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Tag Archives: Angio

need help with vein graft balloon angio only

Posted on by
PROCEDURES
1. Coronary angiogram
2. Left heart catheterization
3. Graft angiogram
4. Percutaneous intervention and balloon angioplasty of vein graft to OM1.
5. Right iliofemoral angiogram

PROCEDURE NOTE
Informed consent was obtained after explaining risks and benefits to the patient. Right groin was draped and prepped in a sterile fashion. Patient was premedicated with 1.5 mg Versed and 100 mcg fentanyl IV. After injecting 2% lidocaine, right common femoral artery was accessed with the help of micropuncture with some difficulty due to previous scarring and 6 French femoral sheath was inserted. 6 French diagnostic catheters were used to cannulate left and right coronary artery. 6 French FR 4 catheter was also used to cannulate the vein grafts. Patient was proceeded with intervention of the vein graft of obtuse marginal branch. Overall patient tolerated procedure well. Right iliofemoral angiogram was performed and femoral sheath was pulled and manual pressure was applied for 20 minutes with good hemostasis. FemoStop was applied at Bell pressure for persistent hemostasis.
*
LEFT HEART CATHETERIZATION
Left ventricular end diastole pressure was 18 mmHg. No significant gradient across aortic valve.

CORONARY ANGIOGRAM
1. Left main was calcified with 70-80% distal stenosis.

2. Left anterior descending artery had severe diffuse disease proximally before it was 100% occluded for previous stents

3. Left circumflex artery was 100% occluded proximally

4. Right coronary artery was under percent occluded at the origin.
*
GRAFT ANGIOGRAM
1. Vein graft to LAD was under percent occluded (chronic)
2. Vein graft to RCA was patent. Stent was noted in the mid body of the graft which was patent with 80% in-stent restenosis. 50-60% stenosis noted in distal RCA after anastomosis before the bifurcation of PDA and PLV branches. PDA branch was patent with no significant disease given collaterals to distal LAD. PLV branch was patent.
3. Vein graft to obtuse marginal branch was patent with TIMI II antegrade flow. Stent at the ostium had 99% in-stent restenosis. There was also 80-90% stenosis of mid part of the body of the graft within the previous stent. Distal part of the vein graft was patent.
*

PERCUTANEOUS INTERVENTION OF VEIN GRAFT OBTUSE MARGINAL BRANCH
6 French JR4 guide catheter was used to cannulate the vein graft to OM 1. Heparin was used for anticoagulation. Initially filter wire was attempted for distal protection which was unsuccessful to advance due to significant ostial stenosis. 0.014 BMW guidewire was advanced and vein graft to OM stenosis was successfully crossed without difficulty. 2.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft was predilated at 16 followed by 18 atm. Nitroglycerin intracoronary was given. Subsequent angiogram revealed TIMI-3 antegrade flow and distal part of the body of the graft but still residual significant stenosis at the ostium. 3.5 x 15 mm noncompliant balloon was advanced and both lesions of vein graft were dilated at 16 atm couple of times. Adenosine followed by nitroglycerin were given through guide catheter. Subsequent angiogram revealed wide-open vein graft to OM with TIMI-3 antegrade flow and no evidence of dissection or perforation. No evidence of distal embolization. Patient was hemodynamically stable and asymptomatic at the end of procedure.

RIGHT ILIOFEMORAL ANGIOGRAM
Right common femoral artery was patent. Sheath insertion was just below the origin of the inferior epigastric artery..

IMPRESSION
1. Severe native 3 vessels coronary artery disease.
2. Patent vein graft to OM1 with 99% ostial stenosis within the stent as well as 80% instent restenosis within the mid body of the graft. (Likely culprit)
3. Patent vein graft to RCA with 80% in-stent restenosis.

RECOMMENDATIONS
Patient has complex coronary disease as described above. He had multiple intervention of vein graft in the past including 3 intervention in vein graft to OM last year. He has significant instent restenosis of drug-eluting stents. Recommend evaluation by cardiac surgery for possible redo CABG. Continue aggressive medical treatment.
*
should I do 93459,92937 -lc since this is vein graft balloon angio or 92920? I bill for hospital
thanks in advance

Medical Billing and Coding Forum

Lower extremity angio

Posted on by
Need some help with codes please, new to this

procedures performed
#1. Ultrasound-guided left common femoral access
#2 selective left lower extremity angiography
#3 selective aortography
#4 selective right lower extremity angiography
#5 selective infrapopliteal angiography with the catheter at the distal popliteal proximal TP trunk
#6 intravascular ultrasound of the proximal tibioperoneal trunk
#7 intravascular ultrasound of the right popliteal and SFA
#8 Phoenix atherectomy 2.2 device of the right SFA
#9 balloon angioplasty with a 6 x 100 mm balloon to mid to distal right SFA
#10 5.5 x 120 mm Abbott supera stent
#11 selective left common femoral artery closure with minx closure device

Medical Billing and Coding Forum

need help with angio

Posted on by
Conclusion

70 year-old female with severe peripheral vascular disease has ongoing nonhealing ulcers in bilateral lower extremities worse on the left than the right. She was known to have severe vascular disease status post stenting to the right superficial femoral artery. Recent CT angiogram showed occlusion of the area of stenting. She was brought in for right common femoral artery. Extremity angiogram and possible intervention. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where conscious sedation (moderate sedation) was performed by myself using Versed and fentanyl. Conscious sedation was started 12:08 PM and monitoring period Ended 1:17 PM. I was present throughout this whole entire period With the patient. Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 5 French sheath was inserted in the left femoral artery. A 5 French rim catheter was used to cross over from right to left over a zip wire and was advanced into the mid left superficial femoral artery for selective left lower extremity angiogram. Ultimately the 5 French system was removed over a Magic torque wire and exchanged for a 6 French destination sheath that was advanced all the way into the mid right common femoral artery
*
Findings:
1 complete occlusion of the entire length of the stented portion of the right superficial femoral artery. The popliteal artery is patent and there is three-vessel distal runoff
2. The left superficial femoral artery is patent with diffuse moderate disease. The left popliteal is patent. There is three-vessel distal runoff
*
Over the Rubicon catheter, a zip wire was able to cross the occlusion all the way into the popliteal artery. The Rubicon catheter was then advanced, there is a prior was removed and exchanged for a V 18 wire. The whole length of the stented portion as well as short segment distal to that was treated with a 5 mm balloon with excellent result and no residual stenosis and significant improvement in flow
*
Final impression
Complete occlusion of the entire length of the stented portion of the right superficial femoral artery successfully treated with balloon angioplasty alone
Of note I did an angiogram of the left subclavian artery due to a significant pressure gradient. The left subclavian artery is occluded beyond the origin of the left internal mammary artery

i am thinking of 75710-lt, 37224-lt but confused about lft subclavian angio he mentioned 36225?
*

Medical Billing and Coding Forum

needing help with Peripheral Angio

Posted on by
I am needing help with what codes should be used for this Peripheral Angiography. Can anyone help me please

DIAGNOSTIC APPROPRIATENESS CRITERIA: 63A
HISTORY:
68 y/o M with PMH of ESRD on HD, PVD without reported claudications, prior TIA, Ogilvie’s syndrome s/p partial colectomy who is for cardiac cath as a part of pre-kidney transplant evaluation. *Pt has fatigue (Anginal equivalent).
Also she has PVD and plan for peripheral angiography
*
ACCESS SITE(S): left radial artery
*
PROCEDURAL OVERVIEW:
After obtaining informed consent and positioning the patient on the catheterization table, a timeout was performed to confirm the patient’s name, date of birth, and procedure. Sedation was initiated and the patient was prepped and draped using standard sterile technique. Lidocaine was used for local anesthesia over the access site, after which the vessel was accessed and a sheath was placed using the modified Seldinger technique. Access was uncomplicated. The right coronary system was engaged by using FR4 Boston Scientific Diagnostic and left coronary system by using FL4 Boston Scientific Diagnostic. At the conclusion of the procedure, hemostasis was achieved using a radial compression device after removal of all catheters, wires, and sheaths.
*
SEDATION:
Moderate sedation on this adult patient was ordered by Dr. ******, administered intravenously in their presence, and monitored by the procedure nurse as an independent trained observer who was present throughout the procedure. The following parameters were monitored: oxygen saturation, heart rate, blood pressure, and response to care. Intra-service sedation start time was 1137 and end time was 1308 during which the attending was present. Total physician intra-service sedation time was 89 minutes. For details on pre-moderate sedation and post-moderate sedation patient evaluation, please review the evaluation forms in Epic. For details on monitored clinical parameters during the intra-service sedation time, please review the procedure nurse documentation in Epic. Total sedation administered as follows: 50 mcg IV fentanyl, 1 mg IV midazolam, and 50 mg IV benadryl. 3 ml of 1% lidocaine was administered subcutaneously at the access site.
*
*
COMPLICATIONS: None
*
HEMODYNAMIC FINDINGS:
AO: 194/49/86
LVEDP: 20 mmHg
*
ANGIOGRAPHY:
*
i. * *Left main: Short vessel that bifurcates into LAD and LCx.
ii.* *LAD: large caliber with luminal irregularities in proximal segment and 40% stenosis in mid segment. 1st diagonal has 30% stenosis in the ostium and luminal irregularities in mid segment.
iii. * LCx: Non-dominant large caliber with luminal irregularities in proximal segment. OM2 is a large branching caliber with 20% stenosis in proximal segment, otherwise mild luminal irregularities.
iv. * RCA: Dominant vessel without angiographic evidence of disease. PDA and rPL without angiographic evidence of disease.
DOMINANCE: Right
*
Peripheral angiography:
Same access for coronary angiography was used which was left radial access. Peripheral angiography was performed by using Pigtail Straight and MPA2 Boston Scientific Diagnostic 125cm.
*
RIGHT
The Common Iliac artery had a non obstructive disease..
The Internal Iliac artery had non obstructive disease.
The External Iliac artery had non obstructive disease.
The Common Femoral Artery had non obstructive disease.
The Profunda femoris artery had non obstructive disease.
The Superficial Femoral artery had non obstructive disease.
The Popliteal Artery had non obstructive disease.
The Post tibial artery had a non obstructive disease.
The Anterior tibial artery had non obstructive disease.
The Peroneal artery had non obstructive disease.
There was a 3 vessel distal run off
*
*
LEFT
The Common Iliac artery had a non obstructive disease..
The Internal Iliac artery had non obstructive disease.
The External Iliac artery had non obstructive disease.
The Common Femoral Artery had non obstructive disease.
The Profunda femoris artery had non obstructive disease.
The Superficial Femoral artery had non obstructive disease.
The Popliteal Artery had non obstructive disease.
The Post tibial artery had a non obstructive disease.
The Anterior tibial artery had non obstructive disease.
The Peroneal artery had non obstructive disease.
There was a 3 vessel distal run off
*
*
*
DIAGNOSTIC INTERPRETATIONS:
– Non-obstructive CAD.
– Peripheral angiography shows calcified vessel without evidence of obstruction.
*
RECOMMENDATIONS AFTER DIAGNOSTIC CATHETERIZATION:
Medical management of nonobstructive CAD.
Aggressive modification of atherosclerotic risk factors.
TR band to be taken off after 2 hours

Thank you
*
*

Medical Billing and Coding Forum

Multiple Cardiology Procedures: Cath/renal angiography with balloon angio and stent

Posted on by
New to cardiology and I think I’m getting myself overwhelmed when searching for the codes but I want to learn. I know some of these are included in others but still confused, HELP please!:confused:

Procedure Performed:
1. RT and LT heart Catherization
2. Aortic valve study
3. Left ventriculogram
4. Coronary angiography
5. Distal abdominal aortography
6. Selective renal angiography with balloon angioplasty and stent placement with a 5.0x18mm heculink placed in the left renal artery proximal.
8. Sheath suture in place. Plan for manual pressure, hold 2 hr post procedure
9. Supervision and interpretation of above.

Medical Billing and Coding Forum

Balloon Angioplasty peroneal artery and balloon angio of tibioperoneal trunk.

Posted on by
The provider is asking for number of codes that are bundled but can be unbundled with mods. Any help is appreciated. The provider wants: 36247, 37229, 37252, 75625, 75726. 75774.

Using micropuncture kit the right femoral artery was cannulated and 5 french sheath was placed in the right femoral artery. We then advanced an omni flush catheter to the level of L4 Distal abdominal aortic angiography was completed. After this, we advanced a Bentson wire into the SFA and the omni Flush was then selectively engaged in the SFA. Angiography was then completed. We then performed an angiography of the left lower extremity. After finding significant amount of stenosis in the tibioperoneal trunk and the peroneal artery being completely occluded, we proceeded with the intervention of artery. We advanced a CXI cath and stiff angled glide cath into the peroneal and we were able to enter in thh true lumen distally. After that, we advanced the CXI cath into the dital peroneal vessel. We then exchanged out in favor of Viper wire and performed artherectomy of the tibioperoneal trunk. After this, we swapped out in favor of an 0.018 Treasure 12 wire and performed balloon angioplasy with a 2.5 x 30 cm balloon of the peroneal artery. We performed balloon angioplasy in the this vessel. Afterh that, we advanced a 4.0 x 30 balloon and performed balloon angioplasty in the TP trunk and then we performed IVUS of the tibioperoneal trunk.

Thank you for taking a look.

bb

Medical Billing and Coding Forum

Carotid Angio?

Posted on by
Would this be a 36222-RT, 62? Thank you!

INDICATION FOR PROCEDURE:
Symptomatic carotid artery stenosis, for possible carotid stent.

ASSISTANT SURGEON:
Dr. B MD.

PROCEDURES PERFORMED:
Right common femoral artery access with a 5-French sheath, selective
right carotid angiogram, intracerebral angiogram.

COMPLICATIONS:
None.

ESTIMATED BLOOD LOSS:
Less than 2 mL.

DESCRIPTION OF PROCEDURE:
After informed consent, discussion of risks and benefits, a 5-French
sheath was placed in the right common femoral artery. The patient does
have an external iliac stenosis, which we got across with 0.18 wire,
which was then exchanged for a bigger micropuncture sheath, which was
exchanged for a stiff 0.35 wire, which was exchanged for a 5-French
sheath. The right carotid was selectively cannulated using the 3DRC
catheters. Selective angiography showed the common carotid to have
mild plaquing. There is ulceration of the common carotid and a maximum
of 30% to 40% of the internal carotid. The internal carotid although
has mild diffuse disease in the cavernous portion and goes on to give
the MCA and ACA. No significant obstruction. No aneurysm is seen.
The contralateral MCA can be seen filling through collaterals through
the anterior communicating, which also fills the MCA on the left. There
were
no complications. Recommend medical therapy. The sheath will be pulled
manually. Further recommendations to follow clinical course.

Medical Billing and Coding Forum

Spinal Angio Assistance with CPT codes

Posted on by
We’re having a discussion on the proper way to bill this procedure. Please review the abbreviated note and provide feed back.

PREOPERATIVE DIAGNOSIS: *SPINAL DURAL ARTERIOVENOUS FISTULA STATUS
POST PARTIAL EMBOLIZATION IN THE OUTSIDE HOSPITAL WITH PROGRESSIVE
LOWER EXTREMITIES WEAKNESS AND INCONTINENCE
*
POSTOPERATIVE DIAGNOSIS: RESIDUAL DURAL ARTERIOVENOUS FISTULA WITH
SINGLE INTRA DURAL DRAINING VEIN AT T6 LEVEL. FEEDING ARTERIES ARE
RECONSTITUTED FROM RIGHT T5 AND LEFT T6 INTERCOSTAL ARTERIES.
SIGNIFICANT DILATED VEINS ABOVE T6 VERTEBRAE LEVEL IS VISUALIZED.
ADAMKIEWICZ ARTERY IS POSSIBLY VISUALIZED FROM LEFT T6
*
OPERATION: FEMORAL SPINAL ANGIOGRAM
*
ANESTHESIA: MAC
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *10 CC
*
STUDIED VESSELS: RIGHT VERTEBRAL ARTERY, RIGHT SUBCLAVIAN ARTERY,
LEFT VERTEBRAL ARTERY, LEFT SUBCLAVIAN ARTERY, RIGHT THYROCERVICAL,
LEFT THYROCERVICAL, RIGHT INTERCOSTAL/RADICULAR ARTERIES (T3/4, T5,
T8, T9, T10, T11, T12, L1, L2, L3), LEFT INTERCOSTAL/RADICULAR
ARTERIES (T4, T5, T6, T7, T8, T9, T10, T11, T12, L2, L3)
*
INDICATIONS: *The patient is an 63 years year old Male with history
of progressive bilateral lower extremity numbness and weakness that
became substantially progressive since May of 2017, which led to an
MRI that raised the concern for a spinal dAVF. He was treated
partially with endovascular embolization in XXXX. He now has a
foley catheter and has severe (2/5 on the right and 3/5 on the left)
weakness in lower extremities.

SUPERVISION AND INTERPRETATION:
1. *Angiographic study demonstrates residual dural arteriovenous
fistula at the level of T6. This is supplied by right T5 and left T6
intercostal arteries. Significant dilated spinal veins are visualized
above T6 level.
2. * The artery of Adamkiewecz is possibly visualized in the Left T6
intercostal artery run.
2. *No immediate complications.
*
VESSELS STUDIED:
1. *Right Vertebral Artery
2. *Right Subclavian Artery
3. *Right T3/4
4. *Right T5
5. *Right T8
6. *Right T9
7. *Right T10
8. *Right T11
9. *Right T12
10. *Right L1
11. *Right L2
12. *Right L3
13. *Left Vertebral Artery
14. *Left Subclavian Artery
15. *Left T4
16. *Left T5
17. *Left T6
18. *Left T7
19. *Left T8
20. *Left T9
21. *Left T10
22. *Left T11
23. *Left T12
24. *Left L2
25. *Left L3
26. *Right common femoral artery.

Coded as such;
36226-50
36215 x 6
36216 x 2
36245-50 x 3

Would appreciate any and all input from forum.

Medical Billing and Coding Forum

Spinal Angio Assistance with CPT codes

Posted on by
We’re having a discussion on the proper way to bill this procedure. Please review the abbreviated note and provide feed back.

PREOPERATIVE DIAGNOSIS: *SPINAL DURAL ARTERIOVENOUS FISTULA STATUS
POST PARTIAL EMBOLIZATION IN THE OUTSIDE HOSPITAL WITH PROGRESSIVE
LOWER EXTREMITIES WEAKNESS AND INCONTINENCE
*
POSTOPERATIVE DIAGNOSIS: RESIDUAL DURAL ARTERIOVENOUS FISTULA WITH
SINGLE INTRA DURAL DRAINING VEIN AT T6 LEVEL. FEEDING ARTERIES ARE
RECONSTITUTED FROM RIGHT T5 AND LEFT T6 INTERCOSTAL ARTERIES.
SIGNIFICANT DILATED VEINS ABOVE T6 VERTEBRAE LEVEL IS VISUALIZED.
ADAMKIEWICZ ARTERY IS POSSIBLY VISUALIZED FROM LEFT T6
*
OPERATION: FEMORAL SPINAL ANGIOGRAM
*
ANESTHESIA: MAC
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *10 CC
*
STUDIED VESSELS: RIGHT VERTEBRAL ARTERY, RIGHT SUBCLAVIAN ARTERY,
LEFT VERTEBRAL ARTERY, LEFT SUBCLAVIAN ARTERY, RIGHT THYROCERVICAL,
LEFT THYROCERVICAL, RIGHT INTERCOSTAL/RADICULAR ARTERIES (T3/4, T5,
T8, T9, T10, T11, T12, L1, L2, L3), LEFT INTERCOSTAL/RADICULAR
ARTERIES (T4, T5, T6, T7, T8, T9, T10, T11, T12, L2, L3)
*
INDICATIONS: *The patient is an 63 years year old Male with history
of progressive bilateral lower extremity numbness and weakness that
became substantially progressive since May of 2017, which led to an
MRI that raised the concern for a spinal dAVF. He was treated
partially with endovascular embolization in XXXX. He now has a
foley catheter and has severe (2/5 on the right and 3/5 on the left)
weakness in lower extremities.

SUPERVISION AND INTERPRETATION:
1. *Angiographic study demonstrates residual dural arteriovenous
fistula at the level of T6. This is supplied by right T5 and left T6
intercostal arteries. Significant dilated spinal veins are visualized
above T6 level.
2. * The artery of Adamkiewecz is possibly visualized in the Left T6
intercostal artery run.
2. *No immediate complications.
*
VESSELS STUDIED:
1. *Right Vertebral Artery
2. *Right Subclavian Artery
3. *Right T3/4
4. *Right T5
5. *Right T8
6. *Right T9
7. *Right T10
8. *Right T11
9. *Right T12
10. *Right L1
11. *Right L2
12. *Right L3
13. *Left Vertebral Artery
14. *Left Subclavian Artery
15. *Left T4
16. *Left T5
17. *Left T6
18. *Left T7
19. *Left T8
20. *Left T9
21. *Left T10
22. *Left T11
23. *Left T12
24. *Left L2
25. *Left L3
26. *Right common femoral artery.

Coded as such;
36226-50
36215 x 6
36216 x 2
36245-50 x 3

Would appreciate any and all input from forum.

Medical Billing and Coding Forum