# Cardiac Catheterization with Angioplasty of Subclavian Artery



## coffee2day (May 16, 2017)

Hello, a provider is wanting to bill selective catheterization codes (CPT 36215, 36140) in addition to a cardiac catheterization procedure, because he angioplastied the subclavian artery for stenosis. 

But I feel all selective caths should be bundled and not separately billable for cardiac cath procedures, even in this scenario, any advice would be appreciated.

He is billing 93455, 37246, 36215, 36140, 75710, 92933 (I feel the selective caths should be removed).

Procedure performed: 1. Angioplasty of the left subclavian, retrograde approach via brachial (clarified with md, only one approach documented starting in radial artery 'retrograde' to the brachial artery, not two separate approaches)
2. Rotational atherectomy and stent of the LAD; history of failed CABG with atretic LIMA. Increased time and effort with marked calcification, resistant lesions, difficult delivery as documented below. 

The left radial site was anesthetized with subcutaneous injection of 2% lidocaine.The patient was approached from the left radial artery using a 6 French Terumo Glidesheath using a counterpuncture technique for access.The J-wire would not advance past proximal left subclavian, and was exchanged for an angled tip Glidewire. This advanced with some difficulty to the aorta, but the 6F Tiger 4.0 catheter would not advance.Given inability to cross proximal subclavian, and marked calcification, angiography was performed of the subclavian with hand injection via DSA with the Tiger 4.0 catheter. The catheter was exchanged for a 4F JL4, which was used to perform left coronary angiography with hand injection of contrast in multiple angled views. This was then exchanged for 5F JR4, which was used to engage and image the native RCA, as well as the SVG to OM2. Hand injection of contrast was performed in multiple views. The catheter was then exchanged for a 5F MPA1, which was used to engage the SVG to rPDA to OM3. Hand injection of contrast was taken in multiple views. The MPA1 was then used to measure the gradient across the proximal subclavian; there was a 22 mm Hg gradient by pullback.
*The catheter was exchanged for an IMA catheter, and a LIMA catheter was advanced and used to engage the LIMA. Angiography was performed with multiple angled projections. 

Based on the results of this angiogram, the patient will proceed to percutaneous coronary intervention of the subclavian and LAD, to be reported in a separate report.6F EBU 3.5 was advanced over a wire to the proximal subclavian. The catheter was flushed, and a Whisper wire was used to cross the proximal subclavian stenosis into the ascending aorta.
*
A 4.0 x 12 mm Trek balloon was used to perform angioplasty of the left subclavian at 14 ATM for 30 seconds, and 2 inflations. The gradient was reduced from 24 mm Hg to 0 mm Hg, with easy subsequent crossing with the 6F guide catheter.*
The Whisper wire was removed, and an angled Glidewire was advanced over a wire to the ascending aorta. The EBU 3.5 was then advanced and flushed after wire removal. It was then manipulated into the left main ostium. A Whisper wire was placed into the distal LAD. Attempts were made to cross the distal occlusion segment with a Finecross and the Whisper and a Fielder, but would not cross. Given small distal vessels, collateral filling, the distal LAD was abandoned. A 2.0 x 12 mm Trek balloon was advanced and used to predilate the LAD at 18 ATM. The mid and proximal segments did not dilate. A 2.75 x 12 mm Trek NC balloon was advanced, and used to predilate at 20 ATM, but the mid and proximal segments still did not dilate.  A Finecross was used to exchange the wire for a Rota Xtra support wire. Rotational atherectomy was performed with a 1.25 mm burr in 9 passes at 150,000 RPMs in the LAD. Predilation was performed again with a 2.75 x 15 mm Trek balloon, but the mid and distal segments still did not dilate fully. A 3.0 x 10 mm Angiosculpt balloon was used to predilate the proximal section at 18-19 ATM, with good expansion. A 3.0 x 8 mm NC balloon was used to predilate the mid LAD at 23 ATM, with expansion. A 3.0 x 38 mm Xience drug eluting stent was deployed at 16 ATM in the mid LAD.  3.0 x 38 mm Xience drug eluting stent was deployed at 16 ATM in the proximal LAD in overlapping fashion.  3.25 x 12 mm Trek NC balloon was used to postdilate the stents at 14 to 22 ATM..Angiography with and without the wire demonstrates no distal dissection, TIMI 3 flow, and no residual disease in the stented area.There were no acute complications.LAD 99% -> 0% post stent.
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## Jim Pawloski (May 17, 2017)

coffee2day said:


> Hello, a provider is wanting to bill selective catheterization codes (CPT 36215, 36140) in addition to a cardiac catheterization procedure, because he angioplastied the subclavian artery for stenosis.
> 
> But I feel all selective caths should be bundled and not separately billable for cardiac cath procedures, even in this scenario, any advice would be appreciated.
> 
> ...



I would agree with you, that 36215, 36140, and 75710 should be deleted. The heart cath does bundle the cath placements, and the arteriogram of the subclavian artery was actually a road map.
HTH,
Jim Pawloski, CIRCC


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## coffee2day (May 17, 2017)

Thank you so much Jim!


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