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Endovascular stent repair of AAA

I am super stuck :confused: I keep leaning towards 34708 but something tells me I’m missing something… Any one want to take a shot and try to help please!

PREOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.

POSTOPERATIVE DIAGNOSIS:
Abdominal aortic aneurysm.

PROCEDURE:
Endovascular stent repair of abdominal aortic aneurysm.

OPERATIVE PROCEDURE:
The patient was brought to the operating room, placed on the operating table.
After adequate general anesthesia, the patient’s groin area was shaved and both
legs were prepped from the toes all the way up to the umbilicus. The patient
was then draped in the usual sterile manner. Bilateral curvilinear groin
incisions were then made and dissection was carried down to the femoral
vessels. On the right side, the common femoral artery was identified and it
was dissected free circumferentially and encircled with a vessel loop. The
patient had enough common femoral artery here that a second vessel loop could
be placed distally such that a segment measuring about 2.5 cm exposed. On the
right side, the common femoral, superficial femoral, profunda vessels were all
dissected free circumferentially and encircled with vessel loops. On each side
using a Cook needle, guidewire was inserted into the femoral vessels followed
by a 5-French sheath. This was all done under fluoroscopic guidance. Once
this was done, we went ahead and placed our Glidewire up further proximally
through the iliacs, through the aneurysm up into the proximal descending
abdominal aorta. Again, all under fluoroscopic guidance. On the left side, a
Kumpe sheath was inserted into the artery. The Glidewire was replaced with a
stiff Bentson wire and over this, we went ahead and passed our main body
device, which was an Endurant II 25 x 14 x 103. The device was positioned into
place, but not deployed. On the right side, we went ahead and placed a pigtail

catheter and an on-table angiogram was then performed. The left renal artery
was identified. The patient had a nephrectomy on the right side. The graft
was then gradually deployed angling the gate more anterolaterally to the left.
The main body was deployed until the gate opened. At this point, the pigtail
catheter on the right side was then removed over a guidewire and replaced with
a Kumpe sheath. Attempt was made to cannulate the gate without success, an
angling sheath had to be then used to cannulate the gate successfully. The
guidewire was then passed up through the gate. Angling sheath was then
removed, and a sheath was then placed over the guidewire as well as a pigtail
catheter and an on-table angiogram was then performed. The distance from our
bifurcation to the iliac takeoff was measured, it appeared that a 16 x 16 x 124
length catheter would be appropriate here and the pigtail catheter and sheath
was then removed over wire and the right limb extension device was then
inserted and then, deployed successfully down to the level of the internal
iliac takeoff on the right. Similarly on the right side, a similar procedure
was performed. It should be noted that our suprarenal anchoring device had
already been deployed and the remaining portion of our graft on the left side
was deployed. The device was then removed and replaced with a sheath. Once
again, a pigtail catheter was also inserted and once again an on-table
angiogram was performed on the left side, distance to our internal iliac
takeoff was measured and it appeared that a 16 x 16 x 93 limb would be the
appropriate size. The pigtail catheter removed and our device was then
threaded over the wire and through our sheath up to our main body graft. The
device was then deployed successfully down to the internal iliac takeoff. At
this point, 2 Reliant balloons were inserted up each limb and inflated
sequentially down the entire length of the aortic graft and the limbs. Once
this was done, a completion aortogram was then performed. This showed good
seal without any endoleaks or no kinks within the graft. At this point, the
sheaths and wires were all removed and the arteriotomies in our femoral vessels
were closed using interrupted 6-0 Prolene sutures. The wounds were irrigated
and aspirated. The wounds were closed in layers with deep layers of 2-0
Vicryl. The skin was closed using 4-0 Monocryl using a subcuticular stitch and
dressed with Steri-Strips, 4×4 gauze, and tape. The patient tolerated the
procedure well without any complications. Anesthesia was reversed. The
patient returned to the recovery room in satisfactory condition. In the
recovery room, the patient was noted to have palpable pedal pulses as he did
preoperatively. Total contrast used was 70 cc and our fluoro time was 34
minutes and 51 seconds.

Medical Billing and Coding Forum

CPT 43240- Is removal of Stent included?

Hi, I was informed that the removal of stents are included in the code for placement of stent. But for some of the procedure (such as 43276), the describes states remove and replacement or even a guideline to state the removal is included in the procedure. One of our GI providers are removing stents then performing the Necrostomy and then places new stents. We are going to code 43240 for the placement of stents and the unlisted code for Necrostomy but can we also code for the removal? The CPT I was thinking is 43247- Foreign body removal. Please any thoughts or guidanice will be greatly appreciated.

Thank You

Medical Billing and Coding Forum

Embolization with coils balloon and stent

Hi I’m looking for some guidance for coding the following procedure. Any help would be greatly appreciated :)

*
INDICATION: 57 y.o. female with multiple cerebral aneurysms
*
COMPARISON: CTA performed on
*

*
ANESTHESIA: General Anesthesia.
*

*
CONSENT:
The procedure, risks, benefits and alternatives to cerebral angiography were discussed with the patient. Informed consent was obtained after all questions were answered. The patient was brought to the Neuroendovascular suite and placed supine on the angiography table. The patient was prepped and draped in the usual sterile fashion.
*
DESCRIPTION OF THE PROCEDURE AND FINDINGS:
ACCESS:
The skin of the right wrist was anesthetized with EMLA cream and 2% lidocaine subcutaneously. Utilizing US guidance and a micropuncture kit, a 6 Fr. Terumo slim glidesheath was placed into the right radial artery. 2D hand injected angiography was performed which demonstrates retgrade opacification of the radial artery, ulnar artery and superficial palmar arch. Heparin 5000 units, 200 mcgs Nitroglycerin and 5 mg verapamil was adminsitered intra-arterially.
*
Intravenous heparin was administered with intermittent boluses to maintain an ACT 2 – 2.5 times the patient’s baseline.
*
A 6 French 071 Benchmark guide catheter over a Simmons-2 catheter and an angled 0.038" Terumo Glidewire was advanced into the right brachial artery.
*
RIGHT VERTEBRAL ARTERY:
The guide catheter was advanced into the right vertebral artery. 2D hand injected angiography was performed centered over the neck and head. The cervical vertebral artery is of normal course and caliber. Intracranially, there is antegrade opacification of the right vertebral artery, right posterior inferior cerebellar artery, basilar artery, bilateral anterior-inferior cerebellar arteries, bilateral superior cerebellar arteries, bilateral posterior cerebral arteries and their branches. The left distal vertebral artery backfills briefly with opacification of the left posterior inferior cerebellar artery. The vessels are of normal course, caliber and taper regularly. There is no aneurysm, focal area of stenosis or early draining vein. The capillary and venous phases are unremarkable. The dural and deep venous sinuses opacify normally.
*
LEFT COMMON CAROTID ARTERY:
The guide catheter was advanced into the left common carotid artery. 2D hand injected angiography was performed centered at the bifurcation which is at the C2/3 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis. The cervical internal and external carotid arteries are of normal course and caliber.
*
LEFT EXTERNAL CAROTID ARTERY:
The guide catheter was advanced into the left external carotid artery. 2D hand injected angiography was performed centered over the patient’s head. Angiography reveals antegrade opacification of the external carotid artery and its branches. The vessels are of normal course, caliber and taper regularly. No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.
*
LEFT INTERNAL CAROTID ARTERY:
The guide catheter was advanced into the left internal carotid artery. 2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections. Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is small, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly. There is no focal area of stenosis or early draining vein. The capillary and venous phases are unremarkable. The dural and deep venous sinuses opacify normally. There is a 2.2 mm x 2.4 mm left ophthalmic artery aneurysm.
*
RIGHT COMMON CAROTID ARTERY:
The guide catheter was advanced into the the right common carotid artery. 2D hand injected angiography was performed centered at the bifurcation which is at the C2/3 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis. The cervical internal and external carotid arteries are of normal course and caliber.
*
RIGHT INTERNAL CAROTID ARTERY:
The guide catheter was advanced into the right internal carotid artery. 2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections. Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is robust, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly. There is no focal area of stenosis or early draining vein. The capillary and venous phases are unremarkable. The dural and deep venous sinuses opacify normally. There is a 2.9 mm x 6.1 mm right posterior communicating artery aneurysm with a 3 mm neck. There is a 3.6 mm x 3.5 mm right paraophthalmic aneurysm with a 2.5 mm neck. There is an occlusion of a distal parietal middle cerebral artery branch with delayed opacification of the downstream territory. 7.35 mg of Integrilin were administered to the right internal carotid artery.
*
EMBOLIZATION:
The right internal carotid artery was selected and under roadmap guidance and 10 mg of verapamil was administered. The guide catheter and glidewire were advanced into the cervical segment of the internal carotid artery. The Simmons-2 catheter and glidewire were removed. Follow-up control angiography was performed which is unchanged from the initial angiogram and demonstrated no vasospasm around the guide catheter. There is slight improvement in opacification of the occluded distal parietal middle cerebral artery branch.
*
Utilizing a road map a 4 mm x 10 mm Scepter C balloon was advanced over a 0.014" Synchro-2 guidewire across the right posterior communicating artery aneurysm os. A 45 degree SL-10 microcatheter was advanced over a 0.014" Aristotle guidewire into the right posterior communicating artery aneurysm. An aneurysmogram was performed which demonstrates opacification of 2.9 mm x 6.1 mm aneurysm with a 3 mm neck.
*
Balloon assisted coil embolization of the aneurysm was performed by advancing a TARGET 360 SOFT 5X10 coil into the aneurysm. This was followed by a TARGET 360 ULT 4X10 coil, which prolapsed out of the aneurysm sac. The coil was removed and the balloon deflated, resulting in a coil loop prolapsing into the right internal and right middle cerebral arteries. The 45 degree SL-10 was removed. A 90 degree SL-10 microcatheter was advanced over a 0.014" Aristotle guidewire into the right posterior communicating artery aneurysm under roadmap control. Balloon assisted coil embolization of the aneurysm was performed by advancing the TARGET 360 ULT 3X8 coil. Control angiography demonstrates a coil loop within the right middle cerebral artery and the right internal carotid artery, otherwise the remaining coils are well seated in the aneurysm sac and the parent vessel to be widely patent.
*
Coil embolization of the aneurysm was performed by advancing the following coils into the aneurysm sac:
TARGET 360 ULT 3X8
TARGET 360 ULT 3X6
TARGET 360 ULT 2X4
*
Follow up control angiography was performed demonstrating a coil loop within the right middle cerebral artery and the right internal carotid artery, otherwise the remaining coils are well seated in the aneurysm sac and the parent vessel to be widely patent.
*
Utilizing a road map the 4 mm x 10 mm Scepter C balloon was advanced over the 0.014" Synchro-2 guidewire across the right paraophthalmic aneurysm os. The 90 degree SL-10 microcatheter was advanced over the 0.014" Aristotle guidewire into the right paraophthalmic aneurysm. An aneurysmogram was performed which demonstrates opacification of 3.6 mm x 3 mm aneurysm with a 2.8 mm neck.
*
Balloon assisted coil embolization of the aneurysm was performed by advancing a MICRUSFRAME 10 3.5X6.6 coil into the aneurysm sac. Control angiography demonstrates the coil mass seated in the aneurysm sac and the parent vessel to be widely patent.
*
Coil embolization of the aneurysm was performed by advancing the following coils into the aneurysm sac:
GALAXY G3 MINI 2.5X4.5
GALAXY G3 MINI 2X3
*
The Scepter C balloon and SL-10 catheter were removed.
*
Under high magnification fluoroscopic roadmap control, a 4.5 mm x 21 mm Neuroform Atlas stent was positioned from the right carotid terminus to the cavernous segment segment of the right internal carotid artery utilizing a XT-17 over the 0.014" Aristotle guidewire and deployed.
*
Control angiography demonstrates a coil loop arising from the right posterior communicating artery aneurysm coil mass into the right middle cerebral artery, with the remaining coils to be well seated in the aneurysm sac and the parent vessel to be widely patent with no opacification of the aneurysm sac, but persistent filling of the aneurysm neck (Raymond 2). Additionally, there is a coil mass seated in the right paraophthalmic aneurysm with no opacification of the aneurysm sac (Raymond 1). There is no evidence of in stent stenosis or thrombosis, and the stent is well apposed to the parent vessel wall.
*
The XT-17 microcatheter and guidewire were removed. Final follow-up control angiograms were performed in the AP, lateral and working projections which demonstrated the coil mass to be well seated within the aneurysm sac and the parent vessel to be widely patent. There is persistent occlusion of the distal parietal middle cerebral artery branch with delayed opacification of the downstream territory.
*
After review of the angiographic data the guide catheter was removed. The right radial artery sheath was removed. Hemostasis was achieved utilizing a TR-Band. The patient tolerated the procedure well. The patient was subsequently transferred to the Neuroendovascular Surgery recovery area at their baseline neurological status.
*
IMPRESSION:
1. Balloon assisted coil embolization of a non-ruptured, right posterior communicating artery aneurysm measuring 2.9 mm x 6.1 mm with a 3 neck. There is no opacification of the aneurysm sac, but persistent filling of the aneurysm neck (Raymond 2). There is a coil loop in the right internal carotid and right middle cerebral arteries.
2. Successful balloon assisted coil embolization of a non-ruptured, right paraophthalmic aneurysm measuring 3.6 mm x 3.5 mm with a 2.5 mm neck. There is no opacification of the aneurysm sac (Raymond 1).
3. Atlas stent deployment from the right internal carotid terminus into the cavernous segment of the right internal carotid artery, successfully tacking down the prolapsed coil loop.
4. Occlusion of the distal parietal middle cerebral artery branch with delayed opacification of the downstream territory treated with Integrilin infusion.
*
MY CPT CODES

61624
36226 RT
36224 50
36228 X 2
75894 26
75898 X 2
NOT SURE ABOUT THE ATLAS STENT

Thank you!

Medical Billing and Coding Forum

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

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

Stent removal

Hi all –

I’m a surgery coder for a Urology group in Las Vegas and my colleague and I have a quandary while performing audits. Frequently the urologists insert ureteral stents when patients have stones to help with the passage of the stones. They’re usually removed inside of a month (rarely longer than ten to fourteen days) but when the removal visit is being coded – they’re usually done in the office – are you using the T-code (example: T83.112A for mechanical breakdown of indelling ureteral stent, initial encounter) for the diagnosis? We’ve seen them with the T-code diagnosis primary, secondary, and not used at all. We’re both inclined to use the diagnosis for why they were inserted in the first place (example: N13.2 Hydronephrosis with obstruction by stone primary and Ureter Stone N20.1 secondary) especially if there’s no actual defect with the stent.

What’s the school of thought here?

Thanks!

Medical Billing and Coding Forum

Denial Renal Stent

I need tricks on getting renal artery stents paid. I used CPT code 37236 and the only dx codes I had were I70.1, I72.2, I10., N18.4. I know none of these codes are payable as per the CMS LCD policy. I only have a vascular study that shows severe bilateral renal artery stenosis and a small renal aneurysm. Exam shows no pain or claudication.

Medical Billing and Coding Forum

lap ureteroureteral anastomosis w stent insertion

How would you code Laparoscopic ureteroureteral anastomosis and left ureteral stent insertion of a transected ureter. This transection occurred during a hysterectomy. My doc entered laparoscopicaly found the transection in the ureter freshen the edges then spatulated at a distance of 8 mm. at this point the stent was advanced to the proximal ureter.

I was thinking unspecified with a comparative of 50760.

Thanks for the help.

Medical Billing and Coding Forum

Endarterectomy with patch angioplasty, selective cath, stent placement — pls review

Hello – We would love someone to review our codes and provide feedback. Also, specifically, it’s our understanding that we code for both access sites, hence the use of 36140-XS-RT. Yes/No – Circumstantial? We are specifically being asked why we want to use this code.

These are the codes we want to use for this inpatient Medicare pt.
35371-RT
37221-RT
36140-XS-RT
75625

Many thanks. Kristi

Pre-op Diagnosis:
1. Atherosclerotic PVD with intermittent claudication RLE [I70.219]
2. CKD
3. HTN

Post-op Diagnosis: same

Procedure(s):
1. Right common femoral endarterectomy with bovine pericardial patch
angioplasty
2. Aortogram via L CFA approach
3. Selective catheterization of R EIA
4. R EIA PTA, stent placement, 8 x 60mm

Anesthesia: General

Estimated Blood Loss: 200 mL

CONTRAST: 50 cc

Drain: none

Total IV Fluids: see anesthesia log

Specimens:
ID Type Source Tests Collected by Time Destination
A : RIGHT FEMORAL PLAQUE Tissue Plaque SURGICAL PATHOLOGY

Implants:
Implant Name Type Inv. Item Serial No. Manufacturer Lot No. LRB No.
Used
PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X W.8 CM PERIPHERAL
STERILE – SN/A Patch PATCH VASCULAR VASCU-GUARD BOVINE PERICARDIUM L8 CM X
W.8 CM PERIPHERAL STERILE N/A SYNOVIS MICRO COMPANIES ALLIANCE INC – A
BAXTER HEALTHCARE CORP CO SP18B02-1270178 Right 1
mynx N/A CARDINAL HEALTH INC F1805704 Left 1

Complications: none

Findings: R EIA occlusion with bulky calcified plaque extending into R
CFA. S/p endarterectomy. Unable to cross EIA lesion from retrograde
approach therefore L CFA access was obtained and lesion was crossed from
an antegrade approach. Self-expanding 8 x 60mm stent was placed was good
result. Palpable pedal pulses upon completion.

Disposition: awakened from anesthesia, extubated and taken to the recovery
room in a stable condition, having suffered no apparent untoward event.

Condition: doing well without problems

Technique:
After informed consent was obtained the patient was taken to the operating
room. Placed in the supine position. General endotracheal anesthesia was
administered. The abdomen and bilateral groins were prepped and draped
usual sterile fashion.

We began by making an incision in the inguinal
right area right groin midline between a cyst in the pubic tubercle in
vertical fashion. We dissected through the skin subcutaneous tissue
Scarpa’s fascia until we encountered the femoral sheath. Any veins that
were seen were tied off and suture ligated. Then got into the femoral
sheath identified our inguinal ligament and then our right common femoral
artery. It was noted to be calcified with some posterior plaque and some
inflammation noted. We dissected systemic fashion inferiorly identifying a
few branches and putting small Vesseloops around. We then identified the
SFA and profunda. Placed vessel loops around them. We then continued our
dissection more proximally we had to divide part of the inguinal ligament
to get more proximal control.

At this point, we began our endarterectomy
we heparinized the patient and obtained ACTs every 30 min to remain
therapeutic. Once the patient was therapeutic we got control with vessel
loops and then performed an arteriotomy with an 11 blade and extended it
with Potts scissors. The common femoral artery had noted hemorrhagic
calcified plaque. We then perform an endarterectomy between the median
intima with a Freer elevator and piecemeal off the plaque in the common
femoral artery. We then made our endpoint at the distal common femoral
artery. There was noted to be calcified posterior plaque on the proximal
aspect of our endarterectomy site with a chronic occlusion.

We attempted
to access through the open endarterectomy vessel the right external iliac
artery with a Glidewire 035 as well as a 5 French sheath. When we
advanced the wire and there was mild resistance proximally we advance into
what we thought was the abdominal aorta we then performed an angiogram
which demonstrated a dissection plane at this point we then stopped access
from this area. We removed the sheath and the wire and then gain access on
the opposite groin. At this point we then gain access to the left groin
under palpation using Seldinger technique.

We accessed the left common
femoral artery and then we upgraded to a 5 French sheath. We then
advanced a Glidewire and a VCF catheter and performed a angiogram with
minimal contrast. This demonstrated extensive infrarenal calcification in
bilateral patent common iliac arteries. The left hypogastric appeared to
be occluded. The left external iliac had multilevel disease but nothing
hemodynamically significant. The right common iliac artery appeared to be
patent the external had a flush occlusion about 1 cm after the takeoff.
The left hypogastric artery appeared to be patent with an ostial lesion.
There was extensive pelvic collaterals and reconstitution at the femoral
head of the common femoral artery. At this point we then upgraded to a 6
French up-Andover sheath and advanced it over the bifurcation into the
right common iliac artery. We then used a support Seeker catheter within
and a stiff 035 glidewire and was able to go through the chronic occlusion
of the left external iliac artery into our endarterectomy site in the
right common femoral artery. We then switched snared the Glidewire
through the right common femoral artery endarterectomy site. At this point
we then placed a 6 French sheath through the Glidewire in the right groin
and then we used a 8 x 60 mustang balloon used to measure the length of
our occlusion. At this point we then decided to use a 8 x 60 self
expanding stent. We deployed the stent in standard fashion at the takeoff
of the hypogastric artery with the endpoint proximal to the femoral head.
We then post dilated with a 8 x 60 mustang balloon. Postop angiogram
demonstrated good apposition of the stent with no hemodynamic significant
stenosis noted. We then at that point, performed a patch angioplasty with
a pericardial patch with 6 0 Prolene in standard fashion. Before
completing the patch angioplasty we forward flushed and backflushed the
common femoral artery. Before completing the full angioplasty, we left
the wire in place and then performed a angiogram which demonstrated
patency of the right common iliac artery as well as external iliac artery
and common femoral artery with no hemodynamic significant stenosis. The
right groin shot demonstrated patency of the profundus as well as the SFA.

At that point we then finished our patch angioplasty and endarterectomy
site. Everything was noted to be hemostatic and mildly oozy. We reversed
the patient with protamine. We dried out any bleeding points with Bovie
electrocautery and clips. We then closed the right groin in layers of
Vicryl multiple. We closed that the subdermal with 3 0 Vicryl pop offs
and the skin with 4 O Monocryl subcuticular stitches. Sterile dressing was
then applied.

On the left groin we downsized to a 6 French sheath over the
wire under fluoroscopic guidance. We then used a 6 French Mynx closure
device and closed the left common femoral artery at the access site. In
standard fashion. Sterile dressing was then applied. At completion of the
procedure the patient had a palpable right pedal pulses. Patient tolerated
the procedure well was extubated transferred to the PACU in stable
condition.

Medical Billing and Coding Forum

cath with subclavian angio stent need help

This 71-year-old female with history of coronary disease status post multivessel stenting in the past who is presenting with combination symptoms of left-sided chest discomfort as well as left arm claudication with neurologic complain of numbness at rest. Workup showed severe left subclavian stenosis. She was referred for coronary angiogram as well as left subclavian angiogram and stenting. 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 10:55 AM and monitoring period Ended 11:55 AM. 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 6 French sheath was inserted in the right femoral artery. Cardiac catheterization was performed using the usual catheters.
Finding:
1: The left main is angiographically normal.
2: The left anterior descending artery is a large vessel that supplies 2 diagonal branches and multiple septal branches. The previous inserted stent in its proximal to mid part is widely patent. There is no significant disease otherwise
3: Left circumflex: The left circumflex artery is a nondominant vessel although large, a previously inserted stent in its proximal part is widely patent. There is mild disease otherwise.
4: Right coronary artery: The right coronary artery is a large dominant vessel. The previously inserted stent proximally is patent with mild in-stent restenosis. There is diffuse multiple areas of 20-30% stenosis.
5: Left heart catheterization showed normal left ventricular end-diastolic pressure
6: Left subclavian angiogram showed more than 90% heavily calcific subclavian stenosis in the proximal part of the left subclavian artery. There is no left vertebral artery that can be visualized. The left internal mammary artery is patent.
7: Selective innominate angiogram showed a patent innominate artery and a right common carotid artery. The origin of the right subclavian artery has 70% calcific stenosis.
*
Impression:
1. Patent left anterior descending artery, left circumflex artery and right coronary artery stents and no progression of disease otherwise
2. Severe stenosis in the origin of the left subclavian artery and moderate to severe stenosis in the right subclavian artery as it takes off from the innominate artery
*
Plan: Proceed with intervention to the left subclavian artery
*
Intervention:
The JR4 was used to intubate the origin of the left subclavian artery. A Magic torque wire was used to cross into the distal left subclavian artery. The 5 French sheath was then removed and exchanged for a 6 French shuttle sheath that was positioned in the ostium of the left subclavian artery. The severe stenosis was predilated with a 6 x 20 mm balloon however with more than 50% residual stenosis and significant gradient. The area was then treated with an 8 x 27 mm balloon expandable stent and postdilated with a 9 x 20 mm balloon with excellent result and no residual stenosis.
*
Final impression:
*
1. Patent left anterior descending artery, left circumflex artery and right coronary artery stents and no progression of disease otherwise
2. Severe stenosis in the origin of the left subclavian artery and moderate to severe stenosis in the right subclavian artery as it takes off from the innominate artery. The left subclavian artery was successfully treated with insertion of 8 x 27 balloon expandable stent with no residual stenosis
*
I am thinking of cpt 93459,37236-lft or should I do 37225? also
thanks in advance
*

Medical Billing and Coding Forum