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Is it 36200+?

  1. #1
    Question Is it 36200+?
    Medical Coding Books
    Indication: Severe bilateral claudication, left greater than right.
    Ankle brachial index was less than 0.5. The patient has a prior
    history of stenting to the right superficial femoral artery.

    Protocol: The patient brought to the endovascular laboratory after
    written informed consent was taken. Right groin is prepped and
    draped in usual fashion. Xylocaine was infiltrated. A 5-French
    sheath was placed. A 5-French OmniFlush catheter was advanced to
    the level of L1. Imaging was obtained of the aorta and subsequently
    catheter pulled back above the bifurcation and bolus chases
    performed using 80 mL of contrast. Total contrast used was 100 mL.
    No complications occurred. The sheath was removed with manual
    compression at the end.

    1. The visualized portions of the aorta are normal.
    2. Bilateral renal artery show only mild disease.
    3. Common iliac, external iliac, and internal iliac arteries
    showing mild disease bilaterally.
    4. Right superficial femoral artery demonstrates presence of a
    stent beginning in the middle third and lower third of the
    vessel. There are three separate stents and all three of them
    are occluded with reconstitution of the vessel at the level of
    the popliteal artery and subsequent circulation below the knee
    demonstrates good flow with only mild disease with all three
    vessels being patent. Good three vessel runoff is noted into
    the right foot.
    5. Left circulation revealed superficial femoral artery showing
    mild disease up to 20% plaque and then subsequently popliteal
    arteries without any significant disease.
    6. Left infrapopliteal circulation shows severe disease. Left
    anterior tibial artery has 100% stenosis with presence of
    collateral with a short occlusion reconstituting and supplying
    the foot. The peroneal artery has 99% stenosis and the left
    posterior tibial artery is totally occluded. There is presence
    of three vessel runoff into the foot.


    1. High-grade stenosis bilaterally with intrastent restenosis and
    total occlusion of the right superficial femoral artery.
    2. Total occlusion of all three vessels with two vessel runoff in
    the left foot.

    Plan: Based on these findings, recommend that left anterior tibial
    artery can be revascularized with atherectomy and balloon approach
    and staged process. The patient will be scheduled in two weeks.

    Does this report constitute billing 3620, 75716-26, 75625-26?

  2. #2
    Alexandria, LA
    Yes, 36200 for catheterization of the aorta, 75625 for the abdominal aortogram and 75716 for the extremities.

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