# Selective Subclavian w/ stent



## CardioCoder79 (Mar 12, 2015)

I am thinking 36225, 37238, and 75605-26. CCI says that the 75605 is a component of 37238 but a modifier is allowed. Need help with this one please. 


PROCEDURES PERFORMED:
1.   Thoracic aortography with digital subtraction.
2.   Selective left subclavian angiography.
3.   PTA and stenting of the left subclavian with an Omnilink 8 x 29 mm
balloon expandable stent.

DESCRIPTION OF PROCEDURE:  The patient was brought to the Cardiac
Catheterization Laboratory and was prepped and draped in the usual sterile
fashion.  After informed consent was obtained and documented on the chart,
the patient was given conscious sedation of Versed and fentanyl.

Using the modified Seldinger technique, a 5-French sheath was placed in the
right femoral artery.  A 5-French pigtail catheter was used for aortography.
A 5-French JL-4 catheter was used to selectively engage the left subclavian.

FINDINGS:  The thoracic aorta is within normal limits of size.  There is no
evidence of aneurysm.  There is no evidence of aortic insufficiency.  The
right brachiocephalic is widely patent.  The right common carotid is widely
patent.  The left common carotid is widely patent.

The left subclavian has a high-grade, 90% stenosis which appears to spare the
ostium.  The left internal mammary artery is widely patent.  The left
vertebral artery is widely patent with antegrade flow.  There was a 65 mmHg 
gradient across the stenosis. 

INTERVENTION:  A 7-French Cook guide sheath was introduced.  The patient was
given systemic anticoagulation with unfractionated heparin.

A long Versacore wire was used to cross the lesion.  Next, an Armada 7 x 20
mm balloon was used for lesion predilatation.  After subsequent angiography,
an Omnilink 8 x 29 mm balloon expandable stent was deployed at nominal
pressure.  Next, an Armada 8 x 20-mm balloon was used for postdilatation.

Final angiography revealed an excellent result with no residual stenosis.
The patient's preprocedural gradient was reduced to 0.

IMPRESSIONS:
1.   High-grade left subclavian stenosis as outlined above.
2.   Status post successful percutaneous transluminal coronary angioplasty
and stenting of the left subclavian with an Omnilink 8 x 29 mm bare-metal
balloon expandable stent.


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## jwiles66 (Mar 12, 2015)

These codes are correct.   You can bill the 75605-26 because it is for the aortogram.  You just cannot bill for an angiogram because it is included.


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## j.monday7814 (Mar 12, 2015)

36225 is not appropriate because he does not have any findings of the vertebrals. documentation about cath placement for each injection is unclear. this is probably 36223 since he has findings of the common carotids...or maybe even just runoff from an aortography, 36221. 

also, 37238 is for a venous stent. 37236 would be the correct code for arterial stent.

75605, 75625, and 75630 would not be billable in this situation, automatically included in 36221-36226


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## dpeoples (Mar 12, 2015)

rsenn1979 said:


> I am thinking 36225, 37238, and 75605-26. CCI says that the 75605 is a component of 37238 but a modifier is allowed. Need help with this one please.
> 
> 
> PROCEDURES PERFORMED:
> ...




IMO, 75605 is not applicable, instead, the code best reflected by the documentation (of the aorta) would be 36221, but that bundles into 36225, and seems to be for guidance purposes. I would not bill 36221.
37238 is incorrect, the stent code should be 37236 (vein vs artery).

I also have questions as to whether 36225 should be billed. It can, but should it? Is it diagnostic? I do not see an indication for the diagnostic portion of the procedure such as a sign or symptom. What was known, before the findings documented above?

If the condition was known (previously diagnosed), and has not changed etc. I would code for the stent placement and the catheter placement only.
37236, 36215.

HTH


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## CardioCoder79 (Mar 16, 2015)

*So confused....*

Wow! Three different answers! 

I was leaning towards 36225 because he does in fact mention the vertebrals..."The left vertebral artery is widely patent with antegrade flow"...and he does document that this is selective left subclavian angiography. 

I agree with the 37236 for artery...my mistake there.


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## j.monday7814 (Mar 16, 2015)

rsenn1979 said:


> Wow! Three different answers!
> 
> I was leaning towards 36225 because he does in fact mention the vertebrals..."The left vertebral artery is widely patent with antegrade flow"...and he does document that this is selective left subclavian angiography.
> 
> I agree with the 37236 for artery...my mistake there.



yeah, I must have glanced over that sentence or was looking for something more detailed. that's enough documentation for 36225 with the 37236. done and done


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## CardioCoder79 (Mar 16, 2015)

Thank you! I thought I was losing my mind there for a second. LOL!


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