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Bilateral or unilateral billable?

  1. Default Bilateral or unilateral billable?
    Medical Coding Books
    The consent form for this procedue was for peripheral but the H&P discusses the right side. I chose to bill only for unilateral based on this but the doctor actually gives enough findings for bilateral. I feel the study was actually for the right side. It was suggested that because the patient had a stent on the left side the doctor would want to see that as well so bilateral would be correct. I'm just not sure I agree.
    Any thoughts? Thanks! Sue

    Preoperative diagnosis: Right foot ulcers

    Postoperative diagnosis: Same

    Procedure: Abdominal aortogram with right lower extremity angiogram

    Anesthesia: Conscious sedation and local

    Indications for procedure: This is an 81-year-old male with a history of severe peripheral vascular disease who presented with new right toe ulcers.

    Details of procedure: The patient was identified and placed supine on the angiography table. Bilateral groins were prepped and draped in the usual sterile fashion. After injection of 2% lidocaine, the left common femoral artery was accessed with an 18-gauge single wall puncture needle. A Bentson wire was inserted and a 4-French sheath was placed. A 4-French pigtail catheter was then advanced into the abdominal aorta. Abdominal aortogram was obtained. The catheter was then pulled down to the aortic bifurcation and bilateral pelvic oblique views were obtained. The pigtail catheter was then exchanged for a 4-French Berenstein catheter. The wire and catheter were then advanced up and over the bifurcation into the distal external iliac artery, constituting a second order cannulation. Right leg angiogram was then performed with findings as noted below. All catheters and wires were removed at the conclusion of the procedure and manual compression was used for hemostasis. The patient tolerated the procedure well with no immediate complications.

    Findings:

    1. Patent abdominal aorta and bilateral renal arteries with no evidence of stenosis.

    2. Patent SMA and celiac arteries, the origins of which are not well appreciated on this AP view.

    3. Calcified distal abdominal aorta, widely patent bilateral common iliac arteries. Widely patent right internal iliac artery. Patent right external iliac artery stent with minimal in-stent disease. The left internal iliac artery appears occluded. Patent left external iliac artery stent with minimal in-stent disease.

    4. Patent left common femoral artery, and left profunda femoris arteries. Severely diseased proximal left SFA.

    5. Widely patent right common femoral, and right profunda femoris arteries.

    6. The right SFA is occluded at its origin. There is reconstitution of the at-knee popliteal artery.

    7. The at-knee and below-knee popliteal arteries are patent.

    8. The right anterior tibial artery occludes just distal to its origin. The tibioperoneal trunk has mild disease proximally but is patent. The peroneal artery continues as the primary runoff to the level of the ankle where it gives off anterior and posterior perforators.

    9. The posterior tibial artery is severely diseased and occludes in its midportion. It reconstitutes by way of peroneal collaterals just above the ankle. It continues into the foot as the common plantar artery and gives rise to what appears to be a lateral plantar artery in the foot.

  2. #2
    Default
    Quote Originally Posted by suela923@aol.com View Post
    The consent form for this procedue was for peripheral but the H&P discusses the right side. I chose to bill only for unilateral based on this but the doctor actually gives enough findings for bilateral. I feel the study was actually for the right side. It was suggested that because the patient had a stent on the left side the doctor would want to see that as well so bilateral would be correct. I'm just not sure I agree.
    Any thoughts? Thanks! Sue

    Preoperative diagnosis: Right foot ulcers

    Postoperative diagnosis: Same

    Procedure: Abdominal aortogram with right lower extremity angiogram

    Anesthesia: Conscious sedation and local

    Indications for procedure: This is an 81-year-old male with a history of severe peripheral vascular disease who presented with new right toe ulcers.

    Details of procedure: The patient was identified and placed supine on the angiography table. Bilateral groins were prepped and draped in the usual sterile fashion. After injection of 2% lidocaine, the left common femoral artery was accessed with an 18-gauge single wall puncture needle. A Bentson wire was inserted and a 4-French sheath was placed. A 4-French pigtail catheter was then advanced into the abdominal aorta. Abdominal aortogram was obtained. The catheter was then pulled down to the aortic bifurcation and bilateral pelvic oblique views were obtained. The pigtail catheter was then exchanged for a 4-French Berenstein catheter. The wire and catheter were then advanced up and over the bifurcation into the distal external iliac artery, constituting a second order cannulation. Right leg angiogram was then performed with findings as noted below. All catheters and wires were removed at the conclusion of the procedure and manual compression was used for hemostasis. The patient tolerated the procedure well with no immediate complications.

    Findings:

    1. Patent abdominal aorta and bilateral renal arteries with no evidence of stenosis.

    2. Patent SMA and celiac arteries, the origins of which are not well appreciated on this AP view.

    3. Calcified distal abdominal aorta, widely patent bilateral common iliac arteries. Widely patent right internal iliac artery. Patent right external iliac artery stent with minimal in-stent disease. The left internal iliac artery appears occluded. Patent left external iliac artery stent with minimal in-stent disease.

    4. Patent left common femoral artery, and left profunda femoris arteries. Severely diseased proximal left SFA.

    5. Widely patent right common femoral, and right profunda femoris arteries.

    6. The right SFA is occluded at its origin. There is reconstitution of the at-knee popliteal artery.

    7. The at-knee and below-knee popliteal arteries are patent.

    8. The right anterior tibial artery occludes just distal to its origin. The tibioperoneal trunk has mild disease proximally but is patent. The peroneal artery continues as the primary runoff to the level of the ankle where it gives off anterior and posterior perforators.

    9. The posterior tibial artery is severely diseased and occludes in its midportion. It reconstitutes by way of peroneal collaterals just above the ankle. It continues into the foot as the common plantar artery and gives rise to what appears to be a lateral plantar artery in the foot.
    I like to see a description of the extremity to the popliteal artery to say a full study was done. So I would bill 36246, 75625, 75710.
    Thanks,
    Jim Pawloski, CIRCC

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