# bilateral carotids &left subclavian



## maryann1224@bellsouth.net (Oct 24, 2012)

for the following report; would the correct codes be? thanks for your assistance!

93459, 36215, 36216,36216,75680,75710

After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite.  The
patient was prepped and draped in a sterile fashion.  Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery.  A #6 French introducer sheath
was placed in the right common femoral artery utilizing the
Seldinger technique.  A #6 French multipurpose catheter was then
used to cross the aortic valve, measure end-diastolic pressure,
and pullback across the aortic valve.  The multipurpose catheter
was used for left and right coronary angiography and saphenous
vein angiography.  It was exchanged for a mammary catheter with
which we performed left subclavian angiography due to the presence
of a plaque at the origin of the left subclavian artery. Left
internal mammary angiography, left and right carotid angiography.
A Perclose was deployed in the right common femoral artery at
completion of the procedure with adequate achievement of
hemostasis after angiography demonstrated an arteriotomy above the
bifurcation suitable for closure device.
CAROTID ANGIOGRAPHY:
The right common carotid artery appears angiographically free of
significant plaquing.  The right internal carotid artery appears
widely patent.  The anterior, posterior, and middle cerebral
arteries are patent.  There are right-to-left collaterals from the
right anterior cerebral artery to the left anterior cerebral
artery through the anterior communicating artery.

The left common carotid artery appears widely patent.  The left
internal carotid artery has a tubular 40% stenosis.

LEFT SUBCLAVIAN ANGIOGRAPHY:
The left subclavian artery has a eccentric plaque at its origin
with a 50% stenosis.  There is no significant gradient upon
pullback across the left subclavian artery suggesting this is not
a hemodynamically flow-limiting lesion.


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## dpeoples (Oct 25, 2012)

maryann1224@bellsouth.net said:


> for the following report; would the correct codes be? thanks for your assistance!
> 
> 93459, 36215, 36216,36216,75680,75710
> 
> ...



On the surface this seems to be a LHC with grafts, 93459. This would by defintion include selection of the subclavian to view the LIMA. I do not really see selection of the carotid arteries and I am skeptical of the left subclavian injection and interpretation. Was medical necessity for the left subclavian and the carotid circulation documented prior to this exam? Is there more to this report?


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## maryann1224@bellsouth.net (Oct 25, 2012)

thank you danny for taking the time to explain....


PROCEDURE:
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite.  The
patient was prepped and draped in a sterile fashion.  Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery.  A #6 French introducer sheath
was placed in the right common femoral artery utilizing the
Seldinger technique.  A #6 French multipurpose catheter was then
used to cross the aortic valve, measure end-diastolic pressure,
and pullback across the aortic valve.  The multipurpose catheter
was used for left and right coronary angiography and saphenous
vein angiography.  It was exchanged for a mammary catheter with
which we performed left subclavian angiography due to the presence
of a plaque at the origin of the left subclavian artery. Left
internal mammary angiography, left and right carotid angiography.
A Perclose was deployed in the right common femoral artery at
completion of the procedure with adequate achievement of
hemostasis after angiography demonstrated an arteriotomy above the
bifurcation suitable for closure device.

FINDINGS:


HEMODYNAMICS:
LV pressure 125/16. Aortic pressure 125/70.

RAO LEFT VENTRICULOGRAM:
Not performed secondary to renal insufficiency.

CORONARY ANGIOGRAPHY:


LEFT MAIN CORONARY ARTERY:
Originates from the left coronary cusp.  It bifurcates into the
left anterior descending coronary artery and left circumflex
artery.  The left main coronary artery has mild plaquing in its
distal third.

LEFT ANTERIOR DESCENDING CORONARY ARTERY:
The left anterior descending artery is diffusely diseased
throughout its proximal and mid segments.  In the proximal segment
there is eccentric plaquing resulting in an eccentric 60% plaque
prior to the origin of the first diagonal.  There is competitive
flow in the first diagonal vessel from its bypass graft. After
the first diagonal vessel, the left anterior descending artery is
severely diseased through its mid segment with a tubular stenosis
resulting in 90% stenosis.  There is competitive flow from the
mammary graft to the distal LAD.

LEFT CIRCUMFLEX CORONARY ARTERY:
The left circumflex artery gives rise to two small obtuse marginal
vessels and then a large branching mid obtuse marginal vessel.  The
branching mid obtuse marginal vessel has a superior branch with
nonobstructive atherosclerotic plaquing.  There is a large
inferior branch that is occluded and bypassed.  The left
circumflex continues in the AV groove and a small vessel after the
mid obtuse marginal vessel is subtotally occluded.  There are
left-to-right collaterals to the occluded posterior descending
artery and posterolateral branches of the right coronary artery.

RIGHT CORONARY ARTERY:
Originates from the right coronary cusp.  It is a a anatomically
dominant vessel.  It is occluded distally.

SAPHENOUS VEIN GRAFTS:
1.  The saphenous vein graft to the diagonal vessel is widely
    patent.
2.  The saphenous vein graft to the inferior branch of the mid
    obtuse marginal vessel is widely patent.
3.  The LIMA to the LAD is patent with a 50% stenosis at the
    anastomosis.

CAROTID ANGIOGRAPHY:
The right common carotid artery appears angiographically free of
significant plaquing.  The right internal carotid artery appears
widely patent.  The anterior, posterior, and middle cerebral
arteries are patent.  There are right-to-left collaterals from the
right anterior cerebral artery to the left anterior cerebral
artery through the anterior communicating artery.

The left common carotid artery appears widely patent.  The left
internal carotid artery has a tubular 40% stenosis.

LEFT SUBCLAVIAN ANGIOGRAPHY:
The left subclavian artery has a eccentric plaque at its origin
with a 50% stenosis.  There is no significant gradient upon
pullback across the left subclavian artery suggesting this is not
a hemodynamically flow-limiting lesion.

IMPRESSION:
1.  NORMAL LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC PRESSURES.
2.  NO GRADIENT ON PULLBACK ACROSS THE AORTIC VALVE.
3.  LEFT VENTRICULOGRAM NOT PERFORMED SECONDARY TO RENAL
    INSUFFICIENCY.
4.  SEVERE THREE-VESSEL CORONARY ARTERY DISEASE.
5.  STATUS POST A.C.B. WITH THREE OUT OF THREE PATENT GRAFTS.
6.  UNBYPASSED POSTERIOR DESCENDING ARTERY AND POSTEROLATERAL
    BRANCHES.
7.  PATENT CAROTID ARTERIES BILATERALLY WITH A SUBTOTALLY OCCLUDED
    LEFT ANTERIOR CEREBRAL ARTERY FILLING VIA COLLATERALS.


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## dpeoples (Oct 25, 2012)

maryann1224@bellsouth.net said:


> thank you danny for taking the time to explain....
> 
> 
> PROCEDURE:
> ...



This does help somewhat. I am still concerned that medical necessity for carotid and left subclavian angiography was not established prior to the exam. None the less, they are codeable IMO.

I see:
93459 for the LHC w/graphs
36215/75710 for left subclavian selection/injection/interpretation
75680/75671 for bilateral carotid angiography. 
I would not code selection of the carotids as this is not documented, and selection is not required for the angiography codes. These vessels can often be seen from a high aortic injection which would be included with the LHC.

HTH


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## maryann1224@bellsouth.net (Oct 26, 2012)

thank you, i appreciate you taking the time to explain the reasoning too.


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