bhargavi
Guru
Conclusion
71-year-old male presenting with episodes of dizziness and near syncope underwent investigation showing suspicious vertebral artery insufficiency as well as clinical suspicion for subclavian steal syndrome was referred for diagnostic selective subclavian, vertebral as well as carotid angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 10:17 AM and monitoring period Ended 11:10 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. A 5 French pigtail catheter was used to perform the arch angiogram. A 5 French JR4 catheter was used to selectively engage the left subclavian artery, left vertebral artery, the left common carotid artery, the innominate artery, the right vertebral artery, the right common carotid artery, as well as the right subclavian artery. Pullback technique was performed from the right subclavian artery into the arch to rule out hemodynamically significant right subclavian as well as innominate artery stenosis
finding:
1: The arch angiogram showed a type III arch. All 3 major vessels appear to be patent.
2: Selective angiogram and catheter placement in the left subclavian artery show no evidence of subclavian stenosis
3: Selective catheter cannulation and angiogram of the left vertebral artery showed no vertebral artery stenosis.
4: The left common carotid artery was selectively engaged. Left carotid angiogram showed patent left common carotid artery. There is 20% stenosis of the origin of the left internal carotid artery. Intracerebral injection showed patent vessels with somewhat poor flow into the anterior communicating artery with minimal crossover from left to right
5: Selective innominate artery catheterization and injection showed no hemodynamically significant innominate stenosis.
6: Selective right common carotid artery catheterization and injection showed evidence of 40% stenosis in the origin subclavian artery angiogram showed minimal disease. Pullback technique from the subclavian into the innominate and from the innominate into the arch showed no gradient internal carotid artery. There is normal intra cerebral flow. There is normal crossover from right to left via the anterior communicating artery.
7: Selective right vertebral artery catheter insertion and angiogram showed a 50% calcific stenosis in the proximal right vertebral artery. There is normal flow into the basilar artery.
8:
Impression:
1. Left subclavian, left vertebral, left common carotid artery. There is 20% stenosis in the origin of the left internal carotid artery
2. No significant stenosis in the innominate, the right common carotid artery, 40% stenosis in the origin of the right internal carotid artery, 50% stenosis in the right vertebral artery, no significant stenosis in the right subclavian artery
Plan: No angiographic evidence of vertebrobasilar insufficiency or subclavian steal syndrome. Patient's symptoms are most likely severe orthostasis. Allow permissive hypertension and avoid sudden positioning.
thanks in advance
should i b ill 36226, 36227? the mue per day is 1 for outpt so i won't be able to add "50" modifier correct? i am hospital coder
71-year-old male presenting with episodes of dizziness and near syncope underwent investigation showing suspicious vertebral artery insufficiency as well as clinical suspicion for subclavian steal syndrome was referred for diagnostic selective subclavian, vertebral as well as carotid angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 10:17 AM and monitoring period Ended 11:10 AM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 6 French sheath was inserted in the right femoral artery. A 5 French pigtail catheter was used to perform the arch angiogram. A 5 French JR4 catheter was used to selectively engage the left subclavian artery, left vertebral artery, the left common carotid artery, the innominate artery, the right vertebral artery, the right common carotid artery, as well as the right subclavian artery. Pullback technique was performed from the right subclavian artery into the arch to rule out hemodynamically significant right subclavian as well as innominate artery stenosis
finding:
1: The arch angiogram showed a type III arch. All 3 major vessels appear to be patent.
2: Selective angiogram and catheter placement in the left subclavian artery show no evidence of subclavian stenosis
3: Selective catheter cannulation and angiogram of the left vertebral artery showed no vertebral artery stenosis.
4: The left common carotid artery was selectively engaged. Left carotid angiogram showed patent left common carotid artery. There is 20% stenosis of the origin of the left internal carotid artery. Intracerebral injection showed patent vessels with somewhat poor flow into the anterior communicating artery with minimal crossover from left to right
5: Selective innominate artery catheterization and injection showed no hemodynamically significant innominate stenosis.
6: Selective right common carotid artery catheterization and injection showed evidence of 40% stenosis in the origin subclavian artery angiogram showed minimal disease. Pullback technique from the subclavian into the innominate and from the innominate into the arch showed no gradient internal carotid artery. There is normal intra cerebral flow. There is normal crossover from right to left via the anterior communicating artery.
7: Selective right vertebral artery catheter insertion and angiogram showed a 50% calcific stenosis in the proximal right vertebral artery. There is normal flow into the basilar artery.
8:
Impression:
1. Left subclavian, left vertebral, left common carotid artery. There is 20% stenosis in the origin of the left internal carotid artery
2. No significant stenosis in the innominate, the right common carotid artery, 40% stenosis in the origin of the right internal carotid artery, 50% stenosis in the right vertebral artery, no significant stenosis in the right subclavian artery
Plan: No angiographic evidence of vertebrobasilar insufficiency or subclavian steal syndrome. Patient's symptoms are most likely severe orthostasis. Allow permissive hypertension and avoid sudden positioning.
thanks in advance
should i b ill 36226, 36227? the mue per day is 1 for outpt so i won't be able to add "50" modifier correct? i am hospital coder