral occlusions of the superficial femoral artery with distal reconstitution.
3. Two- to 3-vessel runoff bilaterally.
RECOMMENDATIONS:
Patient underwent percutaneous transluminal angioplasty and stenting of her right inflow. She has severe bilateral outflow disease which will be considered for surgical revascularization. She has good runoff. She should undergo aggressive medical management and risk factor modification. In that regard, she should be on aspirin lifelong and Plavix for at least 6 weeks. Lipids should be optimized. She will follow up with a vascular surgeon, Dr. , in consideration for her revascularization of her bilateral superficial femoral arteries with surgical technique.
The old person coded one similar to this as 36245 51; 75710 26; 37205; 75960 26; 75630 2659.
OPERATION PERFORMED:
1. Aortogram with lower extremity bolus chase.
2. Angioplasty of right common iliac.
3. Stenting of right common iliac lesion.
REFERRING PHYSICIANS:
1. Dr.
2. Dr.
INDICATION FOR PROCEDURE:
Severe lifestyle-limiting claudication.
HISTORY:
A 58-year-old female with known coronary artery disease, hypertension, dyslipidemia, who presents with lifestyle-limiting bilateral lower extremity claudication. She had an ABI which showed 0.71 on the right lower extremity and 0.68 on the left lower extremity. Subsequent duplex showed possible bilateral aortoiliac disease and bilateral SFA occlusion with distal reconstitution at the popliteals. Given her lifestyle-limiting claudication, she was scheduled for angiogram of the lower extremity to further delineate her lower extremity arterial vasculature and consider for possible revascularization.
PROCEDURE NOTE:
Informed consent was obtained. Risks, benefits, alternatives, complications including, but not limited to, vascular injury, needing emergent surgery, limb loss, amputation, death were explained to patient and son in detail. They agreed to the procedure, understood the complications involved, and is willing to proceed.
Both groins were prepped and draped in the usual sterile fashion. Lidocaine 2% was used for local anesthesia. Next, using a modified Seldinger technique and a micropuncture needle, 4-French arterial sheath was inserted in the right common femoral artery. We then used a pigtail catheter to obtain aortogram and lower extremity bolus chase. We then proceeded to the intervention as outlined below.
At the end of the procedure, the wires and catheters were removed and hemostasis will be obtained with manual compression once ACT is acceptable.
Medications given during the procedure were Versed and fentanyl per protocol, 5000 of intravenous heparin. She will be loaded with Plavix. She is already on aspirin.
INTERVENTION REPORT:
1. Abdominal aorta had mild to moderate atherosclerosis.
2. The right common iliac had an eccentric 70% to 80% stenosis with greater than 35-mm gradient across the stenosis. The left common iliac had mild irregularities.
3. The bilateral external iliacs had mild disease. The internal iliacs were patent.
4. Bilateral common femoral had mild luminal irregularities.
5. The right SFA was proximally 100% occluded. The right SFA reconstituted at the adductor hiatus through collaterals from the profunda. The left SFA was occluded at its origin. It also reconstituted through dense collaterals from the profunda at the adductor hiatus.
6. Bilateral popliteal arteries had mild disease.
7. The right infrapopliteal vessels were poorly seen as the filling was through collaterals and there was hardware in the right lower extremity which obstructed the view. However, it appears to have at least 2-vessel runoff from the peroneal and the anterior tibial. The posterior tibial was not well-visualized proximally but was seen distally. At the ankle of the right leg, there is runoff from the peroneal, the posterior tibial reconstitutes, and the anterior tibial was seen very faintly.
8. The left lower extremity had 3-vessel runoff which again was not very well-visualized given flow through collaterals.
INTERVENTION REPORT:
We accessed the left common femoral artery with a 4-French sheath using a micropuncture technique. A pigtail catheter was placed on the abdominal aorta to visualize the right common iliac stenosis. We up-sized the right groin sheath for a 6-French long 23-cm sheath. This right common iliac lesion was first pre-dilated with a 6 x 20-mm balloon at normal inflations. We then stented this with a 7 x 27-mm balloon. We then post-dilated with an 8 x 20-mm balloon. At the end of the procedure, there was no residual stenosis and no significant gradient across this lesion. The left common iliac ostium looks pristine.
IMPRESSION:
1. Severe right common iliac stenosis which was successfully angioplastied and stented with bare metal stent.
2. Bilateral occlusions of the superficial femoral artery with distal reconstitution.
3. Two- to 3-vessel runoff bilaterally.
RECOMMENDATIONS:
Patient underwent percutaneous transluminal angioplasty and stenting of her right inflow. She has severe bilateral outflow disease which will be considered for surgical revascularization. She has good runoff. She should undergo aggressive medical management and risk factor modification. In that regard, she should be on aspirin lifelong and Plavix for at least 6 weeks. Lipids should be optimized. She will follow up with a vascular surgeon, Dr. , in consideration for her revascularization of her bilateral superficial femoral arteries with surgical technique.
The old person coded one similar to this as 36245 51; 75710 26; 37205; 75960 26; 75630 2659.
