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Tag Archives: Angiography

Left Subclavian Artery Angiography

Posted on by
I am having a hard time figuring out what codes to use for this case. I need some thoughts from other fellow coders. I came up with

36215-59
75710-26-59-LT
36222-50
36226-RT
99152

Please and thank you!

PROCEDURE: Left subclavian artery angiography, attempted PTA of left subclavian artery, selective right and left common carotid angiography, selective right vertebral artery angiography
*
DATE OF PROCEDURE: 11/20/2018
*
INDICATION: Left subclavian artery stenosis and patient was referred to Kalamazoo when she came with acute situation no revascularization was done at that time
*
PROCEDURES PERFORMED:
1. Selective cannulation of left subclavian artery
2. Attempted PTA of left subclavian artery
3. Selective left and right common carotid artery angiography
4. Selective right vertebral artery angiography
*
EQUIPMENT USED:
1. 0.035 Glidewire, 0.018 estato wire
2. 0.035 Navi cross catheter
*
*
DESCRIPTION OF PROCEDURE:
Patient was brought into the Cath Lab, draped and prepped in conventional fashion and using Xylocaine anesthesia a 6 French sheath was placed in the right common femoral artery. With a Judkins diagnostic right catheter left subclavian artery was cannulated and angiography was performed for the procedure were attempted.
*
Cine report:
Left subclavian artery is totally occluded with a stump
*
After the attempted procedure right innominate artery was cannulated and selective carotid artery angiography was performed right common carotid artery doesn’t show any stenosis done show any filling on the left side
*
Left common carotid artery doesn’t show any filling on the left subclavian artery
*
The right vertebral artery shows ostial stenosis of 80-90% however it does fill up the left vertebral artery retrogradely and fills of the distal subclavian artery as well as axillary artery and brachial artery
*
MODERATE SEDATION:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 51 min.
*
CONTRAST:
Medication Name Total Dose
iodixanol (VISIPAQUE) 320 mg/mL injection 43 mL
*
*
PTA AND STENTING:
I tried to pass the 0.035 wire through the subclavian artery and there was a small dye was noted in the side of the subclavian artery which is a presently subintimal and it would not cross into the subclavian artery. Multiple attempt was done and then the Navy cross catheter was used and will not go through the totally occluded subclavian artery. A estato wire was also tried which will not go through the totally occluded subclavian artery. After trying for more than half an hour procedure was stopped. However this vertebral artery does show retrograde flow from the right to the left side and I could see the brachial artery.
*
CINE INTERPRETATION:
1. Totally occluded left subclavian artery with a stump could not be cannulated failed PTA
*
*
FINAL DIAGNOSIS:
1. Total occlusion of left subclavian artery is a stump noted not at the ostium
2. Right and left common carotid artery doesn’t show any stenosis
3. Right vertebral artery shows ostial stenosis of 80% shows retrograde flow to the left vertebral artery filling of the distal subclavian and axillary and brachial artery
*
RECOMMENDATION:
Plan is to bring the patient and try to go through the brachial artery and retrograde fashion because the distal total occlusion may be easier to cross. If it cannot be opened up I discussed with the vascular surgeon her than the plan for the surgery either left carotid subclavian bypass or productive frequent graft attaching to the subclavian artery to the aorta. Patient will be discharged home and will be brought back again. Now since it is totally occluded I don’t think patient need Coumadin. She’ll be followed up as an outpatient
*

Medical Billing and Coding Forum

Right Heart Cath and EKOS, pulmonary angiography question

Posted on by
Would this be just 93456-26 or am I also coding for the EKOS, pulmonary angiography or are they included? What codes am I using if so?

Thanks for your help/code suggestions!

PROCEDURES:
1. Right heart catheterization.
2. Pulmonary angiography.
3. EKOS catheter to the left pulmonary artery.
4. EKOS catheter to the right pulmonary artery.

APPROACH:
Right common femoral vein x2.

INDICATIONS:
Large bilateral pulmonary emboli.

The risks and benefits of right heart catheterization and EKOS catheter
placement were discussed with the patient. She is agreeable to the
procedure. Consent was obtained.

PROCEDURE IN DETAIL:
The patient was prepped and draped in the normal fashion. Ultrasound
was used to visualize the right common femoral vein. With ultrasound
guidance, the common femoral vein was accessed and a 6-French sheath
was introduced x2.

Right heart catheterization was performed using a 6-French balloon-tipped
PA catheter. The mean RA pressure 10 mmHg, RV 43/5 and PA pressure
44/14 mmHg. The mean pulmonary artery pressure is 26 mmHg. Pulmonary
angiogram showed the catheter in good placement.

The Swan-Ganz catheter was exchanged over a guidewire. An EKOS catheter
was placed in the right and left pulmonary artery. TPA infusion at
1 mg/hour was initiated while in
the cath lab. EKOS catheters were sutured in place. The patient was
transferred back to the intensive care unit in stable condition.

Medical Billing and Coding Forum

Peripheral angiography and second order

Posted on by
I keep getting myself confused on coding the peripheral with runoff and second order, anyone please help to correctly code this..:confused:

PROCEDURE PERFORMED:
1. Serial abdominal aortography.
2. Peripheral angiography with runoff to both legs from the distal abdominal
aorta.
3. Moderate sedation.
4. Ultrasound for vascular access of the right radial artery.
5. Second order placement from the left common femoral artery to the right
common femoral artery with the sheath.
6. Balloon angioplasty and CSI atherectomy of the right distal SFA using a 2.0
burr at 60,000 and 80,000 RPM, CSI atherectomy catheter as well as a balloon
angioplasty with drug-coated balloon, 5.0 Lutonix, up to 12 atmospheres for 2
minutes.
7. MynxGrip was placed in left femoral arteriotomy at the end the case with
hemostasis. Wristband placed across right radial arteriotomy at the end the
case with hemostasis.
8. Supervision and interpretation of above.

INDICATIONS:
The patient is a 72-year-old female with worsening bilateral leg pain, right
worse in the left, here for possible peripheral angiography with possible
balloon angioplasty, stent placement, atherectomy as well. Informed witnessed
signed consent placed in the patient’s medical record. The patient understood
the risks, benefits, alternatives, procedure, and wished to proceed. Risks
include, but are not limited to stroke, myocardial infarction, renal failure,
bleeding, limb loss, and death.

DESCRIPTION OF PROCEDURE:
The patient was brought to the cardiac catheterization laboratory in the
fasting state. Right wrist, both groins were prepped and draped in sterile
fashion. 2% lidocaine was infused in right wrist area for local anesthesia.
Using modified Seldinger technique, micropuncture kit and ultrasound for
vascular access. 6-French side-arm sheath was placed in the patient’s right
radial artery. Next, I placed a long pigtail catheter at the level of the
distal abdominal aorta through the wrist. Distal abdominal aortography was
performed. Next, runoff to the feet was performed with digital subtraction.
Next, I did selective angiography of the right leg using the same pigtail
catheter and digital subtraction. Next, I went to intervention. The left
inguinal area was anesthetized with 2% lidocaine. Next, a 6-French side-arm
sheath was successfully placed in the patient’s left femoral artery using a

Destination 45 cm 6-French sheath placed from the contralateral left femoral
artery all the way to the right common femoral artery, second order. Next, I
initially used Advantage wire for sheath placement. This was removed. A
Viper
wire was placed in the distal popliteal artery. Next, I proceeded with CSI
atherectomy with heparin used during the case. ACT greater than 250 seconds.
CSI atherectomy was performed at 60,000 and 80,000 RPM’s. Next, I performed
balloon angioplasty using a 5.0 Lutonix balloon for 2 minutes at 12
atmospheres. Final angiography demonstrated excellent flow. No evidence of
edge dissection or distal thrombus. There was good flow all the way to the
ankle of the right leg.

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

Coding heart cath, w/ coronary angiography

Posted on by
**My first post**
I’m not a professional coder by any stretch but I’ve been trying to learn more since I came into the cardiology field. One of our docs did as follows:

Left heart catheterization with coronary angiography, left ventriculography, angioplasty, carotid arch and four vessels, abdominal aortogram, and right selective runoff. (Report available if more information is needed)

The coder billed 93458.26, 36200, and 75716.

Our reimbursement was only $ 278.98 and I feel sure that a modifier should be attached to not only the 36200, but also the 75716. Insurance denial just states that the 36200 & 75716 were included in the 93458.26. I was thinking the 36200 would need a mod 50, and the 75716 would need to have a 26 & 59. But again, I’m not a coder, just trying to learn as I come across denials so I can fix them.

Thanks!

Medical Billing and Coding Forum

peripheral angiography help needed

Posted on by
Good Morning,
I just took over coding for this MD and have not done lower extremities very often. looking for some clarification on this procedure.
The MD only charged: 75625-26 & 75716-26,59
Shouldn’t he be able to also include cath placement? Or is this truly bundled?
I am getting conflicting information from lower extremity coders.

Any help with proper code selection for this case would be greatly appreciated.

Thank you,

PROCEDURES PERFORMED:
1. Abdominal aortogram.
2. Selective right common femoral artery angiogram and distal runoff.
3. Selective left common femoral artery angiogram of distal runoff.
*
BRIEF HISTORY: This is a 74-year-old gentleman with longstanding history of
smoking recently presented to our clinic for evaluation of symptoms of severe
left lower extremity claudication and abnormal lower extremity arterial
Doppler flow study revealing ABIs in the severe claudication range of the left
lower extremity.
*
PROCEDURE DESCRIPTION: A 6-French sheath was placed in the right common
femoral artery. Abdominal aortogram was performed by placing a 6-French
pigtail catheter in the distal abdominal aorta with subsequent power injection
of contrast. Selective right common femoral artery angiogram and distal
runoff is performed via power injection of contrast through the right common
femoral arterial sheath. Then, we proceeded to advance a 5-French LIMA
diagnostic catheter into the proximal segment of the left common femoral
artery. Left common femoral artery angiogram and distal runoff was performed
via power injection of contrast through the LIMA diagnostic catheter. The
LIMA diagnostic catheter was subsequently advanced into the midsegment of the
left superficial femoral artery. Subsequent injection of contrast was
performed through the LIMA diagnostic catheter to visualize the left
infrapopliteal vessels. No complications were noted.
*
TECHNICAL FACTORS: Omnipaque 140 mL.
*
ABDOMINAL AORTOGRAM: There is presence of infrarenal abdominal aortic
aneurysm. Bilateral common iliac arteries appear to be aneurysmal. The right
common iliac artery reveals no significant luminal stenosis. Left common
iliac artery reveals severe 97% ostial calcific stenosis. Right external
iliac artery appears to be widely patent. Left external iliac artery is
widely patent. Right internal iliac arteries are widely patent with mild
proximal and mid stenosis. Left internal iliac artery reveals moderate 70%
proximal stenosis.
*
RIGHT COMMON FEMORAL ARTERY ANGIOGRAM AND DISTAL RUNOFF: Right common femoral
artery reveals no significant luminal stenosis. Right profundus femoral
artery reveals severe 80% proximal stenosis. Right superficial femoral artery
reveals severe 75% to 80% proximal stenosis and severe diffuse 70-90% mid
stenosis. Distal segment of the right superficial femoral artery reveals mild
luminal stenosis. Right popliteal artery reveals diffuse severe 70-75% mid
stenosis. Right anterior tibial artery is widely patent. Right peroneal
artery is widely patent. Right posterior tibial artery is widely patent.
*
LEFT COMMON FEMORAL ARTERY ANGIOGRAM AND DISTAL RUNOFF: Left common femoral
artery reveals mild 40% distal stenosis. Left profundus femoral artery is
widely patent. Left superficial femoral artery appears to be patent with
diffuse moderate 50% to 60% mid to distal stenosis. Left popliteal artery
appears to be chronically occluded proximally with reconstitution distally via
collaterals. Left anterior tibial artery, left posterior tibial artery and
left peroneal artery are widely patent. These vessels appear to reconstitute
proximally and appeared to be patent all the way down to the foot.
*
SUMMARY:
1. Right lower extremity angiogram and distal runoff reveals severe proximal
80% right profundus femoral artery stenosis, severe 70% to 90% proximal to mid
diffuse right SFA stenosis, severe 70% to 75% mid right popliteal artery
stenosis and a widely patent 3-vessel right infrapopliteal runoff consisting
of patent right posterior tibial artery, patent right peroneal artery and
patent right anterior tibial artery.
2. Severe 97% left common iliac artery ostial calcific stenosis, chronic left
proximal popliteal artery occlusion with reconstitution distally with a
3-vessel left infrapopliteal runoff.
3. Bilateral common iliac artery appeared to be aneurysmal.
*
PLAN: We will ask for vascular surgery consultation for potential surgical
revascularization of the left lower extremity. Pletal 100 mg p.o. b.i.d. will
be started today for symptomatic relief. Emphasize aggressive risk factor
modification including the importance of smoking cessation.

Medical Billing and Coding Forum

Need help with Angiography

Posted on by
Can anyone check my codes with the report below,

37246
37248
75710
75605

Under ultrasound guidance, a 21-gauge micropuncture needle was advanced directly into the rightcommon femoral artery. A 0.018 inch wire was advanced through the needle. The needle was exchanged for 5 French dilator sheath combination. The inner dilator wire removed.
Subsequent, a 0.035 inch exchange length glide wire was advanced into the aorta. The outer sheath was exchanged for a 5 French hemostatic sheath.
A 5 French diagnostic catheter was advanced over the wire and positioned in the thoracic aorta.

Thoracic aortogram was performed. Subsequently, the catheter was exchanged for a 5 French Kampe catheter which was selectively into theleft subclavian artery. Selective subclavian artery and axillary artery angiogram was performed.

The catheter was exchanged for a multi-sidehole straight catheter which was subsequently advanced intothe brachial artery. Selective angiogram of the brachial artery was performed in a stepwise fashion to the antecubital fossa. Subsequently, stepwise fashion arteriogram was performed in the radial and ulnar arteries to the wrist.

The catheter was exchanged for a 2.5 mm x 40 mm angioplasty balloon over a 0.014 inch wire which waspositioned in the stenosis within the radial artery. Angioplasty was performed.
Subsequent, the balloon was positioned into the fistula anastomosis. Angioplasty was performed. Finally,the balloon was positioned in the radial vein. Angioplasty was performed. The balloon and wire wereremoved.
Post angioplasty angiogram was performed.
Selective right common femoral artery angiogram was performed. Angio-Seal closure device wasdeployed at the puncture site following removal of the hemostatic sheath. Hemostasis was obtained.
There are no procedural or immediate postprocedural complications.

Findings:
Initial evaluation demonstrates a patent thoracic arch. The subclavian artery, axillary artery and brachial arteries are widely patent. The radial and ulnar arteries were identified. There is a short segment hemodynamically significant stenosis of greater than 80% in the radial artery proximal to the radial artery fistula anastomosis. In addition, there is diffuse stenosis at the fistula anastomosis as well as in the proximal limb of the fistula. The graft following angioplasty with a 2.5 mm x 40 mm balloon, there is considerable improvement in flow in the fistula. However, there is a short segment critical stenosis in the venous outflow which could not be crossed with the balloon. The patient will return for fistula access with subsequent angioplasty directed toward the arterial anastomosis.
The patient tolerated conscious sedation well.
The right common femoral artery is widely patent. Angio-Seal closure device was deployed at thepuncture site with hemostasis achieved.

Impression:
Initial evaluation demonstrates widely patent thoracic aorta. Normal appearance of the subclavian artery, axillary artery and brachial artery.
There is a hemodynamically significant stenosis in the radial artery proximal to the fistula anastomosis. In addition, there is long segment stenosis in the fistula anastomosis as well as in the venous outflow.
Successful angioplasty was performed in the radial artery as well as in the fistula anastomosis. Therewas a critical stenosis in the venous outflow which could not be crossed with the balloon. The patient will return for angioplasty of the remaining stenosis in the venous outflow.
The patient tolerated conscious sedation well
The right common femoral artery is widely patent. Angio-Seal closure device was successfully deployed.

Medical Billing and Coding Forum