# Renal angiogram from aorta



## margaret fahy (Oct 24, 2013)

10/24/13
Guys,
In the following procedure, dr. states she does an aortogram and documents an angiography of the renal arteries which catheter is still in the aorta.
She then selectively catheterizes the left renal artery and does an angiography there.
Then, the left renal artery angioplasty.
QUESTION:  For the Right renal angiography done while catheter is in the aorta, i won't get any billing for this, as cath did not leave aorta for this angiography and we defer to the selective catheterization....is this correct?

So, i'd code for:
36253 - angiog. left renal artery superselective?...36253, not 36251?
35471/75966 for the left renal artery angioplasty.
Is this correct?
When dr. documents a catheterization done while still in the aorta, this is just an aortogram?

Ultrasound guided right common femoral artery access.
2. Abdominal aortogram.
3. Selective catheterization of left renal artery and angiogram.
4. Selective catheterization of the superior branch of the left
main renal artery and angioplasty using 3 mm balloon catheter.
6. Post angioplasty angiogram of the left renal artery.
7. Hemostasis with manual compression.

PROCEDURE IN DETAILS: The skin of the right groin was prepped
and draped in sterile fashion. Using US guidance a 21-gauge
needle was inserted in the right common femoral artery. Once
arterial blood return was obtained a .018" Nitrex wire was
placed into the artery and advanced to the distal abdominal
aorta. The needle was removed and a 4 French regular vascular
sheath was placed into the artery. Then a 4 French 70 cm pigtail
catheter was advanced into the proximal abdominal aorta and
angiography of the abdominal aorta and renal arteries in frontal
view was obtained utilizing digital subtraction angiography. The
vascular sheath was exchanged into 5 French, 45 cm curved
vascular sheath which advanced over the wire into the lower
abdominal aorta. The catheter was exchanged into 4 French Sos
Omni catheter and selective catheterization of the left renal
artery was performed and angiogram was obtained utilizing
digital subtraction angiography.

FINDINGS:
AORTOGRAM:
The abdominal aorta, visualized branches of the celiac artery
and SMA and aortic bifurcation are normal in caliber without
evidence of stenosis. There is symmetric perfusion of the
kidneys without filling defects. The venous phase demonstrates
patent renal veins and suprarenal IVC. There is no significant
discrepancy in renal size.

LEFT RENAL ARTERY ANGIOGRAM: Single left renal artery is
identified. The left renal artery including the origin is normal
in appearance without evidence of stenosis. There is significant
stenosis involving the superior branch of the left renal artery
proximal to the hilum, with significant associated with post
stenotic dilatation. The inferior branch of the left renal
artery is unremarkable. The intra-renal perfusion and
intra-renal vasculature is normal. There is no vascular
malformation or aneurysm. The left renal vein is unremarkable.

RIGHT RENAL ARTERY ANGIOGRAM: There are 2 renal arteries on the
right. The right renal arteries arteries  are unremarkable with
no evidence of stenoses. The intra-renal perfusion and
intra-renal vasculature is normal.  There is no vascular
malformation or aneurysm. The right renal vein is unremarkable.

LEFT RENAL ANGIOPLASTY:
The images were reviewed carefully and the decision of
angioplasty of the superior branch of the left renal artery was
made. The initial dose of heparin was given. Multiple attempts
were performed to cross the stenotic region within the superior
branch of the left renal artery which was challenging secondary
to tight stenosis and acute angle of the branch. Different types
of wires and catheters were used including: wires: 035
Glidewire, 018 double angle glide GT, .014 Thruway, .014
approach, .014 PT2, catheters: 4 French Sos Omni catheter, 2.4
French microcatheter and 4 French Cobra catheter. The stenosis
was crossed using .014 Thruway wire and a 4F Cobra catheter
which easily cannulated the left renal artery. Angioplasty was
performed utilizing 3 mm Monorail balloon catheter (inflated to
3.2 mm at 14atm). The equivalent left lower pole renal artery
measured 2.6mm.

During selective injection of the lower pole branch a small
collateral was noted in the mid pole possibly in the
distribution of the upper pole renal stenosis. Post angioplasty
angiogram of the left renal artery demonstrated significant
radiologic improvement of the stenosis without evidence of
thrombosis, dissection or extravasation.  The intra-renal
collateral vessel off the left lower pole is now not visible.
The sheath and the wire were then removed and manual compression
was applied until hemostasis was achieved. A sterile occlusive
dressing was applied at the site. There were no complications
and the patient left the IR Suite in stable condition. Dr. was present for the entire procedure.

Permanent fluoroscopic and US images were obtained and stored in
the PACS system.

IMPRESSION
IMPRESSION
1.Single left renal artery. Two right renal arteries.
2.Normal right renal arteries.
3. Significant stenosis involving the superior branch of the
left renal artery with post stenotic dilatation.
4. Angioplasty of the left renal artery superior branch stenoses
using 3 mm Monorail balloon catheter with significant radiologic
improvement without evidence of thrombosis, dissection or
extravasation.
5. Normal symmetric bilateral renal size
6. Normal aortic contour, celiac and SMA


----------



## Jim Pawloski (Oct 24, 2013)

margaret fahy said:


> 10/24/13
> Guys,
> In the following procedure, dr. states she does an aortogram and documents an angiography of the renal arteries which catheter is still in the aorta.
> She then selectively catheterizes the left renal artery and does an angiography there.
> ...



Your right with your codes.  Unless the dr. states that the vessel was catheterized, you cannot use a selective code, to answer your other question.


----------



## margaret fahy (Oct 25, 2013)

*Renal angiography from aorta*

Jim,
Thanks so much for your help.
Have a peaceful day.
Margie


----------

