# selective left axillary artery arteriography?



## Griffith_Tiffany (May 9, 2013)

I am thinking this is not billable, need some reassurance.


PREOPERATIVE DIAGNOSIS:  Symptoms of Canadian Class II to III dyspnea as well as abnormal stress test performed as an outpatient with multiple risk factors for coronary artery disease.
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TITLE OF PROCEDURE:
1.  Multiple attempts made to try and access the right femoral artery, but it appears that her iliac artery is probably occluded as we were unable to access the same with no significant femoral arterial pulsations felt.
2.  Successful selective left axillary artery arteriography performed after left radial access, but she was found to have severe 80 to 90% stenosis involving her proximal left subclavian artery, so further attempts at cardiac catheterization at this time were aborted and we will proceed with CT angiogram of her aortoiliac bifurcation prior to another attempt.

BRIEF HISTORY / INDICATION(S) FOR SURGERY/PROCEDURE:  Symptoms of Canadian Class II to III dyspnea as well as abnormal stress test performed as an outpatient with multiple risk factors for coronary artery disease.

The patient is a 65-year-old female who was evaluated by myself, Dr. Gandhok, for symptoms of Canadian Class II to III dyspnea occurring even with mild exertion and her symptoms was suggestive of an anginal equivalent.  She underwent a myocardial perfusion study which had shown evidence of left anterior descending coronary distribution ischemia, so based on that and her ongoing symptoms and multiple risk factors for coronary artery disease, it was decided to proceed for cardiac catheterization to further evaluate her coronary anatomy.  All risks, benefits, complications and alternatives to the procedure were explained in depth to the patient, following which informed consent was obtained.

DESCRIPTION OF SPECIFIC PROCEDURE FINDINGS:
ANGIOGRAPHIC FINDINGS:  Her left axillary and brachial artery appeared to be patent.  She, however, had 80% stenosis involving a proximal left subclavian artery.

TECHNICAL DESCRIPTION OF PROCEDURE:  As above, multiple efforts were made to try and obtain right femoral arterial access which proved unsuccessful.  Left femoral arterial pulse was almost completely absent.  Left radial attempt was made after she was found to have normal Allen test; however, as there was difficulty in passing the wire past the proximal left subclavian artery, left axillary arteriography was performed which showed evidence of 80% stenosis involving the proximal left subclavian artery.  At this time, it was felt that there was high risk of proceeding with the procedure until we further evaluated her aortoiliac bifurcation and then further attempts at cardiac catheterization will be performed in the near future possibly with vascular surgery assessments as well.  After her left femoral arterial access, we were able to successfully obtain left radial artery access and then this radial artery sheath was successfully removed and a transradial band was applied.  Overall, she tolerated the procedure well.

SPECIMENS REMOVED (If Applicable):  Not applicable.

ESTIMATED BLOOD LOSS (If Applicable):  Minimal.

ASSESSMENT, PLAN AND RECOMMENDATIONS:  As above, we will proceed with the cardiac catheterization in the future after her aortoiliac anatomy is further identified by noninvasive testing.


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## dimmitta (May 13, 2013)

Yes this case is billable. I would bill: 

36120 - Introduction needle/catheter; brachial artery. Reasoning:doctor did access this patient's arm and advanced the catheter to the level of axillary artery
75710 - Angiography, extremity, unilateral, radiological supervision and interpretation. Reasoning: left axillary arteriography was performed and findings indicate 80% stenosis of subclavian artery.

It doesn't matter if his initial intent was to perform a heart cath. He did the work of a diagnostic workup on the left arm and the work performed should be billed accordingly.


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