# Diagnostic Cerebral Angiogram and Venogram



## SPECIALTYCODING (Feb 5, 2019)

Good Morning

I am looking for some assistance with this report to check my CODING.  I appreciate any help you can offer. Study Result 

PROCEDURE: Diagnostic Cerebral Angiogram and Venogram


CONSENT:
The procedure, risks, benefits and alternatives to cerebral angiography were discussed with the patient.  Informed consent was obtained after all questions were answered.  The patient was brought to the Neuroendovascular suite and placed supine on the angiography table.  The patient was prepped and draped in the usual sterile fashion.  Conscious sedation was initiated and maintained as described above.

DESCRIPTION OF THE PROCEDURE AND FINDINGS:

ACCESS:
The skin of the right groin was anesthetized with lidocaine 2%. Utilizing an 18G Cook needle a 5 french Pinnacle sheath was placed into the right common femoral artery. Right common femoral arteriography was performed which reveals the femoral sheath to be above the femoral bifurcation, below the inguinal ligament and the vessel to be of suitable caliber for mechanical closure. Utilizing an 18G Cook needle a 5 French Pinnacle sheath was placed into the right common femoral vein. Right common femoral venography was performed which reveals the vessel to be of suitable caliber for mechanical closure.

A 5 French Vert catheter was advanced over an angled 0.038" Terumo Glidewire into the aortic arch.

RIGHT COMMON CAROTID ARTERY:
The diagnostic catheter was advanced into the the right common carotid artery.  2D hand injected angiography was performed centered at the bifurcation which is at the C4/5 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis.  The cervical internal and external carotid arteries are of normal course and caliber.

RIGHT EXTERNAL CAROTID ARTERY:  
The diagnostic catheter was advanced into the right external carotid artery.  2D hand injected angiography was performed centered over the patient’s head.  Angiography reveals antegrade opacification of the external carotid artery and its branches.  The vessels are of normal course, caliber and taper regularly.  No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.

RIGHT INTERNAL CAROTID ARTERY: 
The diagnostic catheter was advanced into the right internal carotid artery.  2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections.  Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is robust, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly. There is no aneurysm, focal area of stenosis or early draining vein. The capillary and venous phases are unremarkable. The dural and deep venous sinuses opacify normally.

RIGHT VERTEBRAL ARTERY:  
The diagnostic catheter was advanced into the right vertebral artery.  2D hand injected angiography was performed centered over the neck and head.  The cervical vertebral artery is of normal course and caliber.  Intracranially, there is antegrade opacification of the right vertebral artery, right posterior inferior cerebellar artery, basilar artery, bilateral anterior-inferior cerebellar arteries, bilateral superior cerebellar arteries, bilateral posterior cerebral arteries and their branches.  The left distal vertebral artery backfills briefly with opacification of the left posterior inferior cerebellar artery. The vessels are of normal course, caliber and taper regularly.  There is no aneurysm, focal area of stenosis or early draining vein.  The capillary and venous phases are unremarkable.  The dural and deep venous sinuses opacify normally.

LEFT COMMON CAROTID ARTERY:
The diagnostic catheter was advanced into the left common carotid artery.  2D hand injected angiography was performed centered at the bifurcation which is at the C4/5 level. The carotid bifurcation is widely patent without atherosclerotic disease or hemodynamic significant stenosis.  The cervical internal and external carotid arteries are of normal course and caliber.

LEFT EXTERNAL CAROTID ARTERY:
The diagnostic catheter was advanced into the left external carotid artery.  2D hand injected angiography was performed centered over the patient’s head.  Angiography reveals antegrade opacification of the external carotid artery and its branches.  The vessels are of normal course, caliber and taper regularly.  No aneurysm, focal area of stenosis or early draining vein is seen to suggest a fistula.

LEFT INTERNAL CAROTID ARTERY:  
The diagnostic catheter was advanced into the left internal carotid artery.  2D hand injected cerebral angiography was performed in the AP, lateral and oblique projections.  Angiography reveals antegrade opacification of the internal carotid artery, middle cerebral artery, anterior cerebral artery and their branches. The posterior communicating artery is robust, fills the posterior cerebral artery and rapidly clears from competitive flow. The vessels are of normal course, caliber and taper regularly.  There is no aneurysm, focal area of stenosis or early draining vein.  The capillary and venous phases are unremarkable.  The dural and deep venous sinuses opacify normally.

LEFT VERTEBRAL ARTERY:  
The diagnostic catheter was advanced into the left vertebral artery.  2D hand injected angiography was performed centered over the neck and head.  The cervical vertebral artery is of normal course and caliber. Intracranially, there is antegrade opacification of the left vertebral artery, left posterior inferior cerebellar artery, basilar artery, bilateral anterior-inferior cerebellar arteries, bilateral superior cerebellar arteries, bilateral posterior cerebral arteries and their branches. The right distal vertebral artery backfills briefly with opacification of the right posterior inferior cerebellar artery. The vessels are of normal course, caliber and taper regularly.  There is no aneurysm, focal area of stenosis or early draining vein.  The capillary and venous phases are unremarkable.  The dural and deep venous sinuses opacify normally.

VENOGRAPHY: 
The diagnostic catheter was advanced over the 0.038" glidewire into the right internal jugular vein. A Renegade Hi-flo microcatheter was advanced over a 0.014" Traxcess guidewire into the superior sagittal sinus. Venography was performed with superior sagittal injection which demonstrated opacification of the superior sagittal sinus, torcula, bilateral transverse sinuses, bilateral sigmoid sinuses and the bilateral internal jugular veins. There is significant stenosis of the left transverse sinus. 

Venous Pressures were recorded and are as follows: 

Superior sagittal sinus	33 mmHg
Torcula	28 mmHg
Right transverse sinus	25 mmHg
Right transverse-sigmoid junction	19 mmHg
Right sigmoid sinus	16 mmHg
Left transverse sinus	26 mmHg
Left transverse-sigmoid junction	17 mmHg
Left sigmoid sinus	5 mmHg


After review of the angiographic data the diagnostic catheter was removed.  The right common femoral artery and right common femoral vein sheaths were removed.  Hemostasis was achieved at both the venous and arterial sites utilizing Starclose. The patient tolerated the procedure well.  There were no immediate complications.  The patient was subsequently transferred to the Neuroendovascular Surgery recovery area at their baseline neurological status.

IMPRESSION:
1. Normal cerebral angiogram. 
2. Bilateral transverse venous sinus stenosis with significant pressure gradients bilaterally

My codes:
36226-50
36224-50
36227-50
36012 50 x 3 ??
36012 superior sagittal sinus
93770 Not sure about this code
75870 26


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## Jim Pawloski (Feb 18, 2019)

SPECIALTYCODING said:


> Good Morning
> 
> I am looking for some assistance with this report to check my CODING.  I appreciate any help you can offer. Study Result
> 
> ...



I like your codes, but pressure measurements are part of the procedure. 93770 is for non-invasive procedure pressure measurements.
HTH,
Jim Pawloski, CIRCC


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## SPECIALTYCODING (Feb 20, 2019)

Jim,  I appreciate you reviewing the codes for me.

Thank you,
Diana Gaitanis


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## fhromeo30 (Jul 27, 2021)

Jim,

I have a provider who is wanting me to bill an unlisted code for Dural Sinus Pressure measurements because "it needs its own code, it is additional work" .   I am standing on a hard NO on this--but he is friends with Dr. Z and Dr. Z told him to bill an unlisted code.  Have you billed for this ever??  I am looking for something other than a Dr. Z reference to say it bundles.

Francine


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## Jim Pawloski (Jul 28, 2021)

I used to work as an Interventional Radiology Technologist and have seen many Cerebral Arteriograms. However I have not seen or coded for the Dural Sinus Pressure measurements. Except for heart caths, pressure measurements are bundled. So your stuck between a rock and a hard place. Your going to have to get the unlisted code made, but it doesn't mean it going to get paid.
Good Luck,

Jim


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