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Thread: bilateral carotids &left subclavian

  1. #1

    Default bilateral carotids &left subclavian

    for the following report; would the correct codes be? thanks for your assistance!

    93459, 36215, 36216,36216,75680,75710

    After obtaining informed consent, the patient was transported in
    the nonsedated condition to the cardiac catheterization suite. The
    patient was prepped and draped in a sterile fashion. Lidocaine 2%
    was used to infiltrate the skin and subcutaneous tissue overlying
    the right common femoral artery. A #6 French introducer sheath
    was placed in the right common femoral artery utilizing the
    Seldinger technique. A #6 French multipurpose catheter was then
    used to cross the aortic valve, measure end-diastolic pressure,
    and pullback across the aortic valve. The multipurpose catheter
    was used for left and right coronary angiography and saphenous
    vein angiography. It was exchanged for a mammary catheter with
    which we performed left subclavian angiography due to the presence
    of a plaque at the origin of the left subclavian artery. Left
    internal mammary angiography, left and right carotid angiography.
    A Perclose was deployed in the right common femoral artery at
    completion of the procedure with adequate achievement of
    hemostasis after angiography demonstrated an arteriotomy above the
    bifurcation suitable for closure device.
    CAROTID ANGIOGRAPHY:
    The right common carotid artery appears angiographically free of
    significant plaquing. The right internal carotid artery appears
    widely patent. The anterior, posterior, and middle cerebral
    arteries are patent. There are right-to-left collaterals from the
    right anterior cerebral artery to the left anterior cerebral
    artery through the anterior communicating artery.

    The left common carotid artery appears widely patent. The left
    internal carotid artery has a tubular 40% stenosis.

    LEFT SUBCLAVIAN ANGIOGRAPHY:
    The left subclavian artery has a eccentric plaque at its origin
    with a 50% stenosis. There is no significant gradient upon
    pullback across the left subclavian artery suggesting this is not
    a hemodynamically flow-limiting lesion.

  2. #2
    Join Date
    Apr 2007
    Location
    Birmingham, Alabama
    Posts
    886

    Default

    Quote Originally Posted by maryann1224@bellsouth.net View Post
    for the following report; would the correct codes be? thanks for your assistance!

    93459, 36215, 36216,36216,75680,75710

    After obtaining informed consent, the patient was transported in
    the nonsedated condition to the cardiac catheterization suite. The
    patient was prepped and draped in a sterile fashion. Lidocaine 2%
    was used to infiltrate the skin and subcutaneous tissue overlying
    the right common femoral artery. A #6 French introducer sheath
    was placed in the right common femoral artery utilizing the
    Seldinger technique. A #6 French multipurpose catheter was then
    used to cross the aortic valve, measure end-diastolic pressure,
    and pullback across the aortic valve. The multipurpose catheter
    was used for left and right coronary angiography and saphenous
    vein angiography. It was exchanged for a mammary catheter with
    which we performed left subclavian angiography due to the presence
    of a plaque at the origin of the left subclavian artery. Left
    internal mammary angiography, left and right carotid angiography.
    A Perclose was deployed in the right common femoral artery at
    completion of the procedure with adequate achievement of
    hemostasis after angiography demonstrated an arteriotomy above the
    bifurcation suitable for closure device.
    CAROTID ANGIOGRAPHY:
    The right common carotid artery appears angiographically free of
    significant plaquing. The right internal carotid artery appears
    widely patent. The anterior, posterior, and middle cerebral
    arteries are patent. There are right-to-left collaterals from the
    right anterior cerebral artery to the left anterior cerebral
    artery through the anterior communicating artery.

    The left common carotid artery appears widely patent. The left
    internal carotid artery has a tubular 40% stenosis.

    LEFT SUBCLAVIAN ANGIOGRAPHY:
    The left subclavian artery has a eccentric plaque at its origin
    with a 50% stenosis. There is no significant gradient upon
    pullback across the left subclavian artery suggesting this is not
    a hemodynamically flow-limiting lesion.
    On the surface this seems to be a LHC with grafts, 93459. This would by defintion include selection of the subclavian to view the LIMA. I do not really see selection of the carotid arteries and I am skeptical of the left subclavian injection and interpretation. Was medical necessity for the left subclavian and the carotid circulation documented prior to this exam? Is there more to this report?

    Danny L. Peoples
    CIRCC,CPC

  3. #3

    Default

    thank you danny for taking the time to explain....


    PROCEDURE:
    After obtaining informed consent, the patient was transported in
    the nonsedated condition to the cardiac catheterization suite. The
    patient was prepped and draped in a sterile fashion. Lidocaine 2%
    was used to infiltrate the skin and subcutaneous tissue overlying
    the right common femoral artery. A #6 French introducer sheath
    was placed in the right common femoral artery utilizing the
    Seldinger technique. A #6 French multipurpose catheter was then
    used to cross the aortic valve, measure end-diastolic pressure,
    and pullback across the aortic valve. The multipurpose catheter
    was used for left and right coronary angiography and saphenous
    vein angiography. It was exchanged for a mammary catheter with
    which we performed left subclavian angiography due to the presence
    of a plaque at the origin of the left subclavian artery. Left
    internal mammary angiography, left and right carotid angiography.
    A Perclose was deployed in the right common femoral artery at
    completion of the procedure with adequate achievement of
    hemostasis after angiography demonstrated an arteriotomy above the
    bifurcation suitable for closure device.

    FINDINGS:


    HEMODYNAMICS:
    LV pressure 125/16. Aortic pressure 125/70.

    RAO LEFT VENTRICULOGRAM:
    Not performed secondary to renal insufficiency.

    CORONARY ANGIOGRAPHY:


    LEFT MAIN CORONARY ARTERY:
    Originates from the left coronary cusp. It bifurcates into the
    left anterior descending coronary artery and left circumflex
    artery. The left main coronary artery has mild plaquing in its
    distal third.

    LEFT ANTERIOR DESCENDING CORONARY ARTERY:
    The left anterior descending artery is diffusely diseased
    throughout its proximal and mid segments. In the proximal segment
    there is eccentric plaquing resulting in an eccentric 60% plaque
    prior to the origin of the first diagonal. There is competitive
    flow in the first diagonal vessel from its bypass graft. After
    the first diagonal vessel, the left anterior descending artery is
    severely diseased through its mid segment with a tubular stenosis
    resulting in 90% stenosis. There is competitive flow from the
    mammary graft to the distal LAD.

    LEFT CIRCUMFLEX CORONARY ARTERY:
    The left circumflex artery gives rise to two small obtuse marginal
    vessels and then a large branching mid obtuse marginal vessel. The
    branching mid obtuse marginal vessel has a superior branch with
    nonobstructive atherosclerotic plaquing. There is a large
    inferior branch that is occluded and bypassed. The left
    circumflex continues in the AV groove and a small vessel after the
    mid obtuse marginal vessel is subtotally occluded. There are
    left-to-right collaterals to the occluded posterior descending
    artery and posterolateral branches of the right coronary artery.

    RIGHT CORONARY ARTERY:
    Originates from the right coronary cusp. It is a a anatomically
    dominant vessel. It is occluded distally.

    SAPHENOUS VEIN GRAFTS:
    1. The saphenous vein graft to the diagonal vessel is widely
    patent.
    2. The saphenous vein graft to the inferior branch of the mid
    obtuse marginal vessel is widely patent.
    3. The LIMA to the LAD is patent with a 50% stenosis at the
    anastomosis.

    CAROTID ANGIOGRAPHY:
    The right common carotid artery appears angiographically free of
    significant plaquing. The right internal carotid artery appears
    widely patent. The anterior, posterior, and middle cerebral
    arteries are patent. There are right-to-left collaterals from the
    right anterior cerebral artery to the left anterior cerebral
    artery through the anterior communicating artery.

    The left common carotid artery appears widely patent. The left
    internal carotid artery has a tubular 40% stenosis.

    LEFT SUBCLAVIAN ANGIOGRAPHY:
    The left subclavian artery has a eccentric plaque at its origin
    with a 50% stenosis. There is no significant gradient upon
    pullback across the left subclavian artery suggesting this is not
    a hemodynamically flow-limiting lesion.

    IMPRESSION:
    1. NORMAL LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC PRESSURES.
    2. NO GRADIENT ON PULLBACK ACROSS THE AORTIC VALVE.
    3. LEFT VENTRICULOGRAM NOT PERFORMED SECONDARY TO RENAL
    INSUFFICIENCY.
    4. SEVERE THREE-VESSEL CORONARY ARTERY DISEASE.
    5. STATUS POST A.C.B. WITH THREE OUT OF THREE PATENT GRAFTS.
    6. UNBYPASSED POSTERIOR DESCENDING ARTERY AND POSTEROLATERAL
    BRANCHES.
    7. PATENT CAROTID ARTERIES BILATERALLY WITH A SUBTOTALLY OCCLUDED
    LEFT ANTERIOR CEREBRAL ARTERY FILLING VIA COLLATERALS.

  4. #4
    Join Date
    Apr 2007
    Location
    Birmingham, Alabama
    Posts
    886

    Default

    Quote Originally Posted by maryann1224@bellsouth.net View Post
    thank you danny for taking the time to explain....


    PROCEDURE:
    After obtaining informed consent, the patient was transported in
    the nonsedated condition to the cardiac catheterization suite. The
    patient was prepped and draped in a sterile fashion. Lidocaine 2%
    was used to infiltrate the skin and subcutaneous tissue overlying
    the right common femoral artery. A #6 French introducer sheath
    was placed in the right common femoral artery utilizing the
    Seldinger technique. A #6 French multipurpose catheter was then
    used to cross the aortic valve, measure end-diastolic pressure,
    and pullback across the aortic valve. The multipurpose catheter
    was used for left and right coronary angiography and saphenous
    vein angiography. It was exchanged for a mammary catheter with
    which we performed left subclavian angiography due to the presence
    of a plaque at the origin of the left subclavian artery. Left
    internal mammary angiography, left and right carotid angiography.
    A Perclose was deployed in the right common femoral artery at
    completion of the procedure with adequate achievement of
    hemostasis after angiography demonstrated an arteriotomy above the
    bifurcation suitable for closure device.

    FINDINGS:


    HEMODYNAMICS:
    LV pressure 125/16. Aortic pressure 125/70.

    RAO LEFT VENTRICULOGRAM:
    Not performed secondary to renal insufficiency.

    CORONARY ANGIOGRAPHY:


    LEFT MAIN CORONARY ARTERY:
    Originates from the left coronary cusp. It bifurcates into the
    left anterior descending coronary artery and left circumflex
    artery. The left main coronary artery has mild plaquing in its
    distal third.

    LEFT ANTERIOR DESCENDING CORONARY ARTERY:
    The left anterior descending artery is diffusely diseased
    throughout its proximal and mid segments. In the proximal segment
    there is eccentric plaquing resulting in an eccentric 60% plaque
    prior to the origin of the first diagonal. There is competitive
    flow in the first diagonal vessel from its bypass graft. After
    the first diagonal vessel, the left anterior descending artery is
    severely diseased through its mid segment with a tubular stenosis
    resulting in 90% stenosis. There is competitive flow from the
    mammary graft to the distal LAD.

    LEFT CIRCUMFLEX CORONARY ARTERY:
    The left circumflex artery gives rise to two small obtuse marginal
    vessels and then a large branching mid obtuse marginal vessel. The
    branching mid obtuse marginal vessel has a superior branch with
    nonobstructive atherosclerotic plaquing. There is a large
    inferior branch that is occluded and bypassed. The left
    circumflex continues in the AV groove and a small vessel after the
    mid obtuse marginal vessel is subtotally occluded. There are
    left-to-right collaterals to the occluded posterior descending
    artery and posterolateral branches of the right coronary artery.

    RIGHT CORONARY ARTERY:
    Originates from the right coronary cusp. It is a a anatomically
    dominant vessel. It is occluded distally.

    SAPHENOUS VEIN GRAFTS:
    1. The saphenous vein graft to the diagonal vessel is widely
    patent.
    2. The saphenous vein graft to the inferior branch of the mid
    obtuse marginal vessel is widely patent.
    3. The LIMA to the LAD is patent with a 50% stenosis at the
    anastomosis.

    CAROTID ANGIOGRAPHY:
    The right common carotid artery appears angiographically free of
    significant plaquing. The right internal carotid artery appears
    widely patent. The anterior, posterior, and middle cerebral
    arteries are patent. There are right-to-left collaterals from the
    right anterior cerebral artery to the left anterior cerebral
    artery through the anterior communicating artery.

    The left common carotid artery appears widely patent. The left
    internal carotid artery has a tubular 40% stenosis.

    LEFT SUBCLAVIAN ANGIOGRAPHY:
    The left subclavian artery has a eccentric plaque at its origin
    with a 50% stenosis. There is no significant gradient upon
    pullback across the left subclavian artery suggesting this is not
    a hemodynamically flow-limiting lesion.

    IMPRESSION:
    1. NORMAL LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC PRESSURES.
    2. NO GRADIENT ON PULLBACK ACROSS THE AORTIC VALVE.
    3. LEFT VENTRICULOGRAM NOT PERFORMED SECONDARY TO RENAL
    INSUFFICIENCY.
    4. SEVERE THREE-VESSEL CORONARY ARTERY DISEASE.
    5. STATUS POST A.C.B. WITH THREE OUT OF THREE PATENT GRAFTS.
    6. UNBYPASSED POSTERIOR DESCENDING ARTERY AND POSTEROLATERAL
    BRANCHES.
    7. PATENT CAROTID ARTERIES BILATERALLY WITH A SUBTOTALLY OCCLUDED
    LEFT ANTERIOR CEREBRAL ARTERY FILLING VIA COLLATERALS.
    This does help somewhat. I am still concerned that medical necessity for carotid and left subclavian angiography was not established prior to the exam. None the less, they are codeable IMO.

    I see:
    93459 for the LHC w/graphs
    36215/75710 for left subclavian selection/injection/interpretation
    75680/75671 for bilateral carotid angiography.
    I would not code selection of the carotids as this is not documented, and selection is not required for the angiography codes. These vessels can often be seen from a high aortic injection which would be included with the LHC.

    HTH
    Danny L. Peoples
    CIRCC,CPC

  5. #5

    Default

    thank you, i appreciate you taking the time to explain the reasoning too.

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