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Angiogram

  1. Default Angiogram
    Medical Coding Books
    Can we code the following report with
    36245
    75710-26?

    Clinical information. Status post reopening of a peroneal
    occlusion 4 months ago now with rest pain.

    Procedure.
    Informed consent was obtained. The patient was prepped and draped
    appropriately and after infiltration with local anesthesia the
    right common femoral artery was punctured with a 22 gauge and
    contrast injected. Pressures were measured and compared with
    blood pressure readings in the right arm .

    Given that the SFA was open, an antegrade puncture was performed
    on the right side after infiltration with local anesthesia and a
    5-French sheath introduced. Through this contrast was injected
    with filming down the right leg.

    Findings.
    The superficial femoral artery is patent in continuity with the
    popliteal artery but there is extensive atherosclerotic disease.
    Specifically there is an 80% stenosis in the adductor canal and
    the popliteal artery is extensively diseased before it occludes
    immediately below the knee joint. Reconstitution of a small
    peroneal artery is seen 15 cm distally. There is no
    reconstitution of the anterior or posterior tibial arteries until
    the ankle.
    Attempted angioplasty
    Multiple attempts were made to reopen the peroneal artery
    without success. An attempt was then made at a subintimal
    angioplasty in the superficial femoral artery but this was
    unsuccessful.

    Impression.
    There is occlusion of the distal popliteal artery and proximal
    peroneal artery over 15 cm. Failed attempt at recanalization and
    of a sub intimal angioplasty. There is is reconstitution of the
    anterior and posterior tibial arteries at the ankle.
    Prabha CPC

  2. #2
    Default
    I'm thinking 75710/36140

  3. #3
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by MLS2 View Post
    I'm thinking 75710/36140
    I agree. I also wonder how much work was performed in the "attempt" to open the artery? With better documentation you could probably code for an interventional procedure. The procedure does not have to be successful to be coded, only performed.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  4. #4
    Default
    Quote Originally Posted by dpeoples View Post
    I agree. I also wonder how much work was performed in the "attempt" to open the artery? With better documentation you could probably code for an interventional procedure. The procedure does not have to be successful to be coded, only performed.

    HTH
    I want to code for the catheter placement, thinking of my experience in working these procedures that a catheter is used, but since there really is no mention of a catheter or placement of a balloon catheter, I have to agree with you.

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