Peripheral angio

em2177

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San Gabriel Valley,CA
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NEED HELP CODING THIS SCENARIO: :confused:

REASON FOR EVALUATION: Peripheral arterial disease.
HISTORY OF THE PRESENT ILLNESS: This patient is well known to me for history
of severe peripheral arterial disease. We had previously fixed his left leg
with long stenting. He has now noticed progressive right lower extremity
typical intermittent claudication, no longer able to walk 5 minutes. He has
had markedly reduced exercise tolerance which has limited his cardiac
rehabilitation.

The patient had a CT angiogram completed in December showing common femoral
artery stenosis, approximately 50%, with multiple stenoses at the SFA which are
high grade, and moderate stenosis of the posterior tibial occlusion of the
anterior tibial and the peroneal vessel. The posterior tibial was patent.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed to the common
femoral area using standard technique. Access was gained to the left common
femoral artery using a micropuncture technique, and a 6-French sheath was
placed to the left common femoral artery. Angiography in multiple views was
completed through the sheath to evaluate the left system, which is heavily
tortuous and extends into a common iliac stent. We also did runoff through the
left 6-French sheath, down the left leg.
At this time we were able to use a Glidewire with considerable difficulty.
However, it was able to go through the stent and up into the aorta, and we were
able to place a 6-French LIMA catheter to the aorta. Glidewire was brought
back, and the LIMA catheter was engaged to the right common iliac segment. The
Glidewire was placed into the right common femoral artery. However, we were
unable to significantly move the sheath past the right common iliac segment.
Thus, the wire was removed, and angiography with the catheter at the level of
the right common iliac was performed down the right leg.
At this point the catheter was removed over the wire, and manual pressure was
held to the left common femoral artery with good groin hemostasis and no
evidence of oozing, bruising, or hematoma.

IMPRESSION:
1. On the right side there is some tortuosity of the right iliac system.
However, it remains widely patent.
2. There is a heavily calcified moderate-to-severe 60-80% lesion of the right
common femoral artery.
3. In the proximal superficial femoral artery there is a chronic total
occlusion. It is a very diffusely heavily calcified vessel with distal
reconstitution from a profunda artery. The popliteal artery is widely
patent. Due to slow flow we are unable to visualize the infrapopliteal
segment.
4. Left common iliac is heavily tortuous. There is a corkscrew-like segment,
just distal to a widely patent common iliac stent.
5. Left common femoral artery is heavily calcified, but is patent with only
mild-to-moderate 30-60% disease.
6. The SFA is patent. There is proximal moderate disease. This is heavily
calcified. There is long stenting of the entire proximal-to-distal SFA
segment with mild in-stent restenosis. This again is heavily calcified.
7. The left popliteal artery is widely open. The proximal segment of the
bifurcation is also patent.

POST PROCEDURE:pOST PROCEDURE: The patient tolerated the procedure well and remained
hemodynamically stable. There is good groin hemostasis. There is no evidence
of oozing, bruising, or hematoma. We will closely follow on medical therapy.
We will need to further discuss his overall risks,
benefits, and alternatives of peripheral bypass surgery.
 

dpeoples

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Location
Birmingham, Alabama
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NEED HELP CODING THIS SCENARIO: :confused:

REASON FOR EVALUATION: Peripheral arterial disease.
HISTORY OF THE PRESENT ILLNESS: This patient is well known to me for history
of severe peripheral arterial disease. We had previously fixed his left leg
with long stenting. He has now noticed progressive right lower extremity
typical intermittent claudication, no longer able to walk 5 minutes. He has
had markedly reduced exercise tolerance which has limited his cardiac
rehabilitation.

The patient had a CT angiogram completed in December showing common femoral
artery stenosis, approximately 50%, with multiple stenoses at the SFA which are
high grade, and moderate stenosis of the posterior tibial occlusion of the
anterior tibial and the peroneal vessel. The posterior tibial was patent.
PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed to the common
femoral area using standard technique. Access was gained to the left common
femoral artery using a micropuncture technique, and a 6-French sheath was
placed to the left common femoral artery. Angiography in multiple views was
completed through the sheath to evaluate the left system, which is heavily
tortuous and extends into a common iliac stent. We also did runoff through the
left 6-French sheath, down the left leg.
At this time we were able to use a Glidewire with considerable difficulty.
However, it was able to go through the stent and up into the aorta, and we were
able to place a 6-French LIMA catheter to the aorta. Glidewire was brought
back, and the LIMA catheter was engaged to the right common iliac segment. The
Glidewire was placed into the right common femoral artery. However, we were
unable to significantly move the sheath past the right common iliac segment.
Thus, the wire was removed, and angiography with the catheter at the level of
the right common iliac was performed down the right leg.
At this point the catheter was removed over the wire, and manual pressure was
held to the left common femoral artery with good groin hemostasis and no
evidence of oozing, bruising, or hematoma.

IMPRESSION:
1. On the right side there is some tortuosity of the right iliac system.
However, it remains widely patent.
2. There is a heavily calcified moderate-to-severe 60-80% lesion of the right
common femoral artery.
3. In the proximal superficial femoral artery there is a chronic total
occlusion. It is a very diffusely heavily calcified vessel with distal
reconstitution from a profunda artery. The popliteal artery is widely
patent. Due to slow flow we are unable to visualize the infrapopliteal
segment.
4. Left common iliac is heavily tortuous. There is a corkscrew-like segment,
just distal to a widely patent common iliac stent.
5. Left common femoral artery is heavily calcified, but is patent with only
mild-to-moderate 30-60% disease.
6. The SFA is patent. There is proximal moderate disease. This is heavily
calcified. There is long stenting of the entire proximal-to-distal SFA
segment with mild in-stent restenosis. This again is heavily calcified.
7. The left popliteal artery is widely open. The proximal segment of the
bifurcation is also patent.

POST PROCEDURE:pOST PROCEDURE: The patient tolerated the procedure well and remained
hemodynamically stable. There is good groin hemostasis. There is no evidence
of oozing, bruising, or hematoma. We will closely follow on medical therapy.
We will need to further discuss his overall risks,
benefits, and alternatives of peripheral bypass surgery.
I would code:
36245/75716

HTH :)
 
Last edited:
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Danny,
Thats ok. I was thinking to myself.. Have I been coding these wrong?! But then remembered the guidelines. :) I figured you had not caught that. ;)
 

Jim Pawloski

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Danny,
Thats ok. I was thinking to myself.. Have I been coding these wrong?! But then remembered the guidelines. :) I figured you had not caught that. ;)
It is stated that a LIMA (wonder if the catheter was suppose to be RIM) catheter was placed into the rt common iliac artery. Isn't that then a first order catheter placement?

Jim Pawloski, CIRCC
 
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626
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It is stated that a LIMA (wonder if the catheter was suppose to be RIM) catheter was placed into the rt common iliac artery. Isn't that then a first order catheter placement?

Jim Pawloski, CIRCC
Jim,
I am thinking when they say Lima Catheter that is a type of cath and yes first order I believe.
 

Jim Pawloski

True Blue
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Location
Ann Arbor
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Jim,
I am thinking when they say Lima Catheter that is a type of cath and yes first order I believe.
It really should be a IMA catheter (used to select the RIMA and LIMA arteries). I was a little confused myself until I read a dictation where the doctor used a IMA catheter. Then it clicked.
Thanks,
Jim Pawloski, CIRCC
 
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