Wiki need help with cath with subclavian stent coding

bhargavi

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Conclusion




After obtaining informed consent, the patient was prepped and draped in sterile fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the right groin prior to placement of the arterial sheath.  Under fluoroscopic guidance and using modified Seldinger technique, a 6 French arterial sheath was placed without difficulty into the right femoral artery. We then proceeded with left heart catheterization, coronary angiography, selective vein graft angiography, selective LIMA angiography, and nonselective injection of the right femoral artery using hand injections of Omnipaque contrast via 6 French FL4, FR4, and angled pigtail catheters. An injection of the femoral access site immediately after placement of the sheath revealed that the sheath was essentially occlusive in the distal external iliac vessel.  We pulled the sheath back somewhat, and had resumption of TIMI grade III flow with a lengthy area of residual disease in the external iliac.  Findings are as follows:


The left ventricular pressure was 194/17 mmHg. The aortic pressure was 194/81 mmHg.

Left Main: The left main is a large vessel which trifurcates into left anterior descending, left circumflex, and ramus intermedius branches.  There is distal left main 70% stenosis.

Left anterior descending: The left anterior descending is 100% occluded proximally.

Left circumflex: The left circumflex is a large anatomically nondominant vessel which in essence gives rise to 2 major obtuse marginal branches of significance.  There is ostial 70% disease in the left circumflex extending into the origin of the first obtuse marginal branch and into the continuation of the left circumflex.  The first obtuse marginal branch is occluded and known to be bypassed.  The mid left circumflex beyond this lesion has patchy 20 to 30% disease and needs to a medium sized branching second obtuse marginal branch which is free of disease.

Ramus intermedius: The ramus intermedius is a moderately large vessel which has ostial to proximal 90% disease.  The overall appearance of the left circumflex and ramus intermedius branches is not substantially different from the previous angiogram in 2018.

Right coronary artery: The right coronary arteries 100% occluded proximally.

Saphenous vein bypass graft to distal RCA: This graft is large and has a stent visualized extending from the distal portion of the graft across the origin of the PDA into the proximal PL branch.  This graft is patent as is the stent, with minimal in-stent restenosis noted.  The remainder of the runoff is free of disease.

Saphenous vein bypass graft to first obtuse marginal branch: Widely patent with excellent runoff to the obtuse marginal.

Left internal mammary artery to left anterior descending: Widely patent with excellent filling of the left anterior descending back to the point of occlusion and collateral filling of acute marginal branches of the right coronary artery.  Of note, nonselective injection initially via the subclavian vessel revealed a complex ulcerated stenosis in the subclavian just prior to the origin of the vertebral artery that on some views appeared as severe as 60 to 70%.  There was a 40 mm translesional pressure gradient across this stenosis.  Additionally, beginning with injection of this graft, the patient began to complain of burning discomfort in the chest that persisted throughout the remainder of the procedure.

After identification of patent bypass grafts with stable native left circumflex/ramus disease, but worsened stenosis of the left subclavian, we elected to proceed with left subclavian intervention.  Typically, in these cases, the arterial sheath would have been exchanged for a long 6 French destination sheath.  However, due to the occlusive nature of the short 6 French arterial sheath, we elected to utilize a guide catheter instead in order to minimize the likelihood of ischemia to the right lower extremity.  We therefore obtained a 6 French IMA guide catheter.  We initially advanced this guide catheter over a long Magic torque wire, but due to inability to advance balloons through the inner diameter of the sheath, this was later exchanged for a 300 cm V 18 wire.  We then performed predilatation of the culprit lesion utilizing a 6.0 x 16 mm Sterling balloon which was deployed up to 14 atm of pressure.  Follow-up angiography revealed an improvement in angiographic appearance of the vessel.  We then proceeded with stenting.  Again, due to the inner diameter of the guide catheter, we were unable to use large diameter stents, so we placed, in tandem, a 6.0 x 20 and 6.0 x 20 mm express SD stents both deployed in an overlapping fashion to 14 atm of pressure.  Follow-up angiography revealed a further improvement in the angiographic appearance of the vessel.  We then performed postdilatation of the entire stented length utilizing a 7.0 x 40 mm Sterling balloon deployed up to 14 atm of pressure.  Follow-up angiography revealed an excellent angiographic result with no apparent residual stenosis and no evidence of proximal or distal stent edge dissection, thrombosis, or spasm.  There was TIMI grade III flow throughout the subclavian vessel with no significant residual stenosis noted and TIMI grade III flow into the LIMA graft.  We then concluded this portion of the procedure.

As above, throughout the procedure, the patient complained of persistent burning discomfort in the chest which we surmised was due to ischemia to the left anterior descending via the subclavian vessel.  His blood pressure remained elevated despite multiple doses of labetalol 10 mg and hydralazine 10 mg.  He then began to complain of shortness of breath with a drop in his oxygen saturation into the upper 80s.  1 inch of nitroglycerin paste was applied to the chest wall and 40 mg of intravenous Lasix was administered, along with an additional dose of IV hydralazine 10 mg.  We concluded the angioplasty procedure and removed the guidewire and guide catheter.  We then obtained the 6 French FR 4 diagnostic catheter and we measured left ventricular pressures.  This revealed an LV pressure up to 204/31 from a diastolic pressure of 17 before the intervention.  We surmised that with intervention and intermittent LAD territory ischemia from balloon angioplasty and stent placement that he had an increase in wall stiffness that led to development of diastolic heart failure.  By the end of the procedure, he was improved, with an increase in his oxygen saturations to the upper 90s on nonrebreather.  He had put out nearly 600 mL of urine after his first dose of Lasix.

Before the termination of the procedure, we did perform aortography with bilateral iliofemoral runoff utilizing a 5 French contra catheter.  This revealed a patent distal abdominal aorta.  On the right, the common iliac vessel was widely patent.  The internal iliac was patent but diseased.  The external iliac had a long area of diffuse stenosis of at least 50 to 60% severity.  We did not perform angled views because of the patient's respiratory status.  The common femoral vessel was patent but had a tubular 50% stenosis at the site of sheath insertion.  Just below, in either the distal femoral vessel below the head of the femur or proximal SFA, there was an eccentric at least 60 to 70% stenosis.  On the left, there was a proximal left common iliac stenosis of 90%.  The internal iliac was patent though diseased.  The external iliac appeared to have mild disease until the distalmost portion of the external iliac just above the femoral head where there was a focal 75% lesion.  The common femoral vessel was patent.

Left ventriculogram: Left ventriculography was not performed.

Nonselective injection of the right femoral artery revealed acceptable position of the arterial sheath in the common femoral artery above the bifurcation.  Given the presence of significant common femoral disease, manual compression utilized for hemostasis after documentation of an ending activated clotting time of 178 seconds.

The patient was then transferred to the recovery area in stable condition:

Impression:

1.  Severe systemic hypertension, initially with mild elevation of LVEDP but later with a severe elevation of LVEDP post intervention.
2.  Severe native four-vessel disease.
3.  Patent grafts to LAD, OM, and distal RCA.
5.  Severe left subclavian stenosis status post successful angioplasty and balloon expandable stenting x2.
6.  Significant bilateral iliofemoral disease.
7.  Acute pulmonary edema during case most likely secondary to intermittent LAD ischemia combined with difficult to control blood pressures.
8.  Manual compression for hemostasis.

thanks in advance

I am coming up with 93459, 37236, 75716-xu ? is this correct





















 
93459 and 37236 are correct. Since the subclavian was selected for a separate reason (stent placement for subclavian stenosis) than graft visualization (which is bundled with the cath), I would bill 36245 for catheter placement. I would not bill 75716 for angio of the lower extremities because this was performed non-selectively and only visualized the ilio-femoral territory. For this I would bill G0278.

If the subclavian was injected SEPARATELY for independent visualization of the stenosis, I would add 75710.

I would query the physician because of the statement "Of note, nonselective injection initially via the subclavian vessel revealed a complex ulcerated stenosis in the subclavian just prior to the origin of the vertebral artery that on some views appeared as severe as 60 to 70%" Left subclavian imaging via femoral approach is typically selective. Also, was the vertebral visualized? Based upon the answer to this query, I may consider using 36225 instead if 36245 (and 75710 if utilized.)

I hope this helps
 
IMO, I would code 36215-LT for the catheterization of the left subclavian and 75710-LT-59 for the imaging. Don't use 36225 because that code is used for imaging of the vertebral artery from the subclavian catheter position.
HTH,
Jim Pawloski, CIRCC
 
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