# Lisa, CPC



## lclemen (Nov 14, 2012)

I am new at Cardiology coding and I need some help with the following procedure. This was done all on the same day on the same patient.

PROCEDURES: 
1.  Right femoral retrograde arteriotomy and placement of a 6-French 11 cm sheath.  The tissue was very fibrotic, requiring pre-dilation with large dilators and use of an Amplatz Super Stiff wire to pass the 6-French sheath. 
2.  Very proximal subclavian angiogram with runoff to the proximal brachial artery. 
3.  Selective left brachial arteriogram with runoff primarily through the AV fistula. 
4.  Selective angiography of the forearm vessels with runoff to the hand. 
5.  Intra-arterial thrombolytic therapy in the distal brachial artery (TPA). 
6.  Sheath and catheter sutured in place. 

FINDINGS: 
1.  Left subclavian and axillary arteries are normal. 
2.  Left brachial artery is normal. 
3.  Left ulnar artery is open to the palmar arch with significant calcification throughout its course, but no significant stenosis. 
4.  Left radial artery is very spasmogenic, but patent to the arch with good diameter and smooth borders. 
5.  There is no flow into the digits.  Virtually no vessels at all were seen beyond the rudimentary palmar arch, even after nitroglycerin.  The radial artery also did not opacify until after intra-arterial nitroglycerin. 
6.  The AV fistula has a couple areas of aneurysm, but remains patent with good flows and no apparent stenosis in the lower half of the cephalic vein. 



PROCEDURES: 
1.  Selective right brachial angiogram through the existing multipurpose catheter through the 6-French right femoral sheath. 
2.  Selective left hand angiogram through the existing catheter. 
3.  Removal of the multipurpose sheath from the left brachial artery. 
4.  A 6-French femoral sheath sutured in place. 

FINDINGS: 
1.  Ulnar and radial arteries remain patent with smooth borders. 
2.  The palmar arcade is visible and there are now some digital branches going toward the fingers.  
3.  Extremely brisk flow into the fistula limits the blood supply to the hand.  We had to have absolute complete compression of the fistula in order to get some filling of the radial and ulnar arteries.


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## jewlz0879 (Nov 14, 2012)

Can you post the actual report??? The body of the procedure so we can determine proper cath placement for code selection? 

It could be 36215/75710-26 or 36216-75710-26 for the subclavian, again, depending on cath placement. 

It's hard to tell you anything else with just this information. If you can post more, I'm sure we can better assist you.


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## lclemen (Nov 15, 2012)

Here is the first report:

PROCEDURES: 
1.  Right femoral retrograde arteriotomy and placement of a 6-French 11 cm sheath.  The tissue was very fibrotic, requiring pre-dilation with large dilators and use of an Amplatz Super Stiff wire to pass the 6-French sheath. 
2.  Very proximal subclavian angiogram with runoff to the proximal brachial artery. 
3.  Selective left brachial arteriogram with runoff primarily through the AV fistula. 
4.  Selective angiography of the forearm vessels with runoff to the hand. 
5.  Intra-arterial thrombolytic therapy in the distal brachial artery (TPA). 
6.  Sheath and catheter sutured in place. 

FINDINGS: 
1.  Left subclavian and axillary arteries are normal. 
2.  Left brachial artery is normal. 
3.  Left ulnar artery is open to the palmar arch with significant calcification throughout its course, but no significant stenosis. 
4.  Left radial artery is very spasmogenic, but patent to the arch with good diameter and smooth borders. 
5.  There is no flow into the digits.  Virtually no vessels at all were seen beyond the rudimentary palmar arch, even after nitroglycerin.  The radial artery also did not opacify until after intra-arterial nitroglycerin. 
6.  The AV fistula has a couple areas of aneurysm, but remains patent with good flows and no apparent stenosis in the lower half of the cephalic vein. 

INTERVENTION: 
1.  Intra-arterial TPA 5 mg by slow bolus directly into the distal brachial artery. 
2.  TPA 3 mg per hour by intra-arterial injection, to be continued for 3 hours. 

ANTICOAGULATION:   
None indicated at this time. 

HEMOSTASIS:   
1.  The sheath and catheter were sutured in place. 
2.  Will return to the Catheterization Laboratory for arteriogram and anticipated catheter removal this afternoon. 

COMPLICATIONS: 
1.  Initial spasm of the radial artery, probably related to wire manipulation. 
2.  Apparent perforation of a very small branch of the ulnar artery as we did see some extravasation.  The arm was wrapped fairly tightly for some mild extrinsic compression.  Radial pulse stayed very good. 

TECHNICAL NOTES, MODIFIERS, COMORBIDITIES: 
1.  Chronic renal failure, requiring chronic hemodialysis. 
2.  The brachial artery supports high flow into a very high output AV fistula. 
3.  Obesity complicated arterial access. 
4.  Heavy fibrosis of the soft tissue in the right groin complicated arterial access, requiring multiple pre-dilations and a super stiff wire in the arteriotomy before we could place the sheath. 
5.  A lot of pain in the left hand and fingertips complicated positioning for the angiographic views for this patient. 

  Here is the 2nd report:

PROCEDURES: 
1.  Selective right brachial angiogram through the existing multipurpose catheter through the 6-French right femoral sheath. 
2.  Selective left hand angiogram through the existing catheter. 
3.  Removal of the multipurpose sheath from the left brachial artery. 
4.  A 6-French femoral sheath sutured in place. 

FINDINGS: 
1.  Ulnar and radial arteries remain patent with smooth borders. 
2.  The palmar arcade is visible and there are now some digital branches going toward the fingers.  
3.  Extremely brisk flow into the fistula limits the blood supply to the hand.  We had to have absolute complete compression of the fistula in order to get some filling of the radial and ulnar arteries. 

ANTICOAGULATION: 
1.  TPA was running at low dose through the arterial catheter. 
2.  No additional anticoagulation was used. 

HEMOSTASIS: 
Sheath to be pulled in the Intensive Care Unit after coagulation parameters are reassessed. 

TECHNICAL NOTES, MODIFIERS, COMORBIDITIES: 
1.  Good catheter position. 
2.  Absolutely total compression of the AV fistula needed to be maintained in order to adequately fill the radial and ulnar arteries with the catheter positioned in brachial artery distal to the AV fistula anastomosis. 
3.  End-stage renal disease requiring chronic hemodialysis. 
4.  Dilated cardiomyopathy. 
5.  Pulmonary emboli, chronically anticoagulated with Coumadin.  Increases the risk of bleeding.

Again this was all done on the same patient and same day.

Thanks!

Lisa


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## dpeoples (Nov 15, 2012)

lclemen said:


> Here is the first report:
> 
> PROCEDURES:
> 1.  Right femoral retrograde arteriotomy and placement of a 6-French 11 cm sheath.  The tissue was very fibrotic, requiring pre-dilation with large dilators and use of an Amplatz Super Stiff wire to pass the 6-French sheath.
> ...



Here goes:
Case 1) 
37201/75896  for thrombolysis
36217/75710 for selective brachial (left upper extremity) angiography

documentation is insufficient for additional seletive cath placements or angiographies (36218/75774).

Case 2)
75898 for follow up angiography after thrombolysis

I do see a potential problem in that the treatment is for thrombus/thrombosis but that condition is not documented. Is there more to the report? Perhaps I just missed that.

HTH


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