Right Innominate Artery & Right Subclavian Artery Angio and Stent

mcauffman86

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Saint Joseph, MI
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Would like some help with how to code this please. I am confused on what codes should be utilized for this case. Thank you!

Procedure Performed:
Aortic arch angiography
Selective right innominate artery right subclavian angiography.
PTA stent proximal innominate artery with a 8 mm x 19 mm Omnilink Stent.
PTA stent proximal right subclavian artery with a 8 mm x 19 mm Omnilink stent.

Pre-Procedure Diagnosis:
symptomatic innominate artery stenosis.
Stenosis of brachiocephalic artery (HCC)

Post-Procedure Diagnosis:
80-90% calcified stenosis proximal right innominate artery.
70% calcified stenosis proximal right subclavian artery.

Case Classification:
Elective/Scheduled

Stress or Imaging Test Performed:
CTA
Previous selective angiography innominate artery right subclavian artery.

Anginal Class:
N/A

Anti-Anginal Meds:
N/A

FluoroTime and Dose:
Radiation Tracking
Event Details User
2:09 PM Radiation Tracking Panel 1: Dale Leffler, DO Total Procedure Dose (uGy-m2) = 6633.210; Air Kerma (mGy) (mGy (milligray)) = 647.000; Fluoro Time (min) = 22.9 ZV



Moderate Sedation:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 63 min.

Estimated Blood Loss:
Minimal

Complications:
No Complications were logged

Procedure Technique:
The risks, benefits, alternatives explained willing to the patient written informed consent was obtained. The patient is brought to the cardiac catheterization laboratory in the postabsorptive state. The left groin was prepped and draped in the usual sterile fashion conscious sedation was administered. Ultrasound was utilized for access as well as fluoroscopy. 1% lidocaine was used for local infiltration 18 x 7 needle was used to access the left common femoral artery under ultrasound guidance. A J-wire was advanced without resistance and a 6 French sheath was placed utilizing the modified salvage technique. Using ultrasound assistance access was obtained and right radial artery utilizing the true Seldinger technique. A 6 French slender sheath was placed. 3000 units intravenous heparin was administered. 5 mg intra-arterial verapamil was administered. A 5 French pigtail catheter was advanced to the aortic arch and digital subtraction angiography in the 30° LAO projection was performed. The pigtail catheter was then exchanged for a 5 French JP to diagnostic catheter which was advanced to the origin of the innominate artery were digital subtraction angiography was performed of the innominate artery proximal right carotid artery and right subclavian artery. A stiff angled Glidewire exchanged length was advanced via the right radial artery across the lesion segments of the right subclavian artery and innominate artery and placed in the aortic root. ACT was drawn and reported out at 300 no additional heparin was administered. 6 mm x 20 mm balloon was advanced to the proximal innominate artery and multiple inflations were performed. Which on to the proximal portion of the right subclavian artery were multiple inflations were performed. Next a 8 mm x 19 mm on the link stent was advanced to the proximal portion of the innominate artery and deployed at 11 atm. A second 8 mm x 19 mm on the link stent was advanced to the proximal portion of the right subclavian artery and deployed at 10 atm. He stent balloon was used for additional inflations of the subclavian as well as innominate artery with inflations up to 16 atm. Moved completion angiography demonstrated 0% residual stenosis in the innominate artery, TIMI-3 flow noted dissection or perforation the right subclavian stent also demonstrates 0% residual stenosis, TIMI-3 flow, no dissection, perforation and antegrade flow via the vertebral artery postintervention. The patient was assessed periodically throughout the procedure for neurological deficits, none occurred. Hemostasis of the right radial artery was obtained with a TR band. Hemostasis of the left common femoral artery was obtained by direct manual pressure. 300 mg of Plavix was given during the procedure. The patient tolerated the procedure well was transported to the holding area in stable condition.

Contrast:
Medication Name Total Dose
iodixanol (Visipaque) 320 mg/mL injection 170 mL


Hemodynamic Data:
Aortic pressure was: 5/5/2021 5/5/2021 5/5/2021
AO Systolic Pressure 134 132 104
AO Diastolic Pressure 70 70 64
AO Mean Pressure 68 96 84


No flowsheet data found.

There was no gradient between the left ventricle and aorta.

Angiographic Data:
Aortic arch angiography: Type III aortic arch with separate ostium for the innominate artery, left common carotid artery and left subclavian artery. There is a 80-90% calcified stenosis involving the proximal portion of the innominate artery. There is ostial calcification at the arch involving the origin of the left common carotid artery with resultant stenosis of 20%. Focal stenosis involving the origin of the left subclavian artery of 20-30%. The left subclavian artery gives rise to a large vertebral artery. The proximal mid and distal portions of the left common carotid artery widely patent. There is a eccentric stent calcified stenosis involving the origin and proximal portion of the right subclavian artery of 70%. He right vertebral artery is not opacified or seen on nonselective images.

Selective angiography right innominate artery: 80-90% calcified stenosis proximal innominate artery. 70% stenosis calcified proximal right subclavian artery.

Final Diagnosis:
1. 80-90% calcified stenosis proximal innominate artery.
2. 70% calcified stenosis proximal right subclavian artery.
3. Successful PTA/stent right innominate artery 8 x 19 Omnilink stent.
4. Successful PTA/stent right proximal subclavian artery 8 x 19 Omnilink stent.
 

such78

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Baldwin Park, CA
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I have 37236, 37237, 36215, 75710-59/XS, 75774, and 76937

Stress or Imaging Test Performed:
CTA
Previous selective angiography innominate artery right subclavian artery ( If patient had a previous angiography was done for both innominate and subclavian arteries, and this surgery was planned after this, 75710 and 75774 may be not reportable.)
 
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