# arch angiogram - newbie



## Rita Bartholomew (May 16, 2012)

_I don't code many of these, so I'm not sure if I can code  75650, as well as 75671 and 75680.  I have cath placements as 36216, 36215 and 36218._PREOPERATIVE DIAGNOSIS:  Status post stroke, bilateral carotid artery stenoses, question of left carotid artery total occlusion.

POSTOPERATIVE DIAGNOSIS:  Status post stroke, bilateral carotid artery stenoses, question of left carotid artery total occlusion.

PROCEDURES PERFORMED:
1. Angiogram of the cervical and cerebral carotid arteries.
2. Arch angiogram.
3. Selective catheterization of the right common carotid artery.
4. Selective catheterization of the left common carotid artery.
5. Selective catheterization of the right subclavian artery.

SURGEON:  Xxxx Xxxxx, MD

ANESTHESIA:  Local.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS:  None.

ACCESS: 5-French sheath, left common femoral artery, retrograde (ultrasound guided, Mynx closure).

CONTRAST: Isovue 300, 65 mL.

RADIOLOGIC FINDINGS: 
1. There was diffuse calcification to the patient's aortoiliac system which was quite severe.  Two large and very antiquated-appearing stents were noted in the common iliac arteries.  These appear to be wall stents.  On the right side this extended up to the aortic bifurcation on the left side.  This was approximately 2 cm from the aortic bifurcation.  These stents were quite long.
2. The aortic arch was a type 3 arch.  The brachiocephalic artery had a stenosis of 50 to 60% near its origin.  There appeared to be a common origin of the innominate artery and the left common carotid artery.
3. The left subclavian artery was patent.  There was a 30 to 40% stenosis distally.
4. Both vertebral arteries are noted to be widely patent.
5. The right subclavian and right vertebral arteries were patent. 
6. The right common carotid artery was patent.  This artery branched at the C4 level.  There was a less than 50% stenosis noted at the origin of the internal carotid artery as well as another area of approximately 50% stenosis 2 cm downstream.  The more distal artery appeared to be patent.  The intracranial portion of the artery appeared to be normal. The intracranial internal carotid artery appeared to be normal with a normal-appearing middle cerebral and anterior cerebral artery.  There was cross-communication from the right to the left side through the anterior cerebral artery and the left anterior cerebral artery was fed entirely from the right side.  There was some crossover from the right into the left middle cerebral artery as well.  There was some filling of the posterior cervical artery on the right from the right internal carotid artery. 
7. Additional images of the innominate artery lesion show that this lesion was approximately 50% and highly calcific and eccentric.  
8. On the left side, the common carotid artery was patent.  Significant calcification was noted at the bifurcation but the bifurcation was at approximately the C3 level.  There was an angiographic string sign through the first centimeter of the internal carotid artery, at which point the artery reconstituted as a small but patent artery measuring at least 3 mm in diameter.
9. The right external carotid artery was patent.  Intracranially, the internal carotid artery had slow filling, and contributed significantly to the middle cerebral artery.  Venous return was normal.  

OPERATIVE REPORT: The patient was taken to the cardiac catheterization laboratory.  She was placed on the table in a dorsal recumbent position.  After this, the skin of groin area was prepared and draped in the standard sterile fashion and I called a time-out for correct patient and procedural identification per Mercy Hospital protocol.  Next, under local anesthesia, I accessed the left common femoral artery using ultrasound guidance.  A 0.01, 8-inch guidewire advanced easily into the artery, and a 5-French sheath was inserted using Seldinger technique.  The sheath was aspirated and flushed and aspirated and flushed easily.  Through the sheath, a pigtail catheter was advanced into the abdominal aorta, where it was formed.  The patient was followed with arteriographic imaging using the flat-panel detector during the advancement of the wires and catheters, and very significant stenting was noted in the distal abdominal aorta and iliac artery systems.  Next, the pigtail catheter was fashioned in the descending thoracic aorta and bubbles were removed.  The catheter was then advanced into the ascending aorta and using a left anterior oblique projection, an arch angiogram was obtained.  Next, I used Simmons-2 catheter and fashioned the catheter in the descending thoracic aorta and bubbles were removed.  Unfractionated heparin 3000 units were administered IV.  I used the Simmons-2 catheter to selectively catheterize the right subclavian artery, and images of the right subclavian artery and right vertebral artery were noted.  

The catheter was then used to selectively catheterize the right common carotid artery.  A very significant plaque was noted near the origin of innominate artery.

With the Simmons-2 catheter in the right common carotid artery, images of the cervical carotid artery were obtained in AP, lateral and oblique projections, and the intracranial carotid artery were obtained in the AP and lateral projections.  

Next, I selectively catheterized the left common carotid artery, and in a similar manner images of the left cervical carotid artery were obtained in AP, lateral and oblique images, and AP and lateral images of head were obtained.  The findings are noted above.  Images of the left internal carotid artery showed a severe stenosis with angiographic string sign.  Of note, the aortic arch was densely calcified and severely diseased.  A type 3 arch was present.

Upon completion, the Simmons-2 catheter was removed under flat panel detector guidance, and the left groin was re-prepared and re-draped.  The Mynx closure device was used to close the puncture site in the left common femoral artery.  There were no complications.

_Thanks for any  help here._


----------



## bkiesecker (May 16, 2012)

I think that you are correct in your cpt code selection.  Couple things I would watch out for is I would not have coded the arch if it were not for the fact in the very tail end of the report the Doctor gives you result of the arch being calsified and what it looked like. Also in the future I would ask the Doc about that vertbral angiograghy and why he /she did it and what they saw, it may be codeable (75685). Also there are some specific guidlines on ultrasound guidines you might want to look at , if its performed.

over all looks pretty solid 

good luck


----------



## Rita Bartholomew (May 17, 2012)

Thanks.  I looked at the vertebral findings as incidental.  I'll check into the ultrasound guidance.


----------



## dpeoples (May 17, 2012)

Rita Bartholomew said:


> _I don't code many of these, so I'm not sure if I can code  75650, as well as 75671 and 75680.  I have cath placements as 36216, 36215 and 36218._PREOPERATIVE DIAGNOSIS:  Status post stroke, bilateral carotid artery stenoses, question of left carotid artery total occlusion.
> 
> POSTOPERATIVE DIAGNOSIS:  Status post stroke, bilateral carotid artery stenoses, question of left carotid artery total occlusion.
> 
> ...



Rita,
I agree with Robert in that the codes you have selected are appropriate. I would probably add 75685 for the RT Vert because he did a dedicated injection to evaluate that (selection/injection of the RT Subclavian) artery. He gives just enough information on the LT Vert to make me wonder, but I think he just saw that from the arch injection. This can be very subjective. 

HTH


----------



## Rita Bartholomew (May 17, 2012)

Thanks, Danny.  Your advice is always spot-on.


----------

