Question RIGHT INNOMINATE ARTERY ANGIOGRAM AND STENT PLACEMENT WITH CAROTID ARTERY EMBOLIC PROTECTION

mcauffman86

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Saint Joseph, MI
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How would the following op report be coded? I am really hung up on this one since the report states that the stent was placed in the right innominate artery, but embolic protection was used in the right common carotid??? I am going back and forth on whether 37215 would be the correct code or not..........

Pre-Operative Diagnosis: Severe right innominate stenosis invovling the right subclavian artery and Carotid artery stenosis

Post-Operative Diagnosis: same

PROCEDURE:

RIGHT INNOMINATE ARTERY ANGIOGRAM AND STENT PLACEMENT WITH CAROTID ARTERY EMBOLIC PROTECTION.

INDICATION FOR PROCEDURE:
Patient is referred for cardiovascular evaluation due to symptomatic carotid artery and subclavian artery stenosis.
Patient reported long history of dizziness and near syncope.
Due to increasing dizziness patient had a recent hospital workup and was found to have chronic left carotid artery occlusion.
There is also severe right common carotid artery ossification and evidence of right subclavian artery calcification and stenosis with possible right subclavian steal syndrome.
Patient had carotid angiogram and was found to have an 90% severely calcified right innominate artery involving the right subclavian and the right common carotid artery.
Lesion appeared calcific bulky and high risk for embolization.
Due to severe symptoms of dizziness for subclavian steal and diffuse carotid stenosis patient is very symptomatic.
Patient is recommended to have right innominate artery stent placement with right carotid artery embolic protection.

NAME OF PROCEDURE:
1. Arterial access via the right groin.
2. Selective right innominate artery and right carotid artery angiogram.
3. Embolic protection of the right carotid artery using a 7.5 Accunet filter.
5. Angioplasty of the right innominate artery using a 4 x 20 balloon and post-dilatation using a 6 x 20 balloon.
6. Stent placement using a 7 x 18 mm Herculink stent.
7. Thrombectomy using a PriorityOne catheter.

Moderate sedation performed using IV Versed and Fentanyl.
Patient received continuous EKG, hemodynamic and oximetry monitoring.
The attending physician was present and/or scrubbed for the entire procedures.
Duration: 46 minutes.
Total moderate sedation duration = 46 min. .

DESCRIPTION OF PROCEDURE:
The patient was premedicated with Versed and fentanyl and was brought into the cath lab in a fasting state. Lidocaine 1% was used as a local anesthetic. After the right groin was anesthetized, vascular access was achieved without difficulty using a 8-French arterial sheath. Subsequently, an 8F Hockey stick guiding catheter was advanced from the right groin into the right innominate artery without difficulty. Angiography demonstrated a 95% severely calcified tubular stenosis branches into the right subclavian and right common carotid artery. At this point in time, embolic protection was performed using a 7.5 Accunet filter into the right common carotid artery. Using embolic protection, we were able to balloon the right innominate artery using a 4.0 and 6.0 mm balloon with inadequate result and the right innominate artery was stented using a 7.o x 18 mm Herculink stent. We performed thrombectomy to remove any residual debris below the em bolic protection. After that, we removed the embolic protection device without difficulty.
Post-angiogram demonstrated 20% stenosis post-stent placement with good result.
The patient tolerated the procedure well and was transferred to CVL recovery for post-procedure management.

FLUOROSCOPY:
Demonstrated right carotid artery calcification.

CINE INTERPRETATION:
The 95% right innominate artery stenosis supplying the right subclavian and right carotid artery was reduced to 20% post-angioplasty, thrombectomy with embolic protection without complication.
 

arclayton

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I would use 37218 for stenting of the innominate. 37215 is used for carotid stents placed in the cervical portion of the carotid artery. The innominate is in the intrathoracic portion.
 
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