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Not sure how to code this. Help, please.

  1. #1
    Location
    Columbus, Ohio
    Posts
    30
    Default Not sure how to code this. Help, please.
    Medical Coding Books
    The patient was identified in the preoperative area and taken to the catheterization lab. The patient was prepped and draped in the normal sterile fashion. After the timeout procedure was performed, local anesthetic was infused over the right groin. Under ultrasound guidance, the right common femoral artery was cannulated with a large bore needle. A bentson wire was advanced though the needle into the aorta under fluoroscopic view. The needle was exchanged for a 4 french sheath and an omniflush catheter was advanced into the ascending aorta. The wire was removed and an arch aortogram and great vessel angiogram was performed. Multiple attempts were made to cross the left subclavian artery with a wire. The lesion could not be crossed. The catheter was removed over a wire. The sheath was removed and direct pressure was used to aid in hemostasis.

    Vessel Findings:
    * Cerebrovascular Arteries
    The Aortic arch is angiographically free of disease.

    * Upper Extremity/Thoracic Arteries
    The Ascending aorta is angiographically free of disease.
    The Brachiocephalic/Innominate is angiographically free of disease.
    The Right vertebral is angiographically free of disease.
    The Right subclavian is angiographically free of disease.
    The Right axillary is angiographically free of disease.
    The Right brachial is angiographically free of disease.
    The Right ulnar is angiographically free of disease.
    The Right radial is angiographically free of disease.
    The Right deep palmar arch is angiographically free of disease.
    The Left vertebral is angiographically free of disease.
    The Left axillary is angiographically free of disease.
    The Left profunda brachii is angiographically free of disease.
    The Left brachial is angiographically free of disease.
    The Left ulnar is angiographically free of disease.
    The Left radial is angiographically free of disease.
    The Left deep palmar arch is angiographically free of disease.
    There is a lesion present with 100% stenosis, in the Distal Left Subclavian. No intervention was performed on this Lesion.

    * Lower Extremity Arteries
    The Right Femoral is angiographically free of disease.
    The Right superficial femoral is angiographically free of disease.
    The Left Femoral is angiographically free of disease.
    The Left superficial femoral is angiographically free of disease.



    Lesions:
    Distal Left Subclavian
    Stenosis: 100%

    Total Contrast: 19mls

    TIA,
    Kelly

  2. #2
    Location
    Richardson, TX
    Posts
    823
    Default
    36221
    Julie Graham, BA, CPC, CCC

  3. #3
    Default
    could also bill 76937 for the Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites

  4. #4
    Location
    Richardson, TX
    Posts
    823
    Default
    Quote Originally Posted by davidskm View Post
    could also bill 76937 for the Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites
    Correct, however, 76937-26 also requires, "permanent recording and reporting," a great way to capture this would be to have your physicians make a simple statement; "hard copy saved in patient chart."

    Without this documentation, I would not bill 76937-26.
    Julie Graham, BA, CPC, CCC

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