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Is this physician documentation sufficient?

  1. Default Is this physician documentation sufficient?
    Medical Coding Books
    I am struggling with coding selective cath placements, it is something that I did not have to do at my previous job and now as Billing Supervisor in my current clinic I need to do it. One of my Drs has done a procedure which he states is selective carotid and cerebral angiography. My question his documentation sufficient to support the coding of this? I do not feel that it is but like I said, I am not familiar with coding this so I am unsure.

    1. Selective carotid/cerebral angiogrpahy
    2. Abdominal aortogram with runoff

    Procedure in detail:

    After informed consent was obtained the patient was brought into the cath lab and placed on the table. The patient was prepped and draped in a sterile fashion. Access was obtained via the right femoral artery via modified Seldinger technique after 1% lidocaine was used to anesthetize the area. A 6-French sheath was placed in the right femoral artery and flushed without any complications. We introduced a 4-French catheter over a 0.035 J-wire. This was used to selectively engage the bilateral carotid arteries using an angle Glidewire wire. Selective shots of the carotids as well as cerebrals were performed. We then introduced a 5-French Omni flush catheter was used to perform abdominal angiography. We crossed over using this. Selective angiogram shots of left lower extremity were taken as well as the right lower extremity through the sheath. The patient tolerated the procedure well. A 6-French Minx was deployed to obtain hemostasis. There were no complications


    1. Left ICA initiated patent fills the MCA and the ACA.
    2. The right ICA and ECA are patent and fills the MCA and ACA on the right.
    3. The right vertebral was patent.
    4. Distal abdominal aorta is patent. There is no evidence of dissection or aneurysm. Bilateral common iliac arteries internal calories of the external iliac arteries are patent. Bilateral superficial femoral artery profounds femoral artery and common femoral arteries are patent. Bilateral popliteals are patent. There is two vessel runoff bilaterally to the foot.

    I am getting 36217 and 36216 for cath placements. Am I anywhere near correct? And is this documentation sufficient?

  2. Default
    His documentation is very vague and only states selective of the carotids but does not state common, internal or external therefore going strictly by his documentation I would code 36216 Rt Carotid and 36215-59 Lt Carotid. He also states selective shots of the left lower extremity but does not state actual cath placement so that can not be billed. He also mentions the vert, but did he actually select it?

    you S & I codes from the dictation would be:

    75671 bilat carotid cerebral
    75680 bilat carotid cervical
    75685 rt vertebral
    75625 aortagram
    75716 bilat extremity

  3. #3
    For this report the documentation is not clear for catheterisation part.u can query your physician about selective catheterisation; if biateral ICA are selected ?as the procedure states selctive cerebreal shots ;for the lower extremities also?
    My coding for the above documentation would be
    36216-rt common carotid
    36215-lt common carotid
    s&i would be

  4. #4
    I would code 36245 for the right to left leg cath placement. The dictation clearly states that he used the 5-French Omni to cross over into the left leg to do selective angio. Because he doesn't state which vessel, use the 1st order only.

    I wouldn't code an abdominal aortogram because he only mentions the distal aorta (that's at the bifurcation. In order to code 75625, the catheter should be at the level of the renals.

    G0269 - Mynx Closure device.

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