# renal angiogram/stenting



## maryann1224@bellsouth.net (Mar 4, 2013)

the dr performed the following procedure; not sure of the cpt codes.  need assistance please.


1.  Aortogram.
2.  Bilateral selective renal angiogram.
3.  Nonselective left lower extremity angiography.
4.  Additional arterial access.
5.  PTA and stenting of the right renal artery.
6.  PTA and stenting of the left external iliac artery.
7.  Conscious sedation for one hour and 30 minutes.
8.  IVUS of the external iliac artery.

nonsedated condition to the cardiac catheterization suite where he
was prepped and draped in a sterile fashion.  Lidocaine 2% was
used to infiltrate the skin and subcutaneous tissue overlying the
left common femoral artery.  Percutaneous access was obtained and
a #6 French sheath was placed.  I then advanced a Wholey wire and
a pigtail catheter under fluoroscopic guidance into the descending
aorta above the level of the renal arteries  Through the pigtail
catheter we performed aortogram.  We were able to visualize the
presence of the renal arteries but had incomplete view of the
origins of the renal arteries prompting selective renal
angiography.  Prior to performing the selective angiogram we
withdrew the pigtail catheter to the aortic bifurcation and
performed a second aortogram visualized in the iliac arteries.  We
were unable to completely visualize the left external iliac and
common femoral arteries due to occlusion of the left external
iliac artery by our sheath and catheter.  We therefore performed
nonselective angiography of the left external iliac artery by
injecting through the side port of our #6 French sheath. I then
returned with a renal guide catheter, #6 French RDC catheter, and
then a #6 French RD-3 catheter and performed selective left and
right renal angiography.  We found critical stenosis in the right
renal artery prompting our intervention as described below.

FINDINGS:
INTERVENTION:
Based on the findings of critical stenosis in the right renal
artery, uncontrolled hypertension despite over four hypertensive
medications, we proceeded with intervention on the right renal
artery.  We were unable to get a supportive guide position from
the femoral access site due to extreme angulation of the origin of
the right renal artery.  We therefore obtained percutaneous access
in the right brachial artery plaquing a #6 French sheath utilizing
the Seldinger technique and a micropuncture kit.  I then used a #6
French multipurpose guide catheter and advanced this under
fluoroscopic guidance to the level of the renal artery.  With this
I was able to gain a supportive position for imaging of the right
renal artery.  We confirmed high-grade 90% stenosis in the right
renal artery at its origin and proceeded with the intervention.
Intermittent boluses of heparin were administered starting with a
bolus of 5,000 units.  We maintained a ACT of greater than 250
throughout the case.  We used a Spartacore wire which was
negotiated across the lesion in the ostial proximal renal artery
and then used a 5 x 15 mm Boston Scientific Apex balloon to dilate
the lesion.  I positioned a 6 x 18 mm Boston Scientific Express
stent at the origin of the right renal artery making sure to
extend the stent slightly into the aorta.  The stent was then
deployed with two inflations up to a maximum of 12 atmospheres
After removal of the balloons and wires we completed final
angiography.  We had no residual stenosis and no evidence of
perforation, dissection, or distal embolization.

Attention was then turned to the left external iliac artery.
Working through the sheath in the left common femoral artery we
advanced the Wholey wire into the descending aorta as well as the
Spartacore wire.  We used the same #5 mm Apex balloon to dilate
the lesion in the external iliac artery.  There was ectasia at the
level of the external iliac artery prompting us to perform
intravascular ultrasound to get a true measure of the optimal
lumen size in the most normal segment of the vessel.  After IVUS
we decided on a 7 mm diameter balloon and positioned a 7 x 27 mm
Boston Scientific Express LV stent carefully at the lesion in the
external iliac artery.  We dilated this stent with two inflations
up to 12 atmospheres.  Final angiography after removal of balloons
and wires demonstrated normal flow with no perforation,
dissection, or distal embolization.  The patient was not felt to
have adequate anatomy for a closure device and manual pressure
will be held for hemostasis.

would you use : 36200, 36252, 75710, 37205, 37206, 37250? would you also bill for the addt'l arterial access and if so what would that be?  thank you so much for your help!


----------



## Jim Pawloski (Mar 4, 2013)

maryann1224@bellsouth.net said:


> the dr performed the following procedure; not sure of the cpt codes.  need assistance please.
> 
> 
> 1.  Aortogram.
> ...



I would bill it this way.  36252 for renal arteriogram, 36245, 37205, and 75960 for the renal stent placement, 75710 for the iliac arteriogram, 37220 for the iliac stent placement, 37250/ 75945 for the IVUS use.  The 36200 is bundled into the studies, and catheter placement for lower extremity revascularization is also bundled.
HTH,
Jim Pawloski, CIRCC


----------



## sue37412 (Mar 4, 2013)

Jim Pawloski said:


> I would bill it this way.  36252 for renal arteriogram, 36245, 37205, and 75960 for the renal stent placement, 75710 for the iliac arteriogram, 37220 for the iliac stent placement, 37250/ 75945 for the IVUS use.  The 36200 is bundled into the studies, and catheter placement for lower extremity revascularization is also bundled.
> HTH,
> Jim Pawloski, CIRCC


I only saw the right renal documented as having a stent placed. The catheter placement of the bilateral renals does not state if first order or beyond. 36252 37205 75960 are the codes for the renal
75710 and 37221 are for the left external iliac.


----------



## Twixle2002 (Mar 4, 2013)

Aren't the S & I inclusive to the procedures?  I am going by what my cpt coding companion is telling me, so please if I am incorrect, let me know.


----------



## Jim Pawloski (Mar 5, 2013)

Twixle2002 said:


> Aren't the S & I inclusive to the procedures?  I am going by what my cpt coding companion is telling me, so please if I am incorrect, let me know.



The S&I for the lower extremity revascularization is billable if it is a true diagnositc exam before the intervention.  The S&I for the renal stent is billable.
HTH,
Jim Pawloski, R.T. (CV), CIRCC


----------

