PTA/Stent R CIA coding help

missadeel

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Here is the report. I am having trouble coding this.
Thank you!
Melissa


PERIPHERAL ANGIOGRAPHY, (PTA/stent RIGHT CIA below)

INDICATION: Claudication abnormal ABI

DESCRIPTION: Patient was brought to cardiovascular catheterization lab in the fasting and lightly sedated state. The right groin was no size 1% lidocaine without epinephrine. 4 French hemostatic sheath was placed utilizing modified Seldinger technique. Aortoiliac angiography was performed with short pigtail 7mL/s for a total of 10 mL. This was repeated as the first was not performed under digital subtraction. We then were able to select the left iliac over the guidewire and advanced a Glidewire into the SFA but catheter with stopped in the distal EIA given the severe tortuosity in the CIA and EIA. Bolus chase runoff to the ankle was performed. 4 mL/s for a total of 16. Additional spot shot of the distal calf to foot was performed. The catheter was then returned to the aorta. A nitro injection of the right lower extremity was performed and then a pressure pullback across the RCA and the proximal stenosis. The right lower extremity was then injected with bolus chase 4 mL/s a total of 20.

FINDINGS:

Aortic: The distal aorta is patent. There is calcific atherosclerotic disease which is nonocclusive.

Right iliac: Heavily calcified very proximal stenosis with a gradient across it of 30 mmHg. In addition there is moderate disease in the distal CIA to proximal EIA. The hypogastric is patent.

Left iliac: Although patent this is severely tortuous. There are two 180 degree/hairpin turns. 1 of them is in the CIA, and 1 of them is in the EIA. The hypogastric is patent.

Right lower extremity: The CFA is patent. There is peroneal tendon. Profundus patent. The SFA is noted to have mild disease which is moderately calcified into the SFA adductor canal. There is additional mild disease in the popliteal present at the tibial plateau. The AT is approximately occluded. There is a 40% distal TP trunk stenosis which partially involves the PT ostium. Prior to PTA and peroneal are visualized to the ankle.

Left lower extremity: CFA is.. Diffuse disease moderate to severe nature. There is a proximal 80% stenosis and then with up to 80% stenosis adductor canal distal SFA is occluded. Runoff is via the peroneal and PT.

CONCLUSIONS
  1. Severe very proximal RCA stenosis.
  2. Moderate R EIA stenosis
  3. Two-vessel runoff on the right (AT occluded)
  4. Extensive left SFA disease which is heavily calcified.
  5. Two-vessel runoff on the left (AT occluded)

PTA/stent R CIA
 

Jim Pawloski

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I'm not getting 75625 because I don't see any comment of the renals or visceral arteries. I would only code 36246-LT, 75716. A complete aortogram was not performed.
 
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