lawrencema1490
New
Can someone please help me with this report. We code from a physician outpatient setting. I feel like my codes are not correct. I got 36257 & 75716-26. Thanks in advanced!
PROCEDURE PERFORMED: Abdominal aortic angiography, selective angiography of the
right renal artery, selective angiography of the left renal artery, PTA of the left
renal artery.
NARRATIVE: Informed consent was obtained from the patient. The patient was prepped
and draped in the usual fashion. One percent lidocaine solution was injected in the
right groin for local anesthesia. IV sedation was performed using Versed and
fentanyl. A 6-French sheath was inserted in the right common femoral artery using
the modified Seldinger technique without complications. Abdominal aortic angiography
was performed using a 6-French straight pigtail catheter. Selective angiography of
the right and left medial arteries was performed using a 6-French FR4 guide catheter.
HEMODYNAMICS: The aortic opening pressure was 192/56 with a mean pressure of 106.
The aortic closing pressure was 183/62 with a mean pressure of 108.
ANATOMY: The abdominal aorta is normal in caliber. There was a single right renal
artery supplying the right kidney that demonstrated it was medium caliber with 30%
proximal stenosis. There was a single left renal artery supplying the left kidney
with 90% in-stent restenosis.
After reviewing the diagnostic images, the decision was made to proceed with
peripheral intervention with PTA of the proximal left renal artery. The patient was
anticoagulated with IV heparin. A BMW wire was placed through the FR4 guide catheter
into the left renal artery. The patient underwent successful PTA of the proximal
left renal artery using a 5.0 x 15 mm Emerge balloon at a maximum of 12 atm. This
resulted in reduction from 90% to less than 10% original stenosis with TIMI 3 flow
and no evidence of distal embolization. Following the intervention, all wires and
catheters were removed. The right femoral artery arteriotomy site underwent
successful closure using a Mynx closure device, resulting in hemostasis achieved with
no hematoma noted at the end of the case.
IMPRESSION:
1. Nonobstructive disease involving the right renal artery.
2. Critical in-stent restenosis involving the left renal artery.
3. Successful PTA of the proximal left renal artery resulting in reduction from 90%
to less than 10% regional stenosis.
4. Successful Mynx closure of the right femoral arteriotomy site.
right renal artery, selective angiography of the left renal artery, PTA of the left
renal artery.
NARRATIVE: Informed consent was obtained from the patient. The patient was prepped
and draped in the usual fashion. One percent lidocaine solution was injected in the
right groin for local anesthesia. IV sedation was performed using Versed and
fentanyl. A 6-French sheath was inserted in the right common femoral artery using
the modified Seldinger technique without complications. Abdominal aortic angiography
was performed using a 6-French straight pigtail catheter. Selective angiography of
the right and left medial arteries was performed using a 6-French FR4 guide catheter.
HEMODYNAMICS: The aortic opening pressure was 192/56 with a mean pressure of 106.
The aortic closing pressure was 183/62 with a mean pressure of 108.
ANATOMY: The abdominal aorta is normal in caliber. There was a single right renal
artery supplying the right kidney that demonstrated it was medium caliber with 30%
proximal stenosis. There was a single left renal artery supplying the left kidney
with 90% in-stent restenosis.
After reviewing the diagnostic images, the decision was made to proceed with
peripheral intervention with PTA of the proximal left renal artery. The patient was
anticoagulated with IV heparin. A BMW wire was placed through the FR4 guide catheter
into the left renal artery. The patient underwent successful PTA of the proximal
left renal artery using a 5.0 x 15 mm Emerge balloon at a maximum of 12 atm. This
resulted in reduction from 90% to less than 10% original stenosis with TIMI 3 flow
and no evidence of distal embolization. Following the intervention, all wires and
catheters were removed. The right femoral artery arteriotomy site underwent
successful closure using a Mynx closure device, resulting in hemostasis achieved with
no hematoma noted at the end of the case.
IMPRESSION:
1. Nonobstructive disease involving the right renal artery.
2. Critical in-stent restenosis involving the left renal artery.
3. Successful PTA of the proximal left renal artery resulting in reduction from 90%
to less than 10% regional stenosis.
4. Successful Mynx closure of the right femoral arteriotomy site.
