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Tag Archives: Peripheral

Peripheral Angiography/Right Radial revascularizaion & Mechanical Thrombectomy

Posted on by
Good Afternoon,

I am looking for some help with this upper extremity Procedure. I do not have these procedures very often & I am not 100% sure on my code selection.
If someone could take a look & let me know if I chose the correct codes & if not which codes should I have chosen.

Thank you so much for your help :)

These are the codes I submitted:
37184
36217
37211-59
75710-26,59
75774-26,59
99152

The carrier is denying 75710 & 75774 as well as 37211.

PROCEDURES PERFORMED:
1. Percutaneous revascularization of the right radial artery.
2. Intraarterial TPA infusion of the right radial artery.
3. Selective right brachial artery angiogram with distal runoff.
4. Selective right radial artery angiogram of distal runoff.
*
BRIEF HISTORY: This is a 46-year-old morbidly obese female initially
presented to our clinic for evaluation of symptoms of dyspnea on exertion and
abnormal stress test. The patient subsequently underwent a coronary angiogram
on 10/15/2018 via right radial arterial approach. The patient then underwent
a successful percutaneous revascularization of the right coronary artery and
LAD utilizing drug-eluting stents. She was subsequently seen as an outpatient
on 10/24/2018 in our clinic where she noted symptoms of right arm swelling as
well as significant discomfort of her right wrist and the right arm. She
subsequently underwent an arterial duplex ultrasound of the right upper
extremity revealing an occlusion of the right radial artery with maintenance
of patency of the right ulnar artery. However, due to significant discomfort,
the patient was brought urgently on 10/25/2018 for selective right brachial
artery angiogram with possibility of endovascular revascularization.
*
PROCEDURE DESCRIPTION: Conscious sedation was performed by registered nurse
under the supervision of Dr.. A 6 x 23 sheath was placed in the
left common femoral artery. A 5-French LIMA diagnostic catheter was utilized
to engage the right innominate artery. The LIMA diagnostic catheter was
subsequently advanced into the distal segment of the right brachial artery.
Selective right brachial artery angiogram with distal runoff was performed via
hand injection of contrast through the LIMA diagnostic catheter. This
confirmed a proximal thrombotic occlusion of the right radial artery with
maintenance of patency of the right ulnar artery as well as a right
interosseous artery. Then, we proceeded to exchange the 5-French LIMA
diagnostic catheter for a 0.035 Quick-Cross catheter over a 0.035 Versacore
guidewire. Then, we proceeded across the proximally occluded right radial
artery using a 0.014 Whisper guidewire. The Quick-Cross catheter was advanced
into the proximal segment of the right radial artery. Selective right radial
artery angiogram confirmed extensive thrombus within the right radial artery.
At this point, we proceeded to perform a mechanical thrombectomy of the right
radial artery using CAT6 Penumbra aspiration catheter. Multiple runs were
performed. This did result in a significant aspiration of the thrombus
burden. However, the flow within the right radial artery was still sluggish
with a significant residual thrombus throughout the mid and distal segments.
As a result, we proceeded to give 10 mg IV push of intraarterial TPA through
the Quick-Cross catheter placed in the right radial artery. The TPA was given
over 25 minutes. This resulted in a palpable right radial pulse. There was
still a significant amount of thrombus burden within the mid and distal
segment of the right radial artery. As a result, we proceeded to leave the
Quick-Cross catheter in the proximal segment of the right radial artery with a
continuous infusion of TPA overnight at 0.5 mg per hour. The patient will be
brought back electively tomorrow afternoon for recheck right radial artery
angiogram.
*
TECHNICAL FACTORS: Omnipaque 275 mL. Angiomax 0.75 mg IV push followed by
Angiomax infusion drip at 1.75 mg/kg per hour. TPA 10 mg IV push time once
followed by TPA infusion drip at 0.5 mg per hour.
*
POSTOPERATIVE DIAGNOSES:
1. Mechanical thrombectomy of the right radial artery using a CAT6 Penumbra
aspiration catheter.
2. Intraarterial TPA infusion via 0.035 Quick-Cross catheter placed in the
proximal segment of the right radial artery.
3. Proximal thrombotic occlusion of the right radial artery with continued
patency of the right ulnar artery and right interosseous arteries.
*
PLAN: The patient does appear to have manually palpable right radial pulses
at this time. We will continue infusing the TPA infusion overnight to further
diminish the thrombus burden in mid and distal segments. The patient will be
brought back electively tomorrow for recheck right radial artery angiogram.
*
*

Medical Billing and Coding Forum

***please help with peripheral coding***

Posted on by
Coronary Angiogram and Intervention Report
Date of procedure: 12/20/18

Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient

Medical Billing and Coding Forum

Still confused on some of these… Please help Peripheral Coding

Posted on by
Coronary Angiogram and Intervention Report
Date of procedure: 12/20/18

Pre- op Ox: CAD, CCS II chest pain, Abnormal stress test
Post-op Ox: Coronary artery disease

Procedures:
1. Selective left coronary angiography
2. Laser arthrectomy of the proximal and mid left anterior descending artery for 70-80% in-stent restenosis.
Pre procedure 70-80% in-stent restenosis with TIMI 3 flow. Post procedure less th an 50% in-stent restenosis with TIMI 3 flow.
3. Stenting of the proximal left anterior descending
artery for 80% disease with a 3.0 x 12 mm drug-eluting stent Onyx; pre procedure and 80% diseaseTIMI-3 flow.
Post procedure 0% disease with TIMl-3 flow
4. Angioplasty of the mid 70% occluded left anterior descending artery with a 2.25 x 12 mm balloon; pre procedure 70% disease TIMI- 3 flo w. Post procedure less than 50% disease TIMl-3 flow

Anesthesia: Lidocaine 2%

Access Site: Right femoral artery 6 French

Findings:
LMCA · mild disease
LCX · 60· 70 % m id left circumflex artery OMl · mild to moderate disease
LAD • 80% proximal disease prior to stent; 70-80% in-stent restenosis of the proximal-mid left anterior descending artery stent; 70% disease post stent
Dl – moderate disease

Procedure in detail :
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed.
Bilateral groins were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

Right groin was anesthetized with lidocaine and a 6-French sheath was put into place percutaneously via guide-wire exchanger using ultrasound guidance and a micro puncture access kit. All catheters were passed using a Hipped guide* wire. Left system coronary angiography performed using a 6-French EBU3.5 catheter.

Intervention:
A 6 French EBU 3-1/2 guide was used to engage the left system. Once engaged, a run- through wire was placed distally down the left anterior descending artery. The laser catheter was then placed over the run-through wire and attempted to place inside the in-stent restenosis. Multiple attempts were made and the catheter was unable to enter the stent. The wire was pulled back and re-placed inside the stent as there was a concern that the wire may have gone behind the stent. The laser catheter was still unable to be advanced into the stent. A smaller laser catheter was exchanged and still unsuccessful in going inside the stent. After multiple attempts, the laser catheter was finally able to enter the stent and multiple runs were made. Post arthrectomy with laser, an angiogram was done showing less than 50% disease inside the stent. The laser catheter was removed and a 3.0 x 12 mm balloon was used to dilate the in-stent restenosis. Multiple different balloons were used without much improvement.
Given the inability to use the larger laser catheter, the
decision was made to leave the in-stent restenosis as it
is given TIMI -3 flow and less than 50% disease. The laser catheter was removed and an angiogram was done showing no perforations or dissections TIMI 3 flow. A 2.25 x 12 balloon was placed distally to the stent where there was 70%>
stenosis and that area was angioplastied. Post
Angioplasty, there appear to be less than 50% disease and no perforations or dissections TIMI 3 flow. The proximal portion prior to the stent in the LAD appeared to be significantly diseased and a 3.0 x 12 mm drug -eluting stent Onyx was placed. Post stenting, an angiogram was done showing no perforations or dissections and TIMI-3 flow. Heparin given during the entire procedure.

Closure Device: None

EBL: Less than 20 ml Complications: None Lines: None

Specimens: None Condition: Stable

Finding s:
Status post arthrectomy of the proximal to mid left anterior descending artery in-stent restenosis
Angioplasty of the mid left anterior descending artery after the stent
Stenting of the proximal left anterior descending artery with a
3.0 x 12 mm drug-eluting stent Onyx

Recommendation:
Continue with aspirin, Plavix, Lipitor therapy
Consider stage PC! for patients left circumflex artery as an outpatient

Medical Billing and Coding Forum

Help with Peripheral

Posted on by
If anyone can take a look at this please. I am new to peripherals and am currently trying to learn how to code them so I am questioning the one’s I do. Thanks for the help!!!!

Intraoperatively, through a right femoral approach were able to cross all lesions involving the left SFA and popliteal artery. Reconstruction consisted of a combination of laser atherectomy of the high volume high calcific lesions of the SFA and popliteal artery utilizing a Spectranetics atherectomy laser. In addition we performed angioplasty of the SFA and popliteal artery segments. We did require 2 overlapping stent placements. We utilized overlapping supera stents: 5.5 mm x 120 mm, 6.5 mm x 120 mm. Final completion showed excellent flow through the SFA segment with brisk flow through the SFA and popliteal segments with continued three-vessel runoff to the foot and ankle region.
Patient was brought to the special procedure room. He was connected up to the appropriate monitoring devices consisting of heart rate, blood pressure, pulse oximetry.

Anesthesia provided LMA anesthetic. The right groin was then prepped and draped in routine sterile fashion.

The right groin was locally anesthetized with 1% lidocaine without epinephrine. Duplex ultrasound was used to gain entry to the right common femoral guidewire advanced and a 5 French sheath placed over the guidewire. Guidewire was then navigated into the abnormal aorta. In advantage guidewire was used to navigate to the contralateral iliac side placing a guidewire at the level of the left common femoral region. The patient was then systemically heparinized.

Next, we exchanged the 5 French sheath to a long 7 French sheath which was delivered from the right groin to the left common femoral region. Utilizing a combination of CXI catheter along with several guidewires were able to navigate through the SFA and popliteal artery stenosis placing her catheter at the level of the tibial artery for confirmation. Next, we exchanged out to an 018 treasure 12 guidewire. We then delivered the Spectranetics atherectomy turbo device. Left lower extremity runoff confirmed the location necessary for atherectomy and cutting. Several passages were performed of the SFA and popliteal segments. We then performed balloon dilation utilizing a 5 mm angioplasty balloon along the segment from the popliteal up into the SFA region.

Next, we delivered 2 overlapping supera stents as described above. These were then post dilated utilizing a 7 mm angioplasty balloon in the more proximal portion of the SFA. And a 5.5 mm angioplasty balloon in the more distal portion of the SFA junction onto the popliteal artery.

At this point a left lower extremity runoff showed brisk flow with excellent reconstruction of the SFA and popliteal artery segment with continued three-vessel runoff.

Next the 7 French sheath was exchanged at the groin level to a short 7 French sheath. A Perclose device was then introduced and used for hemostasis. The knots were advanced and hemostasis achieved.

Medical Billing and Coding Forum

Help with Peripheral

Posted on by
Need help coding out this peripheral please. New to lowers.
Thank’s

1. Left common femoral arterial access with sheath placement
2. Right pedal access with sheath placement
3. Catheter placement abdominal aorta
4. Selective catheterization third order arterial branch leg
5. Arteriogram aortogram bilateral lower externally runoff
6. Angioplasty right common iliac artery utilizing a 6 mm x 6 cm angioplasty balloon
7. Angioplasty right external iliac artery utilizing a 6 mm x 16 mm drug-coated angioplasty balloon
8. Angioplasty and stent placement of the right superficial femoral and popliteal artery utilizing a 5 mm x 120 mm Supera stent followed by a 5 mm x 120 mm angioplasty balloon

Both right and left groins and right foot were then prepped and draped in routine sterile fashion.

Beginning on the left groin this was locally anesthetized with 1% lidocaine without epinephrine. Using duplex ultrasound were able to access the left common femoral guidewire advanced and a 5 French sheath placed over the guidewire. Left lower extremity runoff was then performed using the side port of the sheath.

Next guidewire was advanced to the L1-2 level Omni Flush catheter was reformed over a guidewire aspirated blood and flushed out with heparinized saline solution diagnostic aortogram iliofemoral arteriogram was then performed in AP and oblique positions. Attempts were then made to cross over to the contralateral right external iliac artery segment. As noted above our wire would preferentially travel into the right internal iliac artery. Despite a number of catheter and guidewire combinations we were not able to adequately navigate into the external iliac artery segment.

Next, we got access in the right pedal region at the ankle utilizing the posterior tibial artery guidewire was advanced and a 5 French sheath placed at this location. A guidewire was then navigated through the posterior tibial artery across the popliteal. Utilizing a combination of catheter and guidewire were able to navigate through the popliteal and SFA occlusion. We placed our catheter in the more proximal SFA and common femoral region to confirm luminal location. We then advanced our guidewire into the external and common iliac artery segment.

Both right and left groins and right foot were then prepped and draped in routine sterile fashion.

Beginning on the left groin this was locally anesthetized with 1% lidocaine without epinephrine. Using duplex ultrasound were able to access the left common femoral guidewire advanced and a 5 French sheath placed over the guidewire. Left lower extremity runoff was then performed using the side port of the sheath.

Next guidewire was advanced to the L1-2 level Omni Flush catheter was reformed over a guidewire aspirated blood and flushed out with heparinized saline solution diagnostic aortogram iliofemoral arteriogram was then performed in AP and oblique positions. Attempts were then made to cross over to the contralateral right external iliac artery segment. As noted above our wire would preferentially travel into the right internal iliac artery. Despite a number of catheter and guidewire combinations we were not able to adequately navigate into the external iliac artery segment.

Next, we got access in the right pedal region at the ankle utilizing the posterior tibial artery guidewire was advanced and a 5 French sheath placed at this location. A guidewire was then navigated through the posterior tibial artery across the popliteal. Utilizing a combination of catheter and guidewire were able to navigate through the popliteal and SFA occlusion. We placed our catheter in the more proximal SFA and common femoral region to confirm luminal location. We then advanced our guidewire into the external and common iliac artery segment.

Treatment then consisted of a combination of angioplasty and angioplasty and stent placement. As described above we treated first the common iliac artery segment followed by the right external iliac artery segment. The right external iliac artery segment utilized a drug-coated balloon. Finally the SFA and popliteal were treated with a combination of balloon angioplasty and stent placement. We utilized a 5 mm x 120 mm stent followed by 5 mm x 120 mm angioplasty balloon. Final completion showed excellent in-line flow on the right leg. This was also demonstrated through a pigtail catheter run in antegrade fashion from the aorta distally. Following our intervention, the right posterior tibial sheath was removed and a tibial band placed for hemostasis. The left groin sheath was removed and the puncture controlled with a minx closure which was hemostatic. Patient tolerated procedure well.

Medical Billing and Coding Forum

Peripheral Coding HELP NEEDED

Posted on by
Can someone help me to code this? This is definitely not my forte.

Procedures:
_x_Selective Coronary Angiography
_x_selctive angiogram of SVG to OM
_x_Selective angiogram of SVG to diag
_x_ selective angio of SVG to RCA
_x_ selective angio of LIMA to LAD
_x_attempted PCI to native LCX of instent restenosis but unable to cross with balloon
Access Site
_x_Left Radial Artery
_x_Right femoral Artery

EBL: 20 ml
Complications: none

Sedation:
Moderate Conscious Sedation was provided under my direct supervision with the sedation trained nurse using
_1_ Mg Versed
_25_ Meg Fentanyl
_o_ Mg of Diphenhydramine
Start time 1710 and end time was _1755 There were no complications.
See hospital trained nurses sedation sheet I signed and dated for completed pre and post service.

Anesthesia: Lidocaine 1% local

Procedure in detail :
I explained to the patient/family the indications, risks, benefits, and alternatives of the procedure. All questions were answered. Pt/family agrees to proceed.
The patient was brought to the Cardiac Catheterization Lab in a fasting state. All appropriate labs had been reviewed. Bilateral groins & wrists were prepped and draped in the usual fashion for sterile conditions. The appropriate time-out procedure was performed with appropriate identification of the patient, procedure, physician, position and documentation all done under my direct supervision and there were no safety issues raised by the staff.

The access area was anesthetized using Lidocaine. Using a modified Seldinger technique, the artery was cannulated and a sheath was inserted.
The left wrist was anesthetized using lidocaine 1%. The left radial artery was cannulated and a 6 French slender sheath was inserted. A 5 French JR4 catheter was then used to engage the right coronary ostium. Selective angiographic images were obtained. The catheter was then disengaged and then engaged into the vein graft to the right coronary ostium. Selective angiographic images were obtained. The catheter was then disengaged and exchanged for a 5 French JL 3.5 catheter. This is engage into the left coronary ostium. Selective angiographic images were obtained. The catheter was then disengaged and exchanged for a 5 French left coronary bypass catheter. This was engaged into the vein graft to the obtuse marginal. Selective antegrade graphic images were obtained.
The catheter was then exchanged for a 5 French internal mammary Cummings catheter. This was engaged into the left internal mammary artery. Selective angiography images were obtained. The catheter was then disengaged and then exchanged for a 5 French AL-1 catheter. This is engage into the vein graft to the diagonal. Selective angiographic images were obtained. The catheter was then removed. The images were reviewed and the decision was made to try to proceed with intervention to the native left circumflex. The patient is complaining of pain in his left wrist and so we decided to abort the left radial approach. The radial sheath was pulled and a pressure band was applied.

The right groin was anesthetized using lidocaine 1%. Right femoral artery was accessed and a 6 French sheath was inserted. A 6 French CLS 3.5 guiding catheter was then used to engage the left coronary ostium. A BMW wire is in used to cannulate into the distal left circumflex and into the second obtuse marginal. I then tried to take a balloon 2.5 x 15 and cross the in-stent restenosis but it would not cross. After several attempts I finally decided to abort the procedure. The patient was not having any chest pain. My suspicion is that the occlusion may be more chronic than acute. The outflow was very small and slow. Catheters were then removed. Right femoral and gram was done and showed the insertion site was in the right common femoral artery. Angio-Seal was then deployed in the right femoral artery. Good hemostasis was observed. Patient tolerated procedure well and is taken to the intensive care unit.

Closure Device: TR band

Findings:
Left Main distal left main 50%
LAD mild disease, competitive flow from LIMA
LCX moderate disease in native vessel, small caliber OM 1 small vessel
OM2 99% instent restenosis of prox stents, distally very small vessel, less than 1 mm RCA moderate diffuse disease
SVG to diagonal CLOSED
SVG to OM1 patent, prox graft 70% SVG RCA patent
LIMA to LAD patent

Dominance right

Lines: None Specimens: none Condition: serious IVF’s: NS at 75 ml/hr

Post sedation Evaluation: Vital signs stable: yes Airway Reflexes present: yes

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

Cath with Peripheral

Posted on by
I have a patient that went in for RHC regarding aortic stenosis. It was a right common fem approach but unable to get through the common iliac due to heavy calcification and a balloon angioplasty was done. After the cath, the Dr. did a abdominal angiograph with runoff and found the patient had severe PVD.

Need help with coding this procedure please. Cath only was to be done. Do I code that first and can you also code abdominal with bilateral runoff. Confused with the iliac angiograph. Would this be a second order?

Any help would be appreciated.

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.

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