Tonyj
True Blue
Medicare won't accept the codes I'm using on a patient with a stroke.
Physician billed 37216, 36228, 70450.
We can't bill the 36228 with the 37216 and MCR won't pay for 37216.
Stumped; Can anyone assist?
Physicia stated, "The stroke was caused by right carotid artery occlusion. There was an intracranial occlusion on CT but it had recanalized with tPA prior to my procedure. I did not perform Thrombectomy or thrombolysis…I just stented the occlusion."
ANESTHESIA: MAC
*
PREOPERATIVE DIAGNOSIS: *ACUTE STROKE SECONDARY TO RIGHT ICA AND M1
TANDEM LESIONS
*
POSTOPERATIVE DIAGNOSIS: *ACUTE STROKE SECONDARY TO RIGHT INTERNAL
CAROTID ARTERY OCCLUSION AND RIGHT M1 OCCLUSION WITH RECANALIZATION
OF THE M1 WITH TPA
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *LESS THAN 200 CC
*
TIME IN: 21:41
*
ACCESS TIME: 21:52
*
ICA RECANALIZATION TIME 22:05
*
RECANALIZATION (TICI) GRADE: 3
*
INDICATIONS: *
The patient is a 64 year old male with diabetes who at 18:00 4/4/17
suffered sudden onset of left sided weakness and dysarthria. He was
brought into XXXX where CT head was negative and CTA
demonstrated likely right ICA occlusion and right M1 occlusion.. He
was given tPA and transferred to xxx for thrombectomy. NIHSS
is 17. mRS is 0. *ASPECTS is 7. * *
*
OPERATION: Left internal carotid artery stenting for acute carotid
occlusion
*
VESSELS SEPARATELY SELECTIVELY CATHETERIZED WITH SELECTIVE
ANGIOGRAPHY: *RIGHT COMMON CAROTID ARTERY; RIGHT INTERNAL CAROTID
ARTERY INTRACRANIAL ANGIOGRAPHY, FOLLOW UP CEREBRAL ANGIOGRAM X 2;
FOLLOW UP CERVICAL ANGIOGRAM X 1 ,
*
PROCEDURE: * *The patient was brought to the Angiographic Suite and
positioned, prepped and draped in the usual sterile fashion. A
time-out was performed. *Once this was done using modified Seldinger
technique with a single wall puncture, a needle, wire and sheath were
introduced into the right common femoral without difficulty or
complication. Once this was completed, a 125 VTK catheter was
advanced over a guidewire up to the aortic arch and was used
separately to catheterize the right common carotid artery.. After
separate selective catheterization, gentle puffs of contrast were
used to confirm no evidence of untoward occurrence and then cervical
angiography was performed. Once this was completed, an 038 Glidewire
was advanced into the common carotid artery and a neuron max was
advanced over the V tek and Neuron max into the right common carotid
artery. Baseline cerebral angiography was then performed.
*
Once this was completed a Synchro 2 standard wire was advanced across
the occlusion without difficulty. A Prowler Select Plus was advanced
over the Synchro 2 Standard into the petrous internal carotid artery.
Intracranial angiography was performed , confirming catheter tip
placement in the ICA. The syncro2standard was removed and a BMW was
brought up in the Prowler Select Plus. The Prowler was removed.
Follow up cervical angiography with the BMW across the lesion
demonstrated the length of the lesion.An integrilin bolus was given
and a drip was started. A 10x29mm carotid wall stent was deployed
across the lesion.
*
Follow up cervical angiography demonstrated good placement of the
stent across the lesion.
*
Follow up cerebral angiography demonstrated no intracranial occlusion
for a TICI3 result.
*
The neuron max was removed and the arteriotomy was closed without
difficulty or complication. The patient was transferred out of the
angio suite with a stable neurologic exam, without signs of
significant hematoma, hemorrhage or loss of distal pulses.
*
FINDINGS:
FEMORAL ANGIOGRAM The right femoral artery is visualized the
vasculature appears to be within normal limits. There is no sign of
significant intimal injury, dissection, dye extravasation or other
untoward recurrence.
*
RIGHT CERVICAL CAROTID VASCULATURE Visualization of the right common,
internal and external carotid arteries. There complete occlusion of
the internal carotid artery 5mm from its origin.
*
RIGHT ICA INTRACRANIAL ANGIOGRAPHY: The microcatheter is located in
the petrous intracranial internal carotid artery. There is no
evidence of intracranial occlusion.
*
Right cervical carotid vasculature after stent placement: The stent
is in good position across the lesion.
*
A follow-up angiogram through the existing catheter after right
carotid stenting demonstrates a well stented right internal carotid
artery with no signs of significant residual stenosis dissection
thrombus or other untoward event.
*
A follow-up angiogram through the existing catheter after right
carotid stenting which demonstrates a stable right intracranial
vasculature. There may be a suggestion of increased perfusion in
general with better collateral flow, however this is not definitive.
Overall there is no sign of any new thromboembolism or untoward event.
*
DYNA CT:
There is increased signal in the right corona radiate and basal
ganglia suggestive of contrast extravasation but may also contain
small areas of hemorrhage. A high quality traditional CT will be
obtained to examine this area further.
Physician billed 37216, 36228, 70450.
We can't bill the 36228 with the 37216 and MCR won't pay for 37216.
Stumped; Can anyone assist?
Physicia stated, "The stroke was caused by right carotid artery occlusion. There was an intracranial occlusion on CT but it had recanalized with tPA prior to my procedure. I did not perform Thrombectomy or thrombolysis…I just stented the occlusion."
ANESTHESIA: MAC
*
PREOPERATIVE DIAGNOSIS: *ACUTE STROKE SECONDARY TO RIGHT ICA AND M1
TANDEM LESIONS
*
POSTOPERATIVE DIAGNOSIS: *ACUTE STROKE SECONDARY TO RIGHT INTERNAL
CAROTID ARTERY OCCLUSION AND RIGHT M1 OCCLUSION WITH RECANALIZATION
OF THE M1 WITH TPA
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *LESS THAN 200 CC
*
TIME IN: 21:41
*
ACCESS TIME: 21:52
*
ICA RECANALIZATION TIME 22:05
*
RECANALIZATION (TICI) GRADE: 3
*
INDICATIONS: *
The patient is a 64 year old male with diabetes who at 18:00 4/4/17
suffered sudden onset of left sided weakness and dysarthria. He was
brought into XXXX where CT head was negative and CTA
demonstrated likely right ICA occlusion and right M1 occlusion.. He
was given tPA and transferred to xxx for thrombectomy. NIHSS
is 17. mRS is 0. *ASPECTS is 7. * *
*
OPERATION: Left internal carotid artery stenting for acute carotid
occlusion
*
VESSELS SEPARATELY SELECTIVELY CATHETERIZED WITH SELECTIVE
ANGIOGRAPHY: *RIGHT COMMON CAROTID ARTERY; RIGHT INTERNAL CAROTID
ARTERY INTRACRANIAL ANGIOGRAPHY, FOLLOW UP CEREBRAL ANGIOGRAM X 2;
FOLLOW UP CERVICAL ANGIOGRAM X 1 ,
*
PROCEDURE: * *The patient was brought to the Angiographic Suite and
positioned, prepped and draped in the usual sterile fashion. A
time-out was performed. *Once this was done using modified Seldinger
technique with a single wall puncture, a needle, wire and sheath were
introduced into the right common femoral without difficulty or
complication. Once this was completed, a 125 VTK catheter was
advanced over a guidewire up to the aortic arch and was used
separately to catheterize the right common carotid artery.. After
separate selective catheterization, gentle puffs of contrast were
used to confirm no evidence of untoward occurrence and then cervical
angiography was performed. Once this was completed, an 038 Glidewire
was advanced into the common carotid artery and a neuron max was
advanced over the V tek and Neuron max into the right common carotid
artery. Baseline cerebral angiography was then performed.
*
Once this was completed a Synchro 2 standard wire was advanced across
the occlusion without difficulty. A Prowler Select Plus was advanced
over the Synchro 2 Standard into the petrous internal carotid artery.
Intracranial angiography was performed , confirming catheter tip
placement in the ICA. The syncro2standard was removed and a BMW was
brought up in the Prowler Select Plus. The Prowler was removed.
Follow up cervical angiography with the BMW across the lesion
demonstrated the length of the lesion.An integrilin bolus was given
and a drip was started. A 10x29mm carotid wall stent was deployed
across the lesion.
*
Follow up cervical angiography demonstrated good placement of the
stent across the lesion.
*
Follow up cerebral angiography demonstrated no intracranial occlusion
for a TICI3 result.
*
The neuron max was removed and the arteriotomy was closed without
difficulty or complication. The patient was transferred out of the
angio suite with a stable neurologic exam, without signs of
significant hematoma, hemorrhage or loss of distal pulses.
*
FINDINGS:
FEMORAL ANGIOGRAM The right femoral artery is visualized the
vasculature appears to be within normal limits. There is no sign of
significant intimal injury, dissection, dye extravasation or other
untoward recurrence.
*
RIGHT CERVICAL CAROTID VASCULATURE Visualization of the right common,
internal and external carotid arteries. There complete occlusion of
the internal carotid artery 5mm from its origin.
*
RIGHT ICA INTRACRANIAL ANGIOGRAPHY: The microcatheter is located in
the petrous intracranial internal carotid artery. There is no
evidence of intracranial occlusion.
*
Right cervical carotid vasculature after stent placement: The stent
is in good position across the lesion.
*
A follow-up angiogram through the existing catheter after right
carotid stenting demonstrates a well stented right internal carotid
artery with no signs of significant residual stenosis dissection
thrombus or other untoward event.
*
A follow-up angiogram through the existing catheter after right
carotid stenting which demonstrates a stable right intracranial
vasculature. There may be a suggestion of increased perfusion in
general with better collateral flow, however this is not definitive.
Overall there is no sign of any new thromboembolism or untoward event.
*
DYNA CT:
There is increased signal in the right corona radiate and basal
ganglia suggestive of contrast extravasation but may also contain
small areas of hemorrhage. A high quality traditional CT will be
obtained to examine this area further.