We’re working on the below procedure and need some input on coding…. any help will do…….(Hi Jim,… Happy 4th of July 2018!!!)……

PROCEDURES PERFORMED:
Bilateral Renal.Angiogram Aortagrarn-Abdominal Aortagram- Root/Acending Left Subcfavian Angiography
Unilateral Extremity Angio Right Bilateral extracraniaf carotid angiogram

INDICATIONS:
173.9 170. 213

FINDINGS:

Abdominal aortogram:
Normal size severely calcified abdominal aorta.
There is a large calcified plague at the level of the left renal artery. extending to the mid abdominal aorta, which creates about 60 percent stenosis of the descending aorta.
There is 20 millimeter gradient between thoracic descending aorta. and distal abdominal aorta. Distal abdominal aorta is ectatic with moderate calcified plague, but without aneurysm, dissection of obstructive disease.

Bilateral selective renal angiogram:
Right main renal artery is a medium-sized vessel without evidence of any obstructive disease
Right kidney appears reduced in size.
Left main renal artery is a small diffusely diseased vessel with 99 percent proximal stenosis
Left kidney is severely reduced in size, atrophic.

Bilateral iliac anqiogram:
Left common iliac artery is the large vessel, with patent stent in the proximal -mid portion, which appears a little undersized for the size of the artery, but nevertheless is wide open.
Left hypogastric artery is patent.
Left external iliac artery is a medium-sized vessel, there is about 40 percent proximal portion proximal portion stenosis immediately after bifurcation with hypogastric. appears nonobstructive.

Left common femoral artery is medium size mildly calcified patent vessel with about 30 percent stenosis, proximal left deep femoral, and superficial femoral arteries are patent.

Right common iliac artery is a large vessel, with about 10 percent ostial stenosis, nonobstructive. Right hypogastric artery is a large vessel. there is 80 percent ostial stenosis. there is 80 percent midportion stenosis, hypogastric artery supplies collaterals to the right deep femoral artery, and in turn to the superficial femoral artery.
Right external iliac artery is occluded entirely.
Right common femoral artery is severely calcified and is chronically occluded with only bifurcation to right deep, and right superficial femoral artery patent.

Aortic arch angiogram, and selective bilateral extracranial carotid angiogram, and selective left subclavian angiogram:

Normal size type 2 aortic arch with moderate calcification of the lesser and greater curvature without obstructive or mobile plague, no aneurysm or dissection.

lnnominate artery is a large calcified vessel, with not more than 20 percent nonobstructive stenosis. It gives rise to the large right subclavian artery. which has no evidence of obstructive disease, and gives medium-size right vertebral artery with antegrade flow.

Right carotid artery is the large vessel. distal common carotid artery has calcific 50 percent stenosis, transitioning into the 70 percent calcific stenosis of the proximal internal carotid artery; mid-distal internal carotid artery is free of significant stenosis.
Right external carotid artery is chronically occluded.

Left carotid artery is a large calcified vessel with 90-95 percent ostial common carotid stenosis, the rest of the common carotid artery is free of significant disease, there is 50 percent calcific stenosis of the proximal internal carotid artery: mid-distal internal carotid arteries free of significant stenosis.
Left external carotid artery is chronically occluded.

Left subclavian is a large vessel with 20-30 percent ostlal stenosls, nonobstructive, gives rise to large left vertebral artery with antegrade flow, followed by 90-95 percent stenosis immediately distal to origin of the vertebral artery, beyond the stenosis the left subclavian artery is free of significant disease and gives rise to medium size LIMA.

Right lower extremity angiogram:
Right common femoral artery is occluded chronically.

Right deep femoral artery receives flow via collaterals from the right hypogastric artery with retrograde filling to the right superficial femoral artery. There is 80 percent ostial stenosis of the right deep femoral artery.

Visualized proximal-mid right superficial femoral artery is fee of any significant stenosis with adequate flow.

Distal SFA/popliteal angiogram was not performed to preserve contrast use.

PROCEDURE NOTES:
The patient was brought to the cath lab in a resting and fasted state. The patient was prepped and draped in the usual sterile fashion.
Vascular access was obtained with the micropuncture kit, and modified Seldinger technique to the left common femoral artery, 5 French sheath was introduced.
Abdominal aortogram, and bilateral iliac angiogram, was obtained with a 5 French contra catheter positioned respectively to proximal abdominal aorta, and distal abdominal aorta in AP projection with power injection of 15, and 10 cc of contrast respectively.
Selective bilateral renal angiogram was obtained with a 5 French IM catheter, selectively engaging right, and left main renal artery.
Right lower extremity angiogram was obtained with a 5 French IM catheter positioned across the aortic bifurcation to the mid right common iliac artery.
Aortic arch angiogram was obtained with a 5 French pigtail catheter positioned to the distal ascending aorta in 30
degree LAO projection with power injection of 15 cc of contrast.
Selective right carotid angiogram was obtained with a 5 French JR4 catheter positioned to the ostial right common carotid artery in RAO projection.
Selective left carotid angiogram was obtained with a 5 French IM catheter positioned to the ostial left common carotid artery in LAO projection.
Selective left subclavian angiogram was obtained with a 5 French IM catheter positioned to the proximal left subclavian artery in AP projection.
For the entire procedure – 82 cc of contrast were used, patient was aggressively hydrated, received 400 cc of normal saline before and throughout the procedure, with plans for additional 400 cc normal saline infusion after the procedure.

LOCAL ANESTHETIC:
Local anesthetic to left groin region with Lidocaine 2%

PROCEDURAL APPROACH:
left femoral artery Merit Medical S-tv\AK 4FR minni access kit, Boston Scientific 5Fr BS Super Sheath 11cm

CONTRAST:
lsovue370- 119 mi’s

EQUIPMENT:
Merit Medical S-MAK 4FR minni access kit Boston Scientific 5Fr BS Super Sheath 11cm Navilyst 0.035x 145cm 3mmJ Wire
Boston Scientific 5Fr. Imager IIContra Flush catheter· Boston Scientific 5Fr. IM
Abbott Versacore Floppy Boston Scientific 5Fr. Str Pigtail Boston Scientific 5Fr. FR 4
LESION INFORMATION: MEDICATIONS:
Sedation Start Time 08:04 llf reeText11
{Narcotics/Sedation} Versed 1 mg IV
{Narcotics/Sedation} Fentanyl 50 mcg IV IV Bolus: .9 NaCl 250 ml total
Oxygen: 3 Umin via nasal cannula Heparin 2000 unit(s)
Wasted 1mg Versed and 50mcg Fentanyl llf reeText11 Sedation Stop Time 09:13 llfreeText"

AIR REST
ECG
AO 151/53 (88) SA AO 125/51 (78)
AO 153/56 (89)

07:56:34
08:16:23
08:20:07
08:50:08

CONCLUSIONS:
Severe diffuse peripheral arterial disease:
Chronic total occlusion of the right external iliac artery. and right common femoral artery. 95% stenosis of the mid left subclavian artery, immediately distal to the left vertebral artery . 60% stenosis of the mid abdominal aorta. immediately distal to the left renal artery.

Carotid artery disease:
Severe -critical stenosis of the ostial left common carotid artery
50% highly calcific stenosis of the left internal carotid artery

Renal Artery
99% stenosis of the left renal artery to the small-atrophic left kidney. No significant stenosis of the right renal artery.

RECOMMENDATIONS:
No Indication for renal artery revascularization.
Will plan to discuss management of the carotid, subclavian. iliac-femoral arterial disease with vascular surgery in regards to preferred option of medical treatment vs: interventional, surgical, or hybrid revascularization.

Add Plavix 75 milligrams daily to medical therapy.

I was thinking:

CPT 36252, 75625, 59, 75716, 36245, 59, 36223, 50, 99152 and 99153

Many, many thanks!!!

Happy 4th!! to all!