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Peripheral study/stenting...

  1. #1
    Question Peripheral study/stenting...NEED HELP
    Medical Coding Books
    Ok, this one is a new one for me. i don't think i've ever had all of these in one procedure. Just wanting to make sure I haven't missed anything.. so far i have:
    37224
    37221
    71710-26
    75650-26
    36217-59
    75625-26

    Any help is very much appreciated!!

    PROCEDURES: Aortic Root Angiography, Selective Right
    Brachiocephalic Angiography, Selective Common Carotid
    Angiography, Selective Left Vertebral Angiography. Selective
    Abdominal Aortogram at the level of the renal arteries, Abdominal
    Aortogram at the level of the Iliac Bifurcation, Selective Right
    Common Iliac angiogram.

    Angioplasty of the right common femoral, and Stenting of the
    ostium of the right common iliac.

    INDICATIONS: Claudication with ABI of .6 on the right.

    History of brachiocephalic stenting in 2005, recent Doppler
    revealing subclavian steal on the right and CTA revealing
    significant stenosis of the right branchiocephalic stents.

    No right femoral pulse could be felt. We did feel the ridge,
    which felt to be the artery and were able to cannulate the right
    femoral even though no pulse could be felt. We had to use a
    glide wire to advance to the distal abdominal aorta. This was
    achieved. Angiograms subsequently of the abdominal aorta
    revealed the abdominal aorta to be patent at the level of the
    renal arteries. There was a 30% or so left renal artery
    stenosis. The right renal appeared okay but it was somewhat
    obscured by the mesenteric artery. Below the renal arteries the
    abdominal aorta had about a 30-40% area of narrowing. It was
    focal and had about a 10mm gradient across this area. The distal
    aorta was patent and the left common iliac widely patent. The
    right common iliac had a severe stenosis. There appeared to be a
    70% stenosis at the origin of the right common iliac and there
    was a 40mm gradient across this lesion. The external iliac had
    no flow and the common femoral filled via internal iliac
    collaterals to the profunda and SFA. The external iliac and the
    common femoral were totally occluded with no flow on the right.


    ACCESS: Access through the left femoral was also achieved.

    A 6 French 55 Rabbe sheath placed. Using crossover technique the
    sheath was placed in the proximal iliac on the right. Angiograms
    were obtained and the lesion is again identified. The total
    occlusion of the external iliac and common femoral was crossed.
    The distal common femoral was difficult to cross but this was
    finally achieved with the wire placed into the SFA. A 4.0 X
    150mm balloon was then utilized. Balloon was inflated up to 10
    bars and finally to 14 bars, which is about a 4.4 size. The total
    external iliac and common femoral stenosis was opened with
    excellent results with 0% residual and excellent flow and return
    of the pedal pulses.

    The ostium of the right internal iliac did dissect with placement
    with the crossover technique. This was at the side of the lesion.
    This was subsequently stented with a 7 x 18 balloon expandible
    bare metal stent. There was 0% residual, excellent flow and
    resolution of the dissection with the placement of the ostial
    iliac stent on the right. Post stent placement excellent results
    were obtained with 0% residual and excellent flow. No compromise
    of the left iliac detected.

    AORTIC ROOT ANGIOGRAPHY: Reveals total occlusion of the
    branchiocephalic on the right with delayed collateral filling
    from the subclavian, the subclavian via the basilar artery. The
    left common carotid and the left subclavian appeared normal.

    SELECTIVE RIGHT BRACHIOCEPHALIC ANGIOGRAM: Reveals the proximal
    ostial branchiocephalic stent to be totally occluded. There is no
    filling of the brachiocephalic, carotid or subclavian noted by
    antegrade flow.

    LEFT COMMON CAROTID ANGIOGRAM: This reveals the common carotid to
    be widely patent with no stenosis. There is minimal stenosis or
    irregularity at the origin of the internal carotid. There is
    excellent filling of the anterior middle cerebrals from the left
    carotid.

    LEFT VERTEBRAL ANGIOGRAPHY: This reveals the left vertebral to be
    very large, widely patent and via the basilar artery. Retrograde
    flow down the right vertebral filling the right subclavian with
    retrograde flow back to the brachiocephalic and also filling the
    right carotid. The basilar artery also supplies both posterior
    cerebral arteries. There is again collateral flow from the
    vertebral on the left to the right subclavian via the right
    vertebral that supplies the right subclavian, also the right
    carotid and the right carotid supplies the anterior middle
    cerbral normally on the right by this collateral flow.

    CONCLUSION:
    1. Total occlusion of the right brachiocephalic with total
    occlusion of previously placed right brachiocephalic stents
    (placed 2005).
    2. Collateral filling of the right common carotid and the right
    subclavian via subclavian steal mechanism via widely patent
    left vertebral basilar system.
    3. Left common carotid, internal carotid widely patent with
    minimal disease as described at the internal carotid origin.
    Last edited by sslater; 06-29-2011 at 02:55 PM.

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by sslater View Post
    Ok, this one is a new one for me. i don't think i've ever had all of these in one procedure. Just wanting to make sure I haven't missed anything.. so far i have:
    37224
    37221
    71710-26
    75650-26
    36217-59
    75625-26

    Any help is very much appreciated!!

    PROCEDURES: Aortic Root Angiography, Selective Right
    Brachiocephalic Angiography, Selective Common Carotid
    Angiography, Selective Left Vertebral Angiography. Selective
    Abdominal Aortogram at the level of the renal arteries, Abdominal
    Aortogram at the level of the Iliac Bifurcation, Selective Right
    Common Iliac angiogram.

    Angioplasty of the right common femoral, and Stenting of the
    ostium of the right common iliac.

    INDICATIONS: Claudication with ABI of .6 on the right.

    History of brachiocephalic stenting in 2005, recent Doppler
    revealing subclavian steal on the right and CTA revealing
    significant stenosis of the right branchiocephalic stents.

    No right femoral pulse could be felt. We did feel the ridge,
    which felt to be the artery and were able to cannulate the right
    femoral even though no pulse could be felt. We had to use a
    glide wire to advance to the distal abdominal aorta. This was
    achieved. Angiograms subsequently of the abdominal aorta
    revealed the abdominal aorta to be patent at the level of the
    renal arteries. There was a 30% or so left renal artery
    stenosis. The right renal appeared okay but it was somewhat
    obscured by the mesenteric artery. Below the renal arteries the
    abdominal aorta had about a 30-40% area of narrowing. It was
    focal and had about a 10mm gradient across this area. The distal
    aorta was patent and the left common iliac widely patent. The
    right common iliac had a severe stenosis. There appeared to be a
    70% stenosis at the origin of the right common iliac and there
    was a 40mm gradient across this lesion. The external iliac had
    no flow and the common femoral filled via internal iliac
    collaterals to the profunda and SFA. The external iliac and the
    common femoral were totally occluded with no flow on the right.


    ACCESS: Access through the left femoral was also achieved.

    A 6 French 55 Rabbe sheath placed. Using crossover technique the
    sheath was placed in the proximal iliac on the right. Angiograms
    were obtained and the lesion is again identified. The total
    occlusion of the external iliac and common femoral was crossed.
    The distal common femoral was difficult to cross but this was
    finally achieved with the wire placed into the SFA. A 4.0 X
    150mm balloon was then utilized. Balloon was inflated up to 10
    bars and finally to 14 bars, which is about a 4.4 size. The total
    external iliac and common femoral stenosis was opened with
    excellent results with 0% residual and excellent flow and return
    of the pedal pulses.

    The ostium of the right internal iliac did dissect with placement
    with the crossover technique. This was at the side of the lesion.
    This was subsequently stented with a 7 x 18 balloon expandible
    bare metal stent. There was 0% residual, excellent flow and
    resolution of the dissection with the placement of the ostial
    iliac stent on the right. Post stent placement excellent results
    were obtained with 0% residual and excellent flow. No compromise
    of the left iliac detected.

    AORTIC ROOT ANGIOGRAPHY: Reveals total occlusion of the
    branchiocephalic on the right with delayed collateral filling
    from the subclavian, the subclavian via the basilar artery. The
    left common carotid and the left subclavian appeared normal.

    SELECTIVE RIGHT BRACHIOCEPHALIC ANGIOGRAM: Reveals the proximal
    ostial branchiocephalic stent to be totally occluded. There is no
    filling of the brachiocephalic, carotid or subclavian noted by
    antegrade flow.

    LEFT COMMON CAROTID ANGIOGRAM: This reveals the common carotid to
    be widely patent with no stenosis. There is minimal stenosis or
    irregularity at the origin of the internal carotid. There is
    excellent filling of the anterior middle cerebrals from the left
    carotid.

    LEFT VERTEBRAL ANGIOGRAPHY: This reveals the left vertebral to be
    very large, widely patent and via the basilar artery. Retrograde
    flow down the right vertebral filling the right subclavian with
    retrograde flow back to the brachiocephalic and also filling the
    right carotid. The basilar artery also supplies both posterior
    cerebral arteries. There is again collateral flow from the
    vertebral on the left to the right subclavian via the right
    vertebral that supplies the right subclavian, also the right
    carotid and the right carotid supplies the anterior middle
    cerbral normally on the right by this collateral flow.

    CONCLUSION:
    1. Total occlusion of the right brachiocephalic with total
    occlusion of previously placed right brachiocephalic stents
    (placed 2005).
    2. Collateral filling of the right common carotid and the right
    subclavian via subclavian steal mechanism via widely patent
    left vertebral basilar system.
    3. Left common carotid, internal carotid widely patent with
    minimal disease as described at the internal carotid origin.
    I have:
    37221 R iliac stent
    37224 R fem angioplasty
    36215-59 R Brachiocephalic
    36215-59 L com carotid
    36216 L Vert
    75650 Arch aorta
    75658 Brachial
    75625 Abd aorta
    75676 L com carotid
    75685 L Vert

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Default
    Thank you!! I went back and redone it but i was still missing a couple!! This one definitely overwhelmed me!!

    Thanks again!!

  4. Default
    Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?

    I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.

    What are your thoughts?

  5. Default
    Quote Originally Posted by kcassidy View Post
    Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?

    I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.

    What are your thoughts?
    Here are my thoughts.

    I see all the documentation for the peripheral PTA/Stent codes. Where is the cath placement documentation for the 36215,16? I dont see where it says the cath was placed in any of these vessels. I see the results only. I didn't think the word Selective was enough to use the cath placement codes. Even though the physician probably did place the cath's the docuementation doesn't prove it. For the abdominal angiogram at the level of the renals 75630 I believe is the code because it looks to me it was one shot at the level of the renals and the interpretation is of the renals,aorta and all the way down to the iliacs. What are your thoughts on this?

    Am I not seeing this whole report?
    Theresa CCS-P CPMA CCC ICDCT-CM

  6. #6
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by kcassidy View Post
    Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?

    I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.

    What are your thoughts?

    hmmm...you're right, I had over looked the word "retrograde". Still, the angiography is not of the upper extremity (75710) so it doesn't meet that definition either. So, if I am to err on the side of caution, I would stick with 75658. The other choice is not to code that portion of the procedure. I will try to find some liturature on this, stay tuned...

    ok, I don't have good information but I have read enough to admit I wrong. The industry standard seems to support 75710 for a brachiocephalic injection and angiography. Please ignore my suggestion of 75658, that is reserved for a retrograde brachial angiography (36120/75658).
    Last edited by dpeoples; 07-29-2011 at 02:43 PM. Reason: changing my answer
    Danny L. Peoples
    CIRCC,CPC

  7. #7
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by theresa.dix@ethc.com View Post
    Here are my thoughts.

    I see all the documentation for the peripheral PTA/Stent codes. Where is the cath placement documentation for the 36215,16? I dont see where it says the cath was placed in any of these vessels. I see the results only. I didn't think the word Selective was enough to use the cath placement codes. Even though the physician probably did place the cath's the docuementation doesn't prove it. For the abdominal angiogram at the level of the renals 75630 I believe is the code because it looks to me it was one shot at the level of the renals and the interpretation is of the renals,aorta and all the way down to the iliacs. What are your thoughts on this?

    Am I not seeing this whole report?
    I would also prefer better documentation of catheter movement/placement. However, I am relying on the word "selective" to mean these vessels were "selected" in my coding choices.
    Danny L. Peoples
    CIRCC,CPC

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