# Left Subclavian Artery Angiography



## mcauffman86 (Nov 21, 2018)

I am having a hard time figuring out what codes to use for this case. I need some thoughts from other fellow coders. I came up with 

36215-59 
75710-26-59-LT 
36222-50
36226-RT
99152

Please and thank you!


PROCEDURE: Left subclavian artery angiography, attempted PTA of left subclavian artery, selective right and left common carotid angiography, selective right vertebral artery angiography
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DATE OF PROCEDURE: 11/20/2018
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INDICATION: Left subclavian artery stenosis and patient was referred to Kalamazoo when she came with acute situation no revascularization was done at that time
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PROCEDURES PERFORMED:
1.  Selective cannulation of left subclavian artery
2.  Attempted PTA of left subclavian artery
3.  Selective left and right common carotid artery angiography
4.  Selective right vertebral artery angiography
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EQUIPMENT USED:
1.  0.035 Glidewire, 0.018 estato wire
2.  0.035 Navi cross catheter
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DESCRIPTION OF PROCEDURE: 
Patient was brought into the Cath Lab, draped and prepped in conventional fashion and using Xylocaine anesthesia a 6 French sheath was placed in the right common femoral artery.  With a Judkins diagnostic right catheter left subclavian artery was cannulated and angiography was performed for the procedure were attempted.
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Cine report:
Left subclavian artery is totally occluded with a stump
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After the attempted procedure right innominate artery was cannulated and selective carotid artery angiography was performed right common carotid artery doesn't show any stenosis done show any filling on the left side
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Left common carotid artery doesn't show any filling on the left subclavian artery
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The right vertebral artery shows ostial stenosis of 80-90% however it does fill up the left vertebral artery retrogradely and fills of the distal subclavian artery as well as axillary artery and brachial artery
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MODERATE SEDATION:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 51 min. 
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CONTRAST:
Medication Name	Total Dose
iodixanol (VISIPAQUE) 320 mg/mL injection	43 mL
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PTA AND STENTING: 
I tried to pass the 0.035 wire through the subclavian artery and there was a small dye was noted in the side of the subclavian artery which is a presently subintimal and it would not cross into the subclavian artery.  Multiple attempt was done and then the Navy cross catheter was used and will not go through the totally occluded subclavian artery.  A estato wire was also tried which will not go through the totally occluded subclavian artery.  After trying for more than half an hour procedure was stopped.  However this vertebral artery does show retrograde flow from the right to the left side and I could see the brachial artery.
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CINE INTERPRETATION: 
1.  Totally occluded left subclavian artery with a stump could not be cannulated failed PTA
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FINAL DIAGNOSIS:
1.  Total occlusion of left subclavian artery is a stump noted not at the ostium
2.  Right and left common carotid artery doesn't show any stenosis
3.  Right vertebral artery shows ostial stenosis of 80% shows retrograde flow to the left vertebral artery filling of the distal subclavian and axillary and brachial artery
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RECOMMENDATION:
Plan is to bring the patient and try to go through the brachial artery and retrograde fashion because the distal total occlusion may be easier to cross.  If it cannot be opened up I discussed with the vascular surgeon her than the plan for the surgery either left carotid subclavian bypass or productive frequent graft attaching to the subclavian artery to the aorta.  Patient will be discharged home and will be brought back again.  Now since it is totally occluded I don't think patient need Coumadin.  She'll be followed up as an outpatient
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## Jim Pawloski (Nov 29, 2018)

mcauffman86 said:


> I am having a hard time figuring out what codes to use for this case. I need some thoughts from other fellow coders. I came up with
> 
> 36215-59
> 75710-26-59-LT
> ...



I would agree with your charges, except for sedation. There was only 15 mins. of sedation time? In my experience, I don't think so. You need to charge 99153 for your additional 15 mins times however long the procedure took.
HTH,
Jim Pawloski, CIRCC


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