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Thread: cerebral angiogram

  1. #1

    Default cerebral angiogram

    Hello All !!!

    Can we code the below procedure with

    36217(R.cerebral)
    36216-59(L.cerebral)
    75671
    75650


    CLINICAL INDICATION: Possible vasculitis with pacemaker precluding
    performance of MRI. Recent possible right cerebral subacute infarction.
    After obtaining informed consent, the patient was placed in the supine
    position and the right groin prepped and draped in a sterile fashion.
    The skin was anesthetized with 1% lidocaine. An 18 gauge single-wall
    needle was used to access right groin/right common femoral artery. Using
    Seldinger technique, a Fr vascular sheath was placed.
    Via a 5 Fr sheath, a 5 Fr pigtail catheter was placed at the level of the
    ascending thoracic aorta and a thoracic aortogram performed in the LAO
    projection. This revealed normal origins to the great vessels. Minimal
    narrowing was identified involving the left vertebral artery
    approximately 5 cm distal to its origin, extending for a length of 1 cm.
    The left vertebral artery appears slightly dominant to the right
    vertebral artery.
    Each of the cerebral arteries was selectively catheterized with a 5 Fr
    Davis catheter. Digital subtraction arteriography in multiple projections
    was performed.
    The patient tolerated the procedure well and there was no hematoma or
    change in the distal vascular examination. The patient was transported
    to her room in stable condition.
    FINDINGS:
    Thoracic aortogram as described above reveals normal origins to the great
    vessels. There is minimal narrowing involving the left vertebral artery
    which was likely injected and revealed only a minimal approximately 20%
    smooth narrowing for a length of 1 cm.
    The vessels have normal caliber without stenosis, acute cut-off, filling
    defect, beading, or aneurysm.
    IMPRESSION:
    Normal four vessel cerebral arteriogram.
    Prabha CPC

  2. #2
    Join Date
    Apr 2007
    Location
    Birmingham, Alabama
    Posts
    886

    Default

    Quote Originally Posted by prabha View Post
    Hello All !!!

    Can we code the below procedure with

    36217(R.cerebral)
    36216-59(L.cerebral)
    75671
    75650


    CLINICAL INDICATION: Possible vasculitis with pacemaker precluding
    performance of MRI. Recent possible right cerebral subacute infarction.
    After obtaining informed consent, the patient was placed in the supine
    position and the right groin prepped and draped in a sterile fashion.
    The skin was anesthetized with 1% lidocaine. An 18 gauge single-wall
    needle was used to access right groin/right common femoral artery. Using
    Seldinger technique, a Fr vascular sheath was placed.
    Via a 5 Fr sheath, a 5 Fr pigtail catheter was placed at the level of the
    ascending thoracic aorta and a thoracic aortogram performed in the LAO
    projection. This revealed normal origins to the great vessels. Minimal
    narrowing was identified involving the left vertebral artery
    approximately 5 cm distal to its origin, extending for a length of 1 cm.
    The left vertebral artery appears slightly dominant to the right
    vertebral artery.
    Each of the cerebral arteries was selectively catheterized (should be specified and detailed to include the catheter end positions, ie Right Internal Carotid etc)

    with a 5 Fr
    Davis catheter. Digital subtraction arteriography in multiple projections was performed. The patient tolerated the procedure well and there was no hematoma or change in the distal vascular examination. The patient was transported to her room in stable condition.
    FINDINGS:
    Thoracic aortogram as described above reveals normal origins to the great
    vessels. There is minimal narrowing involving the left vertebral artery
    which was likely injected and revealed only a minimal approximately 20%
    smooth narrowing for a length of 1 cm.
    The vessels have normal caliber (what vessels?) without stenosis, acute cut-off, filling
    defect, beading, or aneurysm.
    IMPRESSION:
    Normal four vessel cerebral arteriogram.
    here goes:
    Normal origins means 3 vessels arising from the aortic arch; the brachiocephalic, left common carotid and left subclavian. So...
    all you really have documented is 36215 (X), and 75650 for the arch angiography and 75685 for the left vertebral angiography.
    See comments in the above note for more specifics.

    HTH
    Danny L. Peoples
    CIRCC,CPC

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