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Help! Aorto ilio bifemoral angiography/Cath placement

  1. Default Help! Aorto ilio bifemoral angiography/Cath placement
    Medical Coding Books
    I need help to correctly code this report.
    I believe it would be:
    36200
    75630
    36140
    75710
    I am confused if I can bill for cath entrance for aorta, and left and right femoral? Please help!
    SUMMARY:
    Procedures performed: Aorto-ilio-bifemoral angiography. Right common femoral angiography.Complications: No complications occurred during the cath lab visit.
    Indications: Lower extremity: claudication involving the right lower extremity.
    Hemodynamics: Hemodynamic assessment demonstrated no systemic hypertension.
    Aorta:
    Left lower extremity vessels:
    Right lower extremity vessels:
    Procedure: The risks and alternatives of the procedures and conscious sedation were explained to the patient
    and informed consent was obtained. The patient was brought to the cath lab and placed on the table. The
    planned puncture sites were prepped and draped in the usual sterile fashion. ASA rating of 3. Cardiac
    catheterization performed electively. Coronary intervention performed electively. Peripheral catheterization
    performed electively.
    1. Left femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was
    accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was
    advanced over the wire into the vessel.
    2. Aorto-ilio-bifemoral angiography. A catheter was positioned.
    3. Right common femoral angiography. A catheter was positioned under fluoroscopic guidance.
    · Left lower extremity vessels:
    · Left leg angiography demonstrated minor luminal irregularities.
    · Right lower extremity vessels:
    · Right common femoral: There was a discrete 85 % stenosis.
    · Infrarenal abdominal aorta: Normal.
    · Left leg angiography demonstrated minor luminal irregularities.
    · Right lower extremity angiography revealed focal high grade stenosis at the right common femoral artery.
    The remainder of the artery was normal.
    · Right common femoral: There was a discrete 85 % stenosis

  2. #2
    Location
    Birmingham, Alabama
    Posts
    889
    Default
    Quote Originally Posted by thomasgail View Post
    I need help to correctly code this report.
    I believe it would be:
    36200
    75630
    36140
    75710
    I am confused if I can bill for cath entrance for aorta, and left and right femoral? Please help!
    SUMMARY:
    Procedures performed: Aorto-ilio-bifemoral angiography. Right common femoral angiography.Complications: No complications occurred during the cath lab visit.
    Indications: Lower extremity: claudication involving the right lower extremity.
    Hemodynamics: Hemodynamic assessment demonstrated no systemic hypertension.
    Aorta:
    Left lower extremity vessels:
    Right lower extremity vessels:
    Procedure: The risks and alternatives of the procedures and conscious sedation were explained to the patient
    and informed consent was obtained. The patient was brought to the cath lab and placed on the table. The
    planned puncture sites were prepped and draped in the usual sterile fashion. ASA rating of 3. Cardiac
    catheterization performed electively. Coronary intervention performed electively. Peripheral catheterization
    performed electively.
    1. Left femoral artery access. The puncture site was infiltrated with local anesthetic. The vessel was accessed using the modified Seldinger technique, a wire was threaded into the vessel, and a sheath was advanced over the wire into the vessel. (which vessel?)
    2. Aorto-ilio-bifemoral angiography. A catheter was positioned. (where?)
    3. Right common femoral angiography. A catheter was positioned under fluoroscopic guidance. (where?)
    4.Left lower extremity vessels:
    · Left leg angiography demonstrated minor luminal irregularities.
    · Right lower extremity vessels:
    · Right common femoral: There was a discrete 85 % stenosis.
    · Infrarenal abdominal aorta: Normal.
    · Left leg angiography demonstrated minor luminal irregularities.
    · Right lower extremity angiography revealed focal high grade stenosis at the right common femoral artery.
    The remainder of the artery was normal.
    · Right common femoral: There was a discrete 85 % stenosis

    Well, all I see clearly documented is a runoff study (75630). Even the catheter position is omitted. Perhaps you could get the physician to revise the report to include the critical points above?

    HTH
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Location
    Alexandria, LA
    Posts
    518
    Default
    I agree with Danny. I wouldn't code based on this report. It should go back for addendum.

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