based on the bold lettering above, the documentation is sufficient IMO to code selective cath placements in the common carotid arteries only, 36216 for the rt and 36215 for the left.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 is...is 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?
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