# help w/ codes for balloon of carotid



## superorozco (Apr 28, 2009)

Hello! 
I need some guidance to see if i selected the correct codes for the below report. I don't code this often. Here is what i came up with: 37215,36216rt,75976.59rt,93531.26,93543,93544,93555.2659 and 93556.2659. 

DESCRIPTION OF PROCEDURE: This is a 3-month-old male with a history of 
tricuspid atresia with normally dilated vessels. The patient also had a severe PS and sub PS for which the patient had right BT shunt placed in the neonatal period. The patient was followed by Dr. and was recently noted 
to have progressively desaturation as well as significant desaturation when baby is crying. For this the baby was referred to Dr. for cardiac 
catheterization and possible intervention. Dr.met with the parents and 
discussed risks and benefits of the procedure. The risks included but were not limited to cardiac or a vessel perforation causing bleeding requiring blood transfusion and/or emergency surgery, air or a clot embolization causing heart attack or a stroke, arrhythmia, infection, etc. They understood risks and benefits well. They asked me appropriate questions. The consent forms were signed. The patient was brought to the cardiac catheterization lab in a postabsorptive state. Both groins were prepped in the usual sterile fashion. General anesthesia was induced. Her right femoral vein was accessed and a 5.5 French sheath was placed. Later on right femoral artery was accessed but was found to have occlusion of right femoral artery as well as iliac artery. Subsequently left femoral artery was accessed and a 4-French sheath was placed. Subsequently the catheters were introduced through this sheath and the procedure was done. At the end of the procedure catheters and sheaths were pulled out,pressure was held and hemostasis was achieved. The patient was transferred to the recovery area in a good stable condition. The patient was given heparin boluses throughout the procedure to maintain ACT in 300s. 

SATURATION DATA: Superior vena cava saturation was 53% with a right atrial 
saturation of 54% and a left atrial saturation of 58%. Left ventricle 
saturation was 55% and descending aorta saturation was 60%. Later on in the 
case right lower pulmonary vein was accessed and saturation was obtained. It 
was 100% with a pAO2 of 200+. At that time the baby was on 50% FIO2. 

PRESSURE DATA: Left atrial pressure was 10/7 with mean of 5. Left ventricle 
pressure was 92 with end-diastolic pressure of 5. Descending aorta pressure was 75/23 with mean of 43. At the end of the case right atrial pressure was 16/10 with mean of 8 and the descending aorta pressure was 105/40 with mean of 68. 

ANGIOGRAPHIC DATA: The first is a left ventricle angiography done in a straight AP and lateral camera projection. This shows normal left ventricular function. This also shows very stenotic and thread-like right ventricular outflow tract. The pulmonary arteries are not very well visualized but the lung bed lights up. As well as the distal pulmonary artery appeared to be well developed. 

Next is occlusive DAO angiography. This shows the shunt coming off from a right carotid artery. This also shows the aberrant right subclavian artery coming off from DAO. There appears to be some narrowing in the common carotid artery before the shunt. 

Next is a repeat DAO occlusive angio with the camera in caudal angulation. This shows the distal right PA appeared to be well-developed with some narrowing at the proximal area where the shunt anastomosis. 

Next is a cine documentation of occlusion of her right femoral artery. It shows the collateral supply supplying the right leg. 

Next is a selective common carotid angiography. This shows the right BT shunt well. This shows there is some degree of stenosis at the distal end of the shunt. This also shows there is some ostial stenosis of the right upper lobe pulmonary artery and a very mild degree of narrowing at the right lower 
pulmonary artery as well. The left pulmonary artery distally appears to be well developed. The proximal portion of it is not very well visualized. 

Next is a repeat angiography in caudal angulation. This angiography was not 
very helpful as the main pulmonary artery was overlying both PAs. This shows 
some forward flow through the native main pulmonary artery. 


Next is a straight caudal angulation of AP camera and a repeat injection in the carotid. This again showed the not developed distal right and left PA but with some mild degree of narrowing in the middle. 

Next view are the measurement of the previous angiograms. This shows the 
narrowest dimension in the common carotid artery is 1.6 mm with the distal 
carotid measuring 2.2 mm and shunt measuring 4 mm. 

Next is a cine documentation of catheter position in right lower pulmonary vein. 

Next 3 are cine documentation of balloon angioplasty of the common carotid 
artery. This shows the balloon remained in a good stable position and narrow 
waist popping open. 

Next is injection in the common carotid artery. This injection was not 
sufficient enough to show the common carotid artery. 

Next is ascending aorta angiography. This shows the carotid artery to be with still some narrowing in it. There was no evidence of any intimal flap or any extravasation of contrast. 

Next is a cine documentation of balloon angioplasty of carotid artery and right BT shunt. This shows the balloon remained in good stable position and complete inflation with no significant narrowing seen on this balloon toward the end. 

Next is a repeat aortic arch angiography. This shows the narrowed area which 
previously measured to be 1.6 mm is now much better and measures to be 2.9 mm. 

Next is a cine documentation of normal renal collecting system. 

DESCRIPTION OF INTERVENTIONAL PROCEDURE: Description of balloon angioplasty of right common carotid artery. Right common carotid artery was engaged with a NUMA catheter. Subsequently ASAHI grand slam wire was placed in the right 
common carotid artery. Leaving the wire in position the catheter was taken out. Before advancing the balloon ACT was done and it measured to be more than 300. Subsequently a Maverick 3 mm x 15 mm long Maverick balloon which was prepped and de-aired was advanced. The balloon was placed in the right common carotid artery. Subsequently the balloon was inflated. Narrow waist was seen in the balloon which was disappearing with inflation. Subsequent angiography was performed which showed some improvement in the narrow area but still there was a significant narrowing. Subsequently right common carotid artery was again engaged and a BMW wire was passed through right common carotid into the right BT shunt. Subsequently Maverick 4 mm x 15 mm long balloon was advanced. This balloon was advanced into the common carotid and into the proximal part of right BT shunt. Subsequently the balloon was inflated twice. Subsequent angiography was performed which showed the initial area which was measuring to be 1.6 mm now measuring 2.9 mm. As well as there was no intimal flap or any extravasation of contrast. 

CONCLUSION: 
1. A 3-month-old infant with a history of tricuspid atresia and a normally 
dilated vessel. 
2. Progressive desaturation with spells of severe desaturation 
3. Narrowing in the right common carotid artery. 
4. Aberrant right subclavian artery coming off from descending aorta and a 
shunt coming off from right common carotid artery. 
5. Successful ballooning of right common carotid artery with initial 
measurement was 1.6 mm and end result measurement was 2.9 mm of the 
narrowest area. 

thank you! 
Kathy Orozco,CPC 
Midwest Ped Cardiology 
Willowbrook, IL


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## dhuston (Apr 28, 2009)

I wouldn't use 37215 because that's for a carotid stent.  There is no code specific for cervical carotid angioplasty so 35475/75962 is commonly used.  The end of the report says the rt subclavian has a separate origin from the aorta so that would make the rt common carotid a first order off the arch...36215.  Code 75676 for carotid cervical angiogram.  

I can't help with the cardiac portion.

Diane Huston, CPC,RCC


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## superorozco (Apr 29, 2009)

thank you, i did also have 35475 as one of my choices!


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