Peripheral angio/pta stent report

em2177

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San Gabriel Valley,CA
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REASON FOR EVALUATION: Left subclavian steal.

PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion.
A 6-French sheath was placed to the right common femoral artery using Seldinger
technique. Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed.
At this point, we exchanged the short sheath for a 7-French sheath, and a
7-French jrf JR4 with side-hole guide catheter selectively engaged the left
ostial subclavian, and angiography was performed. Initial attempts to get a
Glide wire across were unsuccessful. Thus we used a CholCE PT2 cardiac wire,
which was placed into the left subclavian. Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed. Next the balloon was removed, and a stent
was attempted to be deployed to the proximal segment; however, this was
unsuccessful. Thus, the whole system was removed.
We exchanged the short sheath for an 8-French sheath and used an 8-French guide
catheter to the ostial left subclavian. A Glide wire was placed across the
vessel again, and an 8 x 40 Protege self-expanding stent was used to the
proximal left subclavian with the distal segment deployed prior to the
vertebral artery. We chose a self-expanding stent as opposed to a balloon
expandable stent due to the concern of a possible thrombus and the severity of
the lesion. Thus, once the stent was deployed, angiography was performed.
We had difficulty placing the postdilatation 7-0 balloon. Thus, we used a PT2
wire in the left subclavian and dilated the proximal portion of the stent with
a 5.0 x 30 Quantum Apex postdilatation balloon. Then we replaced the wire with
a Glide wire, and at this point a 7.0 x 40 postdilatation balloon was able to
be placed over the stented segment with postdilatation to 10 atmospheres.
Postdilatation balloon was removed, and repeat angiography was performed. At
this point, there was antegrade flow of the vertebral. There was brisk flow of
the left subclavian. Post blood pressure measurements showed no gradient and
no blood pressure difference.
The patient was asymptomatic, had a normal hemodynamic response to the
procedure, and felt quite well. The wire and catheter were removed. An
8-French Angio-Seal was placed at the right common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma.

IMPRESSION: Preprccedure proximal left subclavian had an 80% to 90% diffuse
severe stenosis. There was retrograde filling of the vertebral artery and a
blood pressure difference in the arms of 22 mmHg.
Post angioplasty and stenting as above with an 8 x 40 Protege self-expanding
stent and 7.0 postdilatation revealed 0% residual stenosis, brisk flow of the
left subclavian, and noW antegrade flow of the vertebral with zero gradient
across the stented segment.
 

dpeoples

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Birmingham, Alabama
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NEED ASSISTANCE IN CODING THIS REPORT. THANK YOU!!!

REASON FOR EVALUATION: Left subclavian steal.

PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion.
A 6-French sheath was placed to the right common femoral artery using Seldinger
technique. Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed.
At this point, we exchanged the short sheath for a 7-French sheath, and a
7-French jrf JR4 with side-hole guide catheter selectively engaged the left
ostial subclavian, and angiography was performed. Initial attempts to get a
Glide wire across were unsuccessful. Thus we used a CholCE PT2 cardiac wire,
which was placed into the left subclavian. Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed. Next the balloon was removed, and a stent
was attempted to be deployed to the proximal segment; however, this was
unsuccessful. Thus, the whole system was removed.
We exchanged the short sheath for an 8-French sheath and used an 8-French guide
catheter to the ostial left subclavian. A Glide wire was placed across the
vessel again, and an 8 x 40 Protege self-expanding stent was used to the
proximal left subclavian with the distal segment deployed prior to the
vertebral artery. We chose a self-expanding stent as opposed to a balloon
expandable stent due to the concern of a possible thrombus and the severity of
the lesion. Thus, once the stent was deployed, angiography was performed.
We had difficulty placing the postdilatation 7-0 balloon. Thus, we used a PT2
wire in the left subclavian and dilated the proximal portion of the stent with
a 5.0 x 30 Quantum Apex postdilatation balloon. Then we replaced the wire with
a Glide wire, and at this point a 7.0 x 40 postdilatation balloon was able to
be placed over the stented segment with postdilatation to 10 atmospheres.
Postdilatation balloon was removed, and repeat angiography was performed. At
this point, there was antegrade flow of the vertebral. There was brisk flow of
the left subclavian. Post blood pressure measurements showed no gradient and
no blood pressure difference.
The patient was asymptomatic, had a normal hemodynamic response to the
procedure, and felt quite well. The wire and catheter were removed. An
8-French Angio-Seal was placed at the right common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma.

IMPRESSION: Preprccedure proximal left subclavian had an 80% to 90% diffuse
severe stenosis. There was retrograde filling of the vertebral artery and a
blood pressure difference in the arms of 22 mmHg.
Post angioplasty and stenting as above with an 8 x 40 Protege self-expanding
stent and 7.0 postdilatation revealed 0% residual stenosis, brisk flow of the
left subclavian, and noW antegrade flow of the vertebral with zero gradient
across the stented segment.
I would code:
37205/75960
36215

You could also code 75710 for the subclavian angio but I would be reluctant due to the fact that the diagnosis of subclavain steal was already known, and the impression states "preprocedure..." indicating to me that an intervention (stent/plasty) was intented.

I would not code for the arch study (75650) because there is no interpretation of the arch. This was likely a guidance shot.

There are two reasons I would not code angioplasty:
1) the usual treatment for subclavian steal (stenosis of subclavain artery) is stenting, and angioplasty is a normal component of stenting.
2) the documentation states "predilation was performed" . This indicates that angioplasty (dilation) was the beginning of the planned treatment, not the primary planned treatment.

HTH :)
 
Last edited:

jmcpolin

True Blue
Messages
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Location
Midvale, UT
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35475
36215
37205
75960
75962

I would code the angioplasty due to used to treat stenosis.
 
Last edited:

jewlz0879

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Richardson, TX
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I would code:
37205/75960
36215

You could also code 75710 for the subclavian angio but I would be reluctant due to the fact that the diagnosis of subclavain steal was already known, and the impression states "preprocedure..." indicating to me that an intervention (stent/plasty) was intented.

I would not code for the arch study (75650) because there is no interpretation of the arch. This was likely a guidance shot.

There are two reasons I would not code angioplasty:
1) the usual treatment for subclavian steal (stenosis of subclavain artery) is stenting, and angioplasty is a normal component of stenting.
2) the documentation states "predilation was performed" . This indicates that angioplasty (dilation) was the beginning of the planned treatment, not the primary planned treatment.

HTH :)
I agree. You don't code PTA when done for 'predilation.' I also do not code PTA's if the intent of the procedure was a stent and they first used PTA.
 

liz_snyder

Contributor
Local Chapter Officer
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Location
Lima, Ohio
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Thank you. This is very helpful. Can you please tell me what modifiers you would use for each one. I have a very similar procedure and wanted to see if I am on the right track. Thanks again.
 

donnajrichmond

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Alexandria, LA
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NEED ASSISTANCE IN CODING THIS REPORT. THANK YOU!!!

REASON FOR EVALUATION: Left subclavian steal.

PROCEDURE: The patient was brought to the catheterization lab and prepped and
draped in a sterile fashion.
A 6-French sheath was placed to the right common femoral artery using Seldinger
technique. Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed.
At this point, we exchanged the short sheath for a 7-French sheath, and a
7-French jrf JR4 with side-hole guide catheter selectively engaged the left
ostial subclavian, and angiography was performed. Initial attempts to get a
Glide wire across were unsuccessful. Thus we used a CholCE PT2 cardiac wire,
which was placed into the left subclavian. Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed. Next the balloon was removed, and a stent
was attempted to be deployed to the proximal segment; however, this was
unsuccessful. Thus, the whole system was removed.
We exchanged the short sheath for an 8-French sheath and used an 8-French guide
catheter to the ostial left subclavian. A Glide wire was placed across the
vessel again, and an 8 x 40 Protege self-expanding stent was used to the
proximal left subclavian with the distal segment deployed prior to the
vertebral artery. We chose a self-expanding stent as opposed to a balloon
expandable stent due to the concern of a possible thrombus and the severity of
the lesion. Thus, once the stent was deployed, angiography was performed.
We had difficulty placing the postdilatation 7-0 balloon. Thus, we used a PT2
wire in the left subclavian and dilated the proximal portion of the stent with
a 5.0 x 30 Quantum Apex postdilatation balloon. Then we replaced the wire with
a Glide wire, and at this point a 7.0 x 40 postdilatation balloon was able to
be placed over the stented segment with postdilatation to 10 atmospheres.
Postdilatation balloon was removed, and repeat angiography was performed. At
this point, there was antegrade flow of the vertebral. There was brisk flow of
the left subclavian. Post blood pressure measurements showed no gradient and
no blood pressure difference.
The patient was asymptomatic, had a normal hemodynamic response to the
procedure, and felt quite well. The wire and catheter were removed. An
8-French Angio-Seal was placed at the right common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma.

IMPRESSION: Preprccedure proximal left subclavian had an 80% to 90% diffuse
severe stenosis. There was retrograde filling of the vertebral artery and a
blood pressure difference in the arms of 22 mmHg.
Post angioplasty and stenting as above with an 8 x 40 Protege self-expanding
stent and 7.0 postdilatation revealed 0% residual stenosis, brisk flow of the
left subclavian, and noW antegrade flow of the vertebral with zero gradient
across the stented segment.
This is a good case to use to show the doctor how important documentation is - and not just for ICD-10 diagnosis coding.
He says "Next a pigtail was placed into the ascending aorta, and aortic root
angiography to evaluate the arch and the bifurcation vessels were completed." - evaluate for what - roadmapping? or was this a diagnostic exam. He needs to state that and document his findings if it was a diagnostic exam. and before he starts calling every bit of imaging "diagnostic" - he needs to understand the rules in CPT. Copy out the rules that are at the beginning of the angiogram S & I section in the CPT book - show him when an angiogram can be separately coded and when it cannot be. Coders are not mind-readers, and auditors are not going to cut him any slack.

As others have mentioned, his calling the angioplasty "pre-dilation" is going to cost him money. He says "Predilatation was performed with a
4 x 40 Apex balloon to 10 atmospheres. Repeat angiography was performed, and
there was still significant stenosis, and thus proximal to the vertebral,
repeat angioplasty was performed." Now I happen to think that this is a true therapy - he dones one inflation to 10, does follow-up angio and sees there is still stenosis and does another inflation. I don't think that's routine pre-dilation just to get the stent through the artery. But, because he said "pre-dilation", this angioplasty cannot be coded. Since you put this in the cardiology forum my guess is that you have a cardiologist who is used to angioplasty being included in the coronary stenting regardless of why it was done and so he needs to retrain himself to document when a balloon dilation is an angioplasty and when it is pre-dilation for placing a stent.
 
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