# Renal Angiography



## OPENSHAW (Feb 12, 2013)

Our doctor performed the following:
I coded this at the bottom.

1.)  Left heart catheterization
2.)  Selective right and left coronary arteriogram
3.)  Left ventriculogram
4.)  Coronary flow pressure with fractional flow reserve measurement with adenosine
5.)  Selective right and left renal arteriogram
6.)  Selective right femoral arteriogram

Diagnosis Postprocedure:  Coronary artery disease, status post stent to the right coronary artery and left anterior descending, 50% stenosis in the left anterior descending after the stent with a normal coronary fractional flow reserve.  

Reason for procedure:  the patient has been having significant episodes of retrosternal chest pain, radiation to the neck that occurs mostly at night, awake the patient up from sleep and the patient is relieved with nitroglycerin.  The patient had a severe spell which he said it was 10/10, approx. 2 or 3 days ago.  The pain accompanied by sob and diaphoresis.  The pt. had a stent placed in the RCA several yrs. ago and a stent placed in the LAD also several yrs. ago.  The pt. also has a long history of severe hypertension with hypertensive heart disease.  She has required approx.  3 to 4 different medications for blood pressure control and even with this amt. of medication use, the blood pressure rtanges between 170/100 to 180/110.  Therefore, it was necessary to proceed with cardiac catheterization and renal arteriogram.

Would I code this as the following:
1.)  93452-26-59
2.)  93460-26
3.)  
4.)  93571-26
5.)  36252, I am not sure about first order, second order, etc.  How do you know which code to use, could be code 36254.
6.)  75710-26-59

Thank you so much for all of your help!


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## Jim Pawloski (Feb 12, 2013)

OPENSHAW said:


> Our doctor performed the following:
> I coded this at the bottom.
> 
> 1.)  Left heart catheterization
> ...



I would bill:
93458-26
93571-26-59
36252 for selective renals, bilateral, includes catheter placement
75710 is part of the closure device, so it's not billable
HTH,
Jim Pawloski, CIRCC


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## OPENSHAW (Feb 13, 2013)

*Renal angiography*

So, Code 93460 is part of Code 36252.  Code 75710 we cannot bill as this is part of the procedure.  The report also states that a right femoral arteriogram was performed and there was some nonocclusive disease in the right femoral.  Also, the selective right and left renal arteriogram was performed.  There was nonocclusive disease in both renal arteries.  

So I cannot bill for Code 93460 as this is part of Code 36252.  Code 75710, I cannot bill for either.  How do you know when to use Code 36252 or 36254, I was a little confused on this.  THANK YOU VERY MUCH!


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## Jim Pawloski (Feb 13, 2013)

OPENSHAW said:


> So, Code 93460 is part of Code 36252.  Code 75710 we cannot bill as this is part of the procedure.  The report also states that a right femoral arteriogram was performed and there was some nonocclusive disease in the right femoral.  Also, the selective right and left renal arteriogram was performed.  There was nonocclusive disease in both renal arteries.
> 
> So I cannot bill for Code 93460 as this is part of Code 36252.  Code 75710, I cannot bill for either.  How do you know when to use Code 36252 or 36254, I was a little confused on this.  THANK YOU VERY MUCH!



93458 is a LHC (coronaries w/wo LV gram, need LVEDP)
93460 is a RT&LT heart cath.
the femoral artery imaging is part of the closure device, no 75710
Renal angio unilateral is 36251, bilateral is 36252.  This is when the catheter is placed in the renal artery.
Superselective renal angio is when the catheter is placed in a branch of the renal artery.  when this happen on one side, code 36253, bilateral is 36254
HTH,
JIm Pawloski, CIRCC


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## theresa.dix@tennova.com (Feb 14, 2013)

OPENSHAW said:


> Our doctor performed the following:
> I coded this at the bottom.
> 
> 1.)  Left heart catheterization
> ...




Hey, wheres the op report?


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## OPENSHAW (Feb 19, 2013)

Diagnosis Postprocedure: Coronary artery disease, status post stent to the right coronary artery and left anterior descending, 50% stenosis in the left anterior descending after the stent with a normal coronary fractional flow reserve. 

1.) Left heart catheterization
2.) Selective right and left coronary arteriogram
3.) Left ventriculogram
4.) Coronary flow pressure with fractional flow reserve measurement with adenosine
5.) Selective right and left renal arteriogram
6.) Selective right femoral arteriogram

Reason for procedure: the patient has been having significant episodes of retrosternal chest pain, radiation to the neck that occurs mostly at night, awake the patient up from sleep and the patient is relieved with nitroglycerin. The patient had a severe spell which he said it was 10/10, approx. 2 or 3 days ago. The pain accompanied by sob and diaphoresis. The pt. had a stent placed in the RCA several yrs. ago and a stent placed in the LAD also several yrs. ago. The pt. also has a long history of severe hypertension with hypertensive heart disease. She has required approx. 3 to 4 different medications for blood pressure control and even with this amt. of medication use, the blood pressure rtanges between 170/100 to 180/110. Therefore, it was necessary to proceed with cardiac catheterization and renal arteriogram.

Description of Procedure:  After informed consent, the right groin was prepped in usual sterile fashion.  After this was done, a Cook needle was placed in the right femoral artery with mild difficulty, after the needle was placed in the right femoral artery.  A J-wire was utilized.  A 6-French sheath was placed in the right femoral artery without any difficulty.  Through this sheath, several catheters were utilized.  The 1st catheter utilized was a JL4.  This was placed in the ostium of the left coronary and several views of the left coronary artery were obtained.  This catheter was then withdrawn over the wire.  The next catheter utilized was a JR4.  This was placed in the ostium of the right coronary and several views of the right coronary were obtained.  This catheter was withdrawn over the wire.  The next catheter utilized was a 6-French angled Pigtail.  This was placed under hemodynamic monitoring to the left ventricle and a left ventriculogram was performed.  After this was done, the catheter was withdrawn over the wire  under hemodynamic monitoring and then pulled back over the wire.  After hemodynamic findings, the aortic pressure was 148/62 with a mean of 96 and the LV pressure was 148 with an end-diastolic of 17 to 33.  After the angiographic findings, the left coronary was injected in several views that was in AP, AP caudal, RAO caudal, RAO cranial, AP cranial, LAO cranial and LAO caudal and there was a large LAD with patent stent.  There was a lesion after the stent that was approximately 50% right before the diagonal 2.  The circumflex appeared some mild nonocclusive disease.  There was approximately 40% stenosis in the OM1 right before the bifurcation to the distal circumflex.  The right coronary was also injected in several views that was in AP, AP cranial, LAO and LAO cranial and exhibited a patent stent.  There was a PDA that exhibited approximately 40% to 50% stenosis in the PDA.  The LV gram was performed in the RAO projection showed an ejection fraction of 70% to 75% with hypercontractile LV.  After inspection of the results, the lesion in the LAD was felt to be 50% and we decided to do coronary flow.  Coronary flow was done as following:  The diagnostic catheter was changed for 6-French Q4 guide.  The Q4 guide was placed in the ostium of the left coronary.  After it was done and after equalization of the pressure wire, it was advanced to the proximal LAD.  After it was there, equalization again was performed and the FFR was 1.0 at that point.  The wire was then advanced to the distal LAD.  Upon placement to the distal LAD, the FFR was 0.96.  After 3 minutes, 140 mEq/kg of adenosine IV was utilized and the FFR was 0.85.  Therefore, it was decided that the lesion was not important enough for an intervention.  Also, a right femoral arteriogram was performed and there was some nonocclusive disease in the right femoral.  Also, the selective right and left renal arteriogram was performed.  There was some nonocculsive disease in both renal arteries.  The patient tolerated the procedure well and received Angiomax during the procedure.  Angio-Seal was not used because the ACT was over 400.  So, the sheath will be received later with a Syvek patch.  The patient recuperated procedure well.  He was sent to the recovery room in stable condition.

EBL:  Less than 40 mL.


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## Jim Pawloski (Feb 19, 2013)

OPENSHAW said:


> Diagnosis Postprocedure: Coronary artery disease, status post stent to the right coronary artery and left anterior descending, 50% stenosis in the left anterior descending after the stent with a normal coronary fractional flow reserve.
> 
> 1.) Left heart catheterization
> 2.) Selective right and left coronary arteriogram
> ...



I would still bill
93458-26
93571-26-59
36252 for selective renals, bilateral, includes catheter placement
HTH,
Jim Pawloski, CIRCC


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## theresa.dix@tennova.com (Feb 20, 2013)

Jim Pawloski said:


> I would still bill
> 93458-26
> 93571-26-59
> 36252 for selective renals, bilateral, includes catheter placement
> ...



Openshaw,
 the reason I wondered about the op report is to see if the cath was actually placed into the renal arteries for selective angios. I think this is something we need to watch for in our reports. There should be a description of the renals and I always wonder if "selective" is enough?


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## Jim Pawloski (Feb 20, 2013)

theresa.dix@ethc.com said:


> Openshaw,
> the reason I wondered about the op report is to see if the cath was actually placed into the renal arteries for selective angios. I think this is something we need to watch for in our reports. There should be a description of the renals and I always wonder if "selective" is enough?



I would have to agree with you on this one, that we need to see selectivity and findings to code for renals.  I would have to say the same thing with "abdominal aortogram" where the renals are not described.  When I code, if I do not see any mention of the renal arteries, I code for the lower extremity angiogram (Catheter is placed inthe aorta and the lower aorta is described along with the iliacs).
Jim Pawloski, CIRCC


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## theresa.dix@tennova.com (Feb 21, 2013)

Jim Pawloski said:


> I would have to agree with you on this one, that we need to see selectivity and findings to code for renals.  I would have to say the same thing with "abdominal aortogram" where the renals are not described.  When I code, if I do not see any mention of the renal arteries, I code for the lower extremity angiogram (Catheter is placed inthe aorta and the lower aorta is described along with the iliacs).
> Jim Pawloski, CIRCC



Thanks Jim. I try to do the same thing. The interpretation drives what code I use for abdominal aortogram.


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