Selective cath placement and angiography of right/left subclavian, internal mammary, right vertebral and right common carotid during LHC with grafts

mcauffman86

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My provider documents that he did a selective cath placements and angiography of several different vessels during a LHC with bypass grafts. However I am very unsure of what codes to use.

I was thinking 93459-26-59 (LHC with angiography of bypass grafts),
36215-LT ( selective cath placement in left subclavian artery)
36217-59-RT (selective cath placements in right innominate artery, right internal mammary artery, right vertebral and right common carotid)
and I am unsure of what S&I codes to use for the imaging as well.....75716??

I am really confused on this one!
HELP!

Procedure Performed:

1. Fluoroscopy of the left precordial area
2. Placement of sheath to right common femoral artery
3. Selective right and left coronary artery angiography
4. Left ventriculography
5. Selective cannulation of the saphenous venous graft X1
6. Selective cannulation of left subclavian artery first pass of the
7. Selective angiography of the innominate and right subclavian artery first-pass at the catheter sitting in this innominate artery
8. Right internal mammary artery angiography second order
9. Right vertebral artery angiography, first-pass ordered with the selective cannulation of Right vertebral artery
10. Selective right common carotid artery angiography first-pass order
11. Perclose of right common femoral artery

Procedure Technique:

Left heart catheterization and coronary angiography was performed via Judkins technique using the right common femoral artery. Hemodynamic recordings were made in the ascending aorta at rest. Selective coronary angiography was performed with injections of visapaque in both RAO and LAO projections at various degrees of obliquity, using a Judkins RCA and LCA catheter. A pigtail catheter was then advanced to the ascending aorta and subsequently to the left ventricle where hemodynamic recordings were obtained. Contrast left ventriculography was then performed at 30 degree RAO using 20 mL of visapaque delivered with a power injector. A pullback hemodynamic recording was then made from LV to AO. The catheter was then withdrawn and Perclose was applied to the right groin. Both good hemostasis and pedal pulses were obtained. The patient tolerated the procedure well and left the laboratory in satisfactory condition.
Saphenous venous graft was cannulated with 6 French t internal mammary artery diagnostic catheter
Selective cannulation of right vertebral artery was done with internal mammary artery diagnostic catheter
Selective cannulation of the right innominate artery or right subclavian artery as well as right internal mammary artery evaluation by Judkins right diagnostic catheter
Selective cannulation of the left subclavian artery with Judkins right diagnostic catheter

Angiographic Data:
Right coronary artery Arises From the right sinus of Valsalva complete occlusion possible was a nondominant artery

Left main artery arises from the left sinus of Valsalva calcification distal tapering with moderate stenosis 50-60%

Left anterior descending artery arises from the left main artery was the ventricular groove asked him has got 70% stenosis multiple lesion proximal to the mid segment calcification about 80-90% is noted and then in the mid segment it shows a retrograde flow of left internal mammary artery graft and after the graft attachment mid to distal LAD does not show discrete lesion but has fibrin small vessel.

Left circumflex artery Arises from the left main artery gives rise to a first obtuse marginal branch that is completely occluded after the AV groove branch was possibly a dominant vessel

Left ventriculogram performed in 30° projection no significant regional wall motion abnormality noted. Ejection fraction is 50% no significant mitral regurgitation is noted there was no gradient across the aortic wall was noted.

Saphenous venous graft arises from the one in origin and that bifurcates into 2 long branches which is attached distally to the first obtuse marginal branch of the left posterior descending artery both native artery is a small vessel but no discrete lesions are noted in the graft or the small native vessels after the attachment

Left subclavian artery completely occluded circumflex at its origin

Innominate vessel severely tortuous and plaque irregularities noted with moderate stenosis right subclavian artery shows tortuosity and plaque irregularity

Right internal mammary artery is patent and free

Right common carotid artery is totally occluded

The right vertebral artery has ostial stenosis of 70% shows antegrade flow and doesn't leak is situated and shows retrograde flow of the left vertebral artery to fill of the subclavian artery
 

arclayton

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I would use 93459 and 36226. CPT Assistant, December 2011, states the subclavian and internal mammary catheterization is included in 93459.
 
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