need help understanding and coding this carotids procedure for facility please

bhargavi

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Procedures performed:​


    1. Right femoral arteriotomy and placement of five French sheath using ultrasound

    2. Conscious sedation for duration over 65 minute minutes with direct face-to-face observation and monitoring of the patient.

    3. Right common carotid artery angiogram cervical

    4. Right internal carotd artery angiogram cerebral

    5. Left common carotid artery angiogram cervical

    6. Left internal carotid angiogram cerebral

    7. Left subclavian artery angiogram

    8. Left vertebral artery angiogram cervical and cerebral

    9. Right subclavian artery angiogram

    10. Right vertebral artery angiogram cervical and cerebral

    11. Right femoral artery angiogram

    12. vascular closure device using 6French angioseal
Description of procedure: patient was brought to angio suite and identified using multiple patient identifiers. Time out was performed by entire team. Patient was placed in supine position on angiography table and bilateral ground and right wrist was cleaned using beta fine solution. Sterile drape was applied. Right femoral artery was palpated and under ultrasound 5 French sheath was placed using micro puncture kit and modified Seldinger technique. This was sutured and continuously flushed with pressurized heroism saline. A 5 French Simms 2  catheter was continuously flushed with heparinized swine and was then navigated over 0.035 guidewire up to arch of sorts where it was reconstituted and following blood vessels were catheterized- Right common, right internal, left common, left internal, left subclavian, left vertebral artery, right subclavian, right vertebral artery. The angiogram was analyzed and subsequently removed from the body without any incident. Patient was examined without any neurological deficits and femoral sheath was removed and angioseal was deployed​
Complications - None

Disposition- patient sent back to ambulatory surgery care for further monitoring
Interpretation :
Right common carotid artery angiogram: Right common carotid artery angiogram demonstrates normal appearing common carotid artery. Right common carotid artery bifurcates at c3 cervical vertebrae. The bifurcation of Right common carotid artery appears normal. It bifurcates into Right internal carotid artery and Right External carotid artery. Origin of Right internal carotid artery shows mild atherosclerosis disease without any evidence of stenosis. The external carotid artery appears normal with normal appearing branches of right external carotid artery.The capillary, tissue and venous phase of above mentioned arteries appears normal.

Right Internal carotid artery angiogram, neck and head - Right internal carotid artery demonstrates normal appearing cervical segment of right internal carotid artery.The cervical segment continues into right petrous segment and cavernous segment of right internal carotid artery. The petrous and cavernous segment appears normal with no major hemodynamic stenosis. The cavernous segment continues into ophthalmic segment. The ophthalmic artery appears normal in shape and caliber. The terminus portion of right internal carotid artery bifurcates into right middle cerebral artery and right anterior cerebral artery. The right middle cerebral M1 segment appears normal. The Middle cerebra artery divides into  the superior and inferior segment which also appears normal. The terminal segment of middle cerebral arteries appears normal. The Anterior cerebral artery A1 segment and A2 segment also appear normal. On lateral view of angiogram pericallosal and callosomarginal arteries can be seen. The capillary, tissues and venous phase of all the above arteries appears normal.

Left common carotid artery angiogram: Left common carotid artery angiogram demonstrates normal appearing common carotid artery. The Left common carotid artery bifurcates at c3 cervical vertebrae. The bifurcation of Left common carotid artery appears normal. It bifurcates into Left internal carotid artery and Left External carotid artery. Origin of Left internal carotid artery appears normal without any evidence of stenosis. The external carotid artery appears normal with normal appearing branches of right external carotid artery.The capillary, tissue and venous phase of above mentioned arteries appears normal.

Left Internal carotid artery angiogram, neck and head - Left internal carotid artery demonstrates normal appearing cervical segment of  internal carotid artery. There appears to be 360 degree loop at proximal portion of left internal carotid artery.The cervical segment continues into petrous segment and cavernous segment of left internal carotid artery. The petrous and cavernous segment appears normal with no major hemodynamic stenosis. The cavernous segment continues into ophthalmic segment. The ophthalmic artery appears normal in shape and caliber. The terminus portion of left internal carotid artery bifurcates into right middle cerebral artery and right anterior cerebral artery. The left middle cerebral M1 segment appears normal. The left A1 and A2 segments also appears normal with normal appearing pericallosal and callosomarginal arteries.​
Left subclavian artery angiogram - Angiogram from proximal Subclavian artery demonstrates normal appearing subclavian artery with no stenosis. The vertebral artery origin appears normal except just distal to origin there appears to be around 40% stenosis as per NASCET criteria of vertebral artery. The other branches of subclavian artery  like Thyrocervical, internal thoracic artery,Transverese cervical  and suprascapular artery appears normal.

Left vertebral artery angiogram- Left vertebral artery angiogram demonstrates normal appearing angiogram of left vertebral artery except around 40% stenosis distal  to origin of left vertebral artery. The V1 and V2 segment appears normal. The left vertebral artery VB junction appears normal with normal appearing PICA (posterior inferior cerebellar artery). Basilar artery appears normal with normal appearing bilateral AICA. The basilar artery ends in bilateral PCA. The bilateral PCA(posterior cerebral arteries) appears normal in shape and caliber.​
Right subclavian artery angiogram - Angiogram from proximal Subclavian artery demonstrates normal appearing subclavian artery with no stenosis. The vertebral artery origin appears to have around 71% stenosis just  8mm distal from origin of right vertebral artery. The post stenotic portion of right vertebral artery appears normal along with other branches of subclavian like Thyrocervical, internal thoracic artery,Transverese cervical  and suprascapular artery.

Right vertebral artery angiogram- Right vertebral artery angiogram demonstrates around 71% stenosis of right vertebral artery at around 8mm distal to origin . The rest of vertebral artery appears normal . The V1 and V2 segment appears normal. The  vertebral artery VB junction appears normal with normal appearing PICA (posterior inferior cerebellar artery)on right. Basilar artery appears normal with normal appearing bilateral AICA. The basilar artery ends in bilateral PCA. The capillary, tissue and venous phase all appears normal.

Right common femoral artery angiogram- Right CFA angiogram demonstrate normal appearing right CFA proximally with normal bifurcation. The site of arteriotomy appears well above bifurcation of CFA.​

thanks in adance

I am hospital coder

should I do 36224-50, 36225-50, xs, 36226-50? or should I add 75710 for cfa? I understand as 36222 and 36223 will be bundled into 36224- am I understanding correctly? and each 36- codes are mue -1 per date of service per nthrive for outpatient so what does this mean? I can bill bilateral on one day or no?





















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ernist8489

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Awesome questions.
This case would be coded as follows
36224-50, 36226-50.
1). No we would not code 75710-XS,RT
As the femoral arteriogram was not truly diagnostic in nature, nor did the physician encounter any vessel disease intraoperatively in the RT fem.
The rt Femoral angiogram was inherent to the main procedures therefore it's bundled into CPT Codes 36221-36228.

2).You were correct on reporting 36224 (ICA) for the bilateral selective carotid angiograms as 36222&36223 bundle into 36224.

3).We would not report 36225 in this instance as it bundles into 36226.
(Vertebrals were physically selected Bilaterally following the subclavian selections)

The documentation states that the right and left subclavian arteries were selected and angiogram performed of both circulations followed by the catheters being maneuvered on each side more selectively into the RT and LT Vertebral arteries with Cervical/Cerebral angiography of the Vertebrobasilar Circulation (Including the Cerebellar arteries). So we report only 36226-50.
On the right side of the body the right subclavian is a 2nd order artery as it is a continuation of the 1st order Inominate artery. The RT vertebral artery is a 3rd order vessel and a branch from the 2nd order Right subclavian (Hence the reason the subclavian angio 36225 bundles into the Vertebral Angio 36226.)
Same rules apply on the left as the left subclavian selective angio 36225 bundles into the left vertebral angio 36226, the only difference on the left being the left subclavian branches directly off of the aortic Arch as a 1st order selection, and left vertebral selection being a 2nd order.
So we code only 36224-50 , 3622650 Only.

Hope this Helps. Feel free to reach out directly if you ever have IR questions!
Thanks.
Erik Brown, CIRCC,CPC
 

bhargavi

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forgot to ask can I add 36228-50 since he mentioned middle cerebral artery - I believe its one of the branch. and also I am not sure when to add 36227? isn't external carotid part of intracranial?
where can I find the information about branches of carotids? anyone please help this is all new neuro interventions to me
thanks again in advance
 
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