In reviewing charges for the cath lab I found this case and had questions regarding the charges that were entered and the dictation associated with the case.
Charges entered:
75625, 75716, 37228
Based on the dictation I queried physician to clarify procedures preformed. As the dictation states Selective Right Leg Angio, Angioplasty to Anterior Tibial artery. The final impression describes finding for an Abdominal Aortagram and Right Leg vasculature and PTA.
The Op report is below. Because of the difference in the charges I reviewed cine films of procedure and the films show Abdominal Aortagram with a omniflush catheter placed at the level just below renal arteries and then a bilateral runoff from just above bifurcation to the toes. I asked the physician about the lack of documentation regarding catheter placement in aorta and including abd/BFA in procedure portion of the op report. The physician stated they would not amend dictation for maneuvers that did not perform. The physician mention it is addressed in the final impression.
So is it enough to have findings of abdominal aortagram with detail of procedure (cath placement) in order to code for it.
When I review the report I think I can only code/charge 75710 and 37228
I would like to hear your thoughts....
Procedures: Selective right leg angiogram
Right anterior tibial angioplasty
Right dorsalis pedis angioplasty
Procedure Report:
Both groins were prepped and
The skin overlying the left femoral artery was infiltrated with 1% Lidocaine without epinephrine. The common femoral artery was punctured with a 19G needle. An .035 glide wire was inserted into the aorta and the needle was exchanged for a Omni flush catheter which was used to guide the wire into the right iliac system. The soft glide was exchanged for a stiff 035 glide wire over a 4F glide catheter. The 5F sheath was exchanged for a 6F Arrow sheath which was guided into the superficial femoral artery. Multiple injections were obtained of the right leg vasculature. The angiogram revealed multiple stenoses of the right anterior tibial artery with an area of distal occlusion including the proximal dorsalis pedis artery.
Next?An 018 wire traversed the occlusion of the distal anterior tibial artery and dorsalis pedis artery. A 2 x 120 mm balloon was the inflated across this area. The balloon was brought back and inflated in the mid portion of the anterior tibial artery and inflated to nominal pressure. Completion angiogram revealed persistent stenoses. Therefore, a 3 x 120 mm balloon was inflated across the area, and the more proximal anterior tibial artery. Completion angiogram now showed complete patency of the entire anterior tibial artery and dorsalis pedis artery.
Impression: The right renal artery has a 70-80% stenosis at its origin, and 20% stenosis of the left renal artery. Widely patent right iliac system, superficial, common and profunda femoral arteries, and popliteal artery. The right anterior and dorsalis pedis arteries are diffusely diseased and occludes above the ankle. The dorsalis pedis artery is occluded proximally and then reopens for a short segment. Both the anterior tibial and dorsalis pedis artery were successfully treated with angioplasty such that normal appearing flow was reconstituted to the plantar arch. The posterior tibial artery is patent down the calf into the foot. The peroneal artery is very small and minimally contributory to the perfusion of the leg.
Charges entered:
75625, 75716, 37228
Based on the dictation I queried physician to clarify procedures preformed. As the dictation states Selective Right Leg Angio, Angioplasty to Anterior Tibial artery. The final impression describes finding for an Abdominal Aortagram and Right Leg vasculature and PTA.
The Op report is below. Because of the difference in the charges I reviewed cine films of procedure and the films show Abdominal Aortagram with a omniflush catheter placed at the level just below renal arteries and then a bilateral runoff from just above bifurcation to the toes. I asked the physician about the lack of documentation regarding catheter placement in aorta and including abd/BFA in procedure portion of the op report. The physician stated they would not amend dictation for maneuvers that did not perform. The physician mention it is addressed in the final impression.
So is it enough to have findings of abdominal aortagram with detail of procedure (cath placement) in order to code for it.
When I review the report I think I can only code/charge 75710 and 37228
I would like to hear your thoughts....
Procedures: Selective right leg angiogram
Right anterior tibial angioplasty
Right dorsalis pedis angioplasty
Procedure Report:
Both groins were prepped and
The skin overlying the left femoral artery was infiltrated with 1% Lidocaine without epinephrine. The common femoral artery was punctured with a 19G needle. An .035 glide wire was inserted into the aorta and the needle was exchanged for a Omni flush catheter which was used to guide the wire into the right iliac system. The soft glide was exchanged for a stiff 035 glide wire over a 4F glide catheter. The 5F sheath was exchanged for a 6F Arrow sheath which was guided into the superficial femoral artery. Multiple injections were obtained of the right leg vasculature. The angiogram revealed multiple stenoses of the right anterior tibial artery with an area of distal occlusion including the proximal dorsalis pedis artery.
Next?An 018 wire traversed the occlusion of the distal anterior tibial artery and dorsalis pedis artery. A 2 x 120 mm balloon was the inflated across this area. The balloon was brought back and inflated in the mid portion of the anterior tibial artery and inflated to nominal pressure. Completion angiogram revealed persistent stenoses. Therefore, a 3 x 120 mm balloon was inflated across the area, and the more proximal anterior tibial artery. Completion angiogram now showed complete patency of the entire anterior tibial artery and dorsalis pedis artery.
Impression: The right renal artery has a 70-80% stenosis at its origin, and 20% stenosis of the left renal artery. Widely patent right iliac system, superficial, common and profunda femoral arteries, and popliteal artery. The right anterior and dorsalis pedis arteries are diffusely diseased and occludes above the ankle. The dorsalis pedis artery is occluded proximally and then reopens for a short segment. Both the anterior tibial and dorsalis pedis artery were successfully treated with angioplasty such that normal appearing flow was reconstituted to the plantar arch. The posterior tibial artery is patent down the calf into the foot. The peroneal artery is very small and minimally contributory to the perfusion of the leg.
