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Vascular HELP PLEASE!!

  1. #1
    Default Vascular HELP PLEASE!!
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    I am sorry if this is already somewhere. I was hoping some one could help me. I am new to vascular coding and need help with the following Op note.... I'm thinking 75716, 75630 and 36245

    PROCEDURES:
    1. Percutaneous right femoral arterial access under direct ultrasound
    guidance.
    2. Cannulation of aorta.
    3. Aortogram.
    4. Bilateral runoff to the ankles.

    INDICATIONS:
    The patient is an 82-year-old man with a history of a left ischemic toe. He
    underwent ultrasound evaluation and the ultrasound showed abnormality at the
    popliteal and distal vessels. He presents now for an angiogram.

    DESCRIPTION OF PROCEDURE:
    The patient was taken to the angiography suite and placed in a supine
    position. Mild sedation was given, and the groins and abdomen were prepped
    and draped in a sterile manner. A 1% lidocaine was used to infiltrate the
    surgical area. Under ultrasound guidance percutaneously, the right femoral
    artery was accessed and a guide wire was inserted under fluoroscopy. Over the
    guide wire, a 4-French introducer was placed. Over the guide wire into the
    introducer, a 4-French pigtail catheter was inserted and guided to the mid
    aorta. An aortogram was performed, the catheter was pulled back to the
    bifurcation of the iliac arteries. Bilateral runoff to the ankles was done.
    The pigtail catheter was removed. The introducer was also removed and
    hemostasis was obtained by direct pressure for 20 minutes. Dressings were
    placed and the patient was transferred to the recovery room stable. No
    complication was seen.

    ESTIMATED BLOOD LOSS:
    Minimal.

    FINDINGS:
    The patient was found to have a torturous aorta, but no hemodynamically
    significant lesions within the aorta.

    On the right side, the iliac system is patent including the common iliac
    artery, the external and internal iliac arteries. The femoral system was also
    patent including the common femoral artery, the superficial femoral artery,
    and the profunda femoris. The superficial femoral artery had no lesions
    within the artery. The above-knee popliteal artery has a small
    atherosclerotic change, which caused a 10% narrowing of the above-knee
    popliteal artery. The popliteal artery was continuous to the sub-trifurcation
    vessels and these included the anterior tibial artery, posterior tibial
    artery, and the peroneal artery. These arteries were continuous down to the
    ankle.

    On the left side, the iliac system was patent including the common iliac,
    internal iliac, and external iliac artery. The femoral system was also patent
    including the common femoral, the superficial femoral artery, and the profunda
    femoris. There were some atherosclerotic changes just above the knee at the
    proximal popliteal artery. However, this cause no narrowing of the artery
    beyond 5%. The popliteal artery itself was widely patent as well as 3-vessel
    runoff to the ankle via the anterior tibial artery, posterior tibial artery,
    and peroneal artery. At this time, the patient will follow up for further
    discussion of the findings as well as further management of his toe.
    Last edited by NancyZ76; 10-30-2018 at 11:23 AM.
    Nancy Z

  2. #2
    Default
    anyone???
    Nancy Z

  3. #3
    Default
    anyone???
    Nancy Z

  4. #4
    Default
    I haven't coded for vascular in a while, but it looks like 36200 and 75630 to me
    Carol Gaston CPC CRC CPCO

  5. #5
    Default
    Quote Originally Posted by cgaston View Post
    I haven't coded for vascular in a while, but it looks like 36200 and 75630 to me

    Thank you!!
    Nancy Z

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