need help with b/l renals angio and stenting

bhargavi

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Conclusion



This patient with recent accelerating severe hypertension on multiple antihypertensive medications with difficult to control blood pressure underwent noninvasive imaging which revealed a severe stenosis in the left renal artery, she subsequently underwent CT angiography which confirmed severe stenosis at the ostial segment of the single main left renal artery, patent right renal artery, renal digital subtraction angiography and possible intervention is requested for renal preservation and blood pressure control

After obtaining informed consent for the patient a 6 French sheath was placed into the right common femoral artery.  Diagnostic right and left selective renal arteriography was then performed, and after documentation of the severe stenosis in the proximal ostial segment of the left renal artery with gradient of greater than 50 mmHg, the initial diagnostic 6 French catheter was exchanged out for a 6 French guiding catheter, this was a LIMA guiding catheter which was then positioned in the ostium of the left renal artery and a 0.014 wire was advanced into the distal renal artery and angioplasty was performed with a 3 mm balloon followed by placement of a single Boston Scientific balloon expandable stent, Express SD, 5 mm x 19 mm length, deployed to high pressure, the entire stented segment was then postdilated with a 6 mm balloon to high pressure with final angiographic result excellent and resolution of gradient.  After withdrawal of the wire and the balloon and final angiography, the sheath was utilized for a selective angiogram and was placed in the distal right common femoral artery, closure was then obtained with a Mynx closure device without complication.  The patient did receive 3000 units of heparin at the initiation of the intervention and there were no complications.

Hemodynamics:

Central aortic pressure 140/80.

There was a greater than 50 mm gradient across the ostial stenosis in the left renal artery with 6 French diagnostic catheter placed across.


Digital subtraction angiography:

There was a single right renal artery which had minimal ostial tapering no significant gradient, less than 20% ostial narrowing minimal calcification otherwise patent vessel

Left renal artery was noted to have ostial stenosis of 80%, with significant gradient, there was moderate calcification at this ostial segment.  The mid and distal left renal artery was patent.


Intervention:

As detailed above, angioplasty was performed of the left renal artery, due to residual stenosis and recoil stenting was performed with placement of a single stent as detailed above excellent angiographic result resolution of gradient no significant residual stenosis


Summary conclusion:

Severe ostial left renal artery stenosis atherosclerotic renal vascular disease with renovascular hypertension

Successful angioplasty and balloon expandable stent treatment of the left renal artery ostial proximal stenosis



thanks in advance
should I do 36252, 37246-rt, 37236-lft, 75726? or I think 75726 is bundled in 37236?
 

ernist8489

Networker
Messages
25
Best answers
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Conclusion



This patient with recent accelerating severe hypertension on multiple antihypertensive medications with difficult to control blood pressure underwent noninvasive imaging which revealed a severe stenosis in the left renal artery, she subsequently underwent CT angiography which confirmed severe stenosis at the ostial segment of the single main left renal artery, patent right renal artery, renal digital subtraction angiography and possible intervention is requested for renal preservation and blood pressure control

After obtaining informed consent for the patient a 6 French sheath was placed into the right common femoral artery.  Diagnostic right and left selective renal arteriography was then performed, and after documentation of the severe stenosis in the proximal ostial segment of the left renal artery with gradient of greater than 50 mmHg, the initial diagnostic 6 French catheter was exchanged out for a 6 French guiding catheter, this was a LIMA guiding catheter which was then positioned in the ostium of the left renal artery and a 0.014 wire was advanced into the distal renal artery and angioplasty was performed with a 3 mm balloon followed by placement of a single Boston Scientific balloon expandable stent, Express SD, 5 mm x 19 mm length, deployed to high pressure, the entire stented segment was then postdilated with a 6 mm balloon to high pressure with final angiographic result excellent and resolution of gradient.  After withdrawal of the wire and the balloon and final angiography, the sheath was utilized for a selective angiogram and was placed in the distal right common femoral artery, closure was then obtained with a Mynx closure device without complication.  The patient did receive 3000 units of heparin at the initiation of the intervention and there were no complications.

Hemodynamics:

Central aortic pressure 140/80.

There was a greater than 50 mm gradient across the ostial stenosis in the left renal artery with 6 French diagnostic catheter placed across.


Digital subtraction angiography:

There was a single right renal artery which had minimal ostial tapering no significant gradient, less than 20% ostial narrowing minimal calcification otherwise patent vessel

Left renal artery was noted to have ostial stenosis of 80%, with significant gradient, there was moderate calcification at this ostial segment.  The mid and distal left renal artery was patent.


Intervention:

As detailed above, angioplasty was performed of the left renal artery, due to residual stenosis and recoil stenting was performed with placement of a single stent as detailed above excellent angiographic result resolution of gradient no significant residual stenosis


Summary conclusion:

Severe ostial left renal artery stenosis atherosclerotic renal vascular disease with renovascular hypertension

Successful angioplasty and balloon expandable stent treatment of the left renal artery ostial proximal stenosis​


thanks in advance
should I do 36252, 37246-rt, 37236-lft, 75726? or I think 75726 is bundled in 37236?

Hello there! You were close however We only report these two procedure codes 37236-LT, 36252 .
(No angioplasty or intervention was performed in the right renal artery, only selective arteriogram on the right, the left renal had an angioplasty followed by a stent placement, the angioplasty code 37246 is not reported as it bundles into the stent placement 37236 being as it was done in the same artery)
Code 75726 for visceral angiography would not be reported as no selective visceral arteriogram were performed and all angiography for this case is included in 36252.
So per the documentation we have a bilateral selective Renal Artery Angiogram, and a left distal Renal Artery Angioplasty and Stent placement. The right renal selective arteriogram details that there was 20% minimal ostial narrowing and barely any calcification and is otherwise a patent vessel so he didn't do any intervention on the right renal.
No separate Selective Visceral arteriogram was performed as 75726 is reported for selective angiography of the celiac families, the Super and Inferior Mesenteric families and other visceral vasculature, so just fyi don't report 75726 for renal angiography.
Aortography is also a bundled component of codes 36251-36254.
All Arterial and Venous anatomic families follow the same hierarchy for coding interventions when performed in the same vessel at the same time, all lower level procedures done bundle into the more intensive procedures performed.
The hierarchy goes from least invasive to highest invasive. 1). Angioplasty, 2). Stent placement. 3). Atherectomy. 4). Stent and Atherectomy 5). Mechanical Thrombectomy& Thrombolysis. 6). Embolization.
I see this was several months back and am sorry to see that no-one answered this for you. I so happen to love educating and guiding other coders on how to code all aspects of interventional Radiology/Cardiovascular/Endovascular.
I am Erik Brown, CIRCC, CPC. Any time you have a question like this or any other coding question pertaining to an IR/CV/Vascular/Neurointerventional, Ortho, Anesthesia, E/M, Neurosurgery, Interventional Pain and Spine, Dialysis, I will gladly help and provide a detailed rationale of what the procedural guidelines are and how we abstract certain aspects of the documentation to lead us to proper CPT and ICD-10-CM assignment. Modifiers as well.
 

ernist8489

Networker
Messages
25
Best answers
0
This patient with recent accelerating severe hypertension on multiple antihypertensive medications with difficult to control blood pressure underwent noninvasive imaging which revealed a severe stenosis in the left renal artery, she subsequently underwent CT angiography which confirmed severe stenosis at the ostial segment of the single main left renal artery, patent right renal artery, renal digital subtraction angiography and possible intervention is requested for renal preservation and blood pressure control

After obtaining informed consent for the patient a 6 French sheath was placed into the right common femoral artery.  Diagnostic right and left selective renal arteriography was then performed, and after documentation of the severe stenosis in the proximal ostial segment of the left renal artery with gradient of greater than 50 mmHg, the initial diagnostic 6 French catheter was exchanged out for a 6 French guiding catheter, this was a LIMA guiding catheter which was then positioned in the ostium of the left renal artery and a 0.014 wire was advanced into the distal renal artery and angioplasty was performed with a 3 mm balloon followed by placement of a single Boston Scientific balloon expandable stent, Express SD, 5 mm x 19 mm length, deployed to high pressure, the entire stented segment was then postdilated with a 6 mm balloon to high pressure with final angiographic result excellent and resolution of gradient.  After withdrawal of the wire and the balloon and final angiography, the sheath was utilized for a selective angiogram and was placed in the distal right common femoral artery, closure was then obtained with a Mynx closure device without complication.  The patient did receive 3000 units of heparin at the initiation of the intervention and there were no complications.

Hemodynamics:

Central aortic pressure 140/80.

There was a greater than 50 mm gradient across the ostial stenosis in the left renal artery with 6 French diagnostic catheter placed across.


Digital subtraction angiography:

There was a single right renal artery which had minimal ostial tapering no significant gradient, less than 20% ostial narrowing minimal calcification otherwise patent vessel

Left renal artery was noted to have ostial stenosis of 80%, with significant gradient, there was moderate calcification at this ostial segment.  The mid and distal left renal artery was patent.


Intervention:

As detailed above, angioplasty was performed of the left renal artery, due to residual stenosis and recoil stenting was performed with placement of a single stent as detailed above excellent angiographic result resolution of gradient no significant residual stenosis


Summary conclusion:

Severe ostial left renal artery stenosis atherosclerotic renal vascular disease with renovascular hypertension

Successful angioplasty and balloon expandable stent treatment of the left renal artery ostial proximal stenosis


thanks in advance
should I do 36252, 37246-rt, 37236-lft, 75726? or I think 75726 is bundled in 37236?
Hello there! You were close however We only report these two procedure codes 37236-LT, 36252 .
(No angioplasty or intervention was performed in the right renal artery, only selective arteriogram on the right, the left renal had an angioplasty followed by a stent placement, the angioplasty code 37246 is not reported as it bundles into the stent placement 37236 being as it was done in the same artery)
Code 75726 for visceral angiography would not be reported as no selective visceral arteriogram were performed and all angiography for this case is included in 36252.
So per the documentation we have a bilateral selective Renal Artery Angiogram, and a left distal Renal Artery Angioplasty and Stent placement. The right renal selective arteriogram details that there was 20% minimal ostial narrowing and barely any calcification and is otherwise a patent vessel so he didn't do any intervention on the right renal.
No separate Selective Visceral arteriogram was performed as 75726 is reported for selective angiography of the celiac families, the Super and Inferior Mesenteric families and other visceral vasculature, so just fyi don't report 75726 for renal angiography.
Aortography is also a bundled component of codes 36251-36254.
All Arterial and Venous anatomic families follow the same hierarchy for coding interventions when performed in the same vessel at the same time, all lower level procedures done bundle into the more intensive procedures performed.
The hierarchy goes from least invasive to highest invasive. 1). Angioplasty, 2). Stent placement. 3). Atherectomy. 4). Stent and Atherectomy 5). Mechanical Thrombectomy& Thrombolysis. 6). Embolization.
I see this was several months back and am sorry to see that no-one answered this for you. I so happen to love educating and guiding other coders on how to code all aspects of interventional Radiology/Cardiovascular/Endovascular.
I am Erik Brown, CIRCC, CPC. Any time you have a question like this or any other coding question pertaining to an IR/CV/Vascular/Neurointerventional, Ortho, Anesthesia, E/M, Neurosurgery, Interventional Pain and Spine, Dialysis, I will gladly help and provide a detailed rationale of what the procedural guidelines are and how we abstract certain aspects of the documentation to lead us to proper CPT and ICD-10-CM assignment. Modifiers as well.
 
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