need help with carotid stent coding

bhargavi

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Middletown, DE
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Conclusion



Report for: Transfemoral approach diagnostic angiogram cerebral with angioplasty and stenting of the left internal carotid artery

Reason for angiogram: Carotid artery critical stenosis on the left, with a recent history of concerning for TIA.  Patient is a very high risk patient and she has refused CEA.

Brief history: Patient with a very complicated medical history of multiple drug allergies, A. fib cannot be anticoagulated because of allergies history of prior CVA with some numbness on her right side of her cheek from the nerve damage who has had recent ultrasound while she was in hospital for dizziness and ultrasound showed almost near occlusion of the left internal carotid artery .patient was seen in the clinic and I discussed with her regarding CEA procedure but she refused to undergo the wanted to do angioplasty and stenting .​

I explained to the patient regarding that she is a very high risk patient because of multiple drug allergies and her age and severe atherosclerotic plaque .patient patient husband understood the risks of the procedure and agreed to go ahead.​

Informed consent: The procedure was explained to the patient in layman terms. Multiple images and diagrams were used to explain the procedure. The risk of the procedure which includes but not limited to groin hematoma, retroperitoneal hematoma, contrast neohropathy, Major and minor stroke, vascular dissection and death was explained to the patients in layman terms. All questions were appropriately answered, patient and patient family elected to have the above procedure performed.  Patient is allergic to Plavix so patient was loaded with Brilinta and aspirin prior to procedure.  She was also prepped with steroids and Benadryl because of her multiple allergies with severe reaction.

Anesthesia: conscious sedation: Patient was placed on continuous hemodynamic monitoring and direct face to face observation was done during the procedure for over 60 plus minutes. Conscious sedation administration using 3 mg Versed and 50mcg fentanyl was done. Continue monitoring and direct management of conscious sedation was done by me during whole procedure and post procedure
Procedures performed:​


    1. Right femoral arteriotomy using ultrasound
      2.   Conscious sedation for duration of more than 60 minutes with direct face-to-face observation and monitoring of the patient.
      3.  Left internal carotid artery angiogram head and neck.
      4.  Catheterization of left internal carotid artery using distal protection device Angioguard 5 mm extra-support
      5.  Balloon angioplasty pre-and post stenting using distal protection device with balloon measuring 4 x 20 mm.
      6.  Stenting of left internal carotid artery using precise carotid stent 7 x 40 mm.
      7.  Angiogram of left internal carotid artery post angioplasty and stenting of the head and neck.
      8.  Intra-arterial left internal carotid artery 10 mg integrelin infusion through existing catheter
      9.  Angiogram of right common femoral artery and using closure device for arteriotomy Angio-Seal 6 French.​

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 6 French sheath was placed using micro puncture kit and modified Seldinger technique using ultrasound. This was sutured and continuously flushed with pressurized heroism saline. A 6 French ENVOY base catheter over 5 French Simmons 2 catheter was continuously flushed with heparinized swine and was then navigated over 0.035 guidewire up to arch of aorta where it was reconstituted and following blood vessels were catheterized-left common carotid artery. The angiogram was analyzed which demonstrated almost near occlusion of more than 95% stenosis as per NASCET criteria of the left internal carotid artery at the bifurcation.

At this time ACT was checked and patient was given heparin bolus to keep and maintain the ACT above 300.

Distal protection device Angioguard was prepared and using fluoroscopy and roadmapping technique distal protection device was navigated through stenotic area along with using a buddy wire transcend platinum.  Distal protection device was deployed at the straight distal cervical segment without any complication.  Angiogram was done which showed some stasis of the flow due to critical stenosis and near occlusion following distal protection device deployment.  At this point aviator balloon measuring 4 x 30 mm was navigated using roadmapping and fluoroscopic technique over distal protection device wire.  Balloon was deployed at critical stenotic area and 10 mm pressure was applied for angioplasty.  Once balloon was deflated angiogram was done which showed good results of angioplasty and at that time balloon was taken out.  After that precise carotid stent measuring 7 x 40 mm was deployed using roadmapping of fluoroscopic technique.  The stent deployment system was taken out and angiogram was done which showed some decrease flow.  At that time 10 mg of integrelin was infused directly through the catheter into the left internal carotid artery.  Post infusion  showed improvement in flow.   The end result showed degree of stenosis prior to angioplasty and stenting from 95% to less than 20% as per NASCET criteria.

Once the desired results were achieved all catheters were taken out and her arteriotomy site was closed with Angio-Seal device.

Interpretation :​

Left Internal carotid artery angiogram, neck and head -angiogram of the left internal carotid artery demonstrated more critical, near occlusion degree of the left internal carotid artery at the bifurcation as per NASCET criteria.  The flow to the left external carotid artery appears normal along with normal-appearing external carotid artery branches.  The left middle cerebral artery has mild atherosclerotic disease.  MCA branches in the superior inferior segment which appears normal also the anterior cerebral artery appears normal in shape and caliber.​
Left internal carotid artery angiogram neck and head post angioplasty and stenting: Left internal carotid artery angiogram post angioplasty and stenting demonstrate good results with a good perfusion of the rest of the left internal carotid artery both extracranial and intracranial portion.  The degree of stenosis post angioplasty and stenting is less than 20% as per NASCET criteria.  The left external carotid artery also appears normal with normal-appearing branching.  There appears to be mild vasospasm distal to the fragment of stent.  The capillary, venous phase of the above-mentioned artery 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.​

Impression:
1.  Angiogram demonstrated more than critical stenosis almost near occlusion of the left internal carotid artery at the bifurcation.
2.  Angioplasty and stenting of the left internal carotid artery was done with good outcome with the degree of stenosis post angioplasty stenting to less than 20% as per NASCET criteria.

Plan: Patient will be admitted to neuro ICU for further monitoring and management.  Patient will continue take aspirin and brilinta  along with the Lipitor and good blood pressure control.  Upon discharge from the hospital patient will be seen in neuro interventional clinic as a follow-up in next 1 to 2 weeks.

I am coming up with 37215 which includes angio and catheter insertion and everything
thanks in advance
**Also patient was brought back to lab within hour as patient had complication so physician did left carotid angio again - is this billable? for facility coding
 
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