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Peripheral Angiography/Right Radial revascularizaion & Mechanical Thrombectomy

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

Finger radial digital nerve exploration

Hello Fellow Coders,

Does anyone know if cpt 64702 can be used for exploration only. Pt has dist finger closed fractures and developed absent sensation so the MD wants to confirm the digital nerve was not lacerated as well. Surgeon incised middle aspect of the finger with exploration and closure.

I’ve exhausted my resources and not sure since 64702 states Neuroplasty as well.

Thanks in advance

Medical Billing and Coding Forum

Intramedullary nail radial shaft fracture

Need help please! Patient presented with both bone shaft fracture radius and ulna. The doctor states in his note:
"I placed a small flexible intramedullary nail in her radius. I did not have to open this."
He also states in procedure description:
"I initially made a small incision just proximal to the growth plate of the distal radius. I used a drill and a small awl to make a starting point was able to advance a small Synthes flexible rod down the shaft, across the fracture into the proximal radius. This provided excellent stability to the forearm."
There was nothing done to the ulna.
So, there’s no IM nailing or percutaneous code for the shaft of the radius. Would you use an ORIF code with 52 modifier?

Thank you!!

Tobi C.

Medical Billing and Coding Forum

Spinal accessory nerve to suprascapular and partial radial to axillary nerve transfer

Hello,

I am new to ortho coding. I am trying to find the cpt codes for nerve transfers.

I came up with:

Spinal accessory nerve to suprascapular transfer 64713

Right partial radial to axillary nerve transfer 64999

I cannot find a code to compare the unlisted code to.

I would appreciate all the help. Here is the op-report. Thank you

The patient was identified in the preoperative holding area. We reviewed the operative indications, operative plan and recovery. The right shoulder was marked as the operative site and confirmed with the patient. He was then brought to the operating room. He was placed in the prone position. All bony prominences were well padded. Preoperative antibiotics were given per standard protocol. The right shoulder girdle and upper extremity was then prepped and draped in the normal sterile fashion.
A timeout was performed per standard protocol, identifying the patient, the procedure and the operative site. All personnel were in agreement and there were no discrepancies identified.
A transverse incision was made over the superior aspect of the scapula, beginning medial to the superior angle and eventually extending over the acromion. The incision was taken through skin, subcutaneous tissue and fascia down to the trapezius muscle. The fibers of the trapezius were split transversely to identify the spinal accessory nerve. Once we identified the nerve, we used a nerve stimulator to confirm its identity and its function. We carried our dissection laterally to identify the suprascapular nerve. We had difficulty identifying the suprascapular nerve. Proximally, we identified a section of the nerve, proximal to the notch, that appeared damaged. We carried our dissection distally to the acromion and the spinoglenoid notch. Unfortunately, the nerve was not identified in the notch despite wide exposure, suggesting that perhaps the nerve was avulsed distally, with the spinoglenoid notch serving as a second tethering point.
*
We decided at this point to revisit the suprascapular nerve at a later time and instead to continue with the partial radial nerve to axillary transfer. The incision was extended longitudinally over the posterior aspect of the arm. The incision was taken through the skin, subcutaneous tissue and fascia down to the triceps. The radial nerve was identified in the triangular space. We identified its branches, and used a nerve stimulator to evaluate the function of each branch. We selected the branch that provided only elbow extension as our donor nerve; another branch that provided wrist extension was preserved. We then carried our dissection proximally to the quadrangular space to identify the axillary nerve. We isolated the anterior motor branch. The donor radial nerve was divided as distal as possible, and the axillary nerve was divided as proximal as possible. The microscope was then brought into the operating field. The nerve ends were prepared and coapted under the microscope using 8-0 Nylon sutures. The repair was reinforced with fibrin glue (Eviseal).
*
We turned our attention back to the suprascapular nerve. Again, we found that the proximal portion of the nerve appeared unhealthy, and distally it was absent from the spinoglenoid notch. As such, a spinal accessory to suprascapular nerve transfer would be nonfunctional, and we abandoned this second nerve transfer, deciding it was best to preserve trapezius function as it was one of the few stabilizing muscles remaining around his shoulder.

Medical Billing and Coding Forum