# Bilateral Arteriogram



## amym (Jul 18, 2011)

I need HELP! coding this!

PROTOCOL:  The patient underwent chemistry evaluation, which revealed a 
creatinine of 4.2.  Two weeks ago when the patient was admitted his 
creatinine was 3.7, which was treated to a lower level of 2.0 upon 
discharge on July 1, 2011.  Now his creatinine is back up to 4.2.  Give 
the need for the procedure we went ahead and proceeded with the 
procedure after discussion with Dr. Bhamani. 

Based on these findings the patient underwent selective imaging without 
the use of bolus chase method and total contrast used was 31 mL of 
Visipaque.  The access was obtained via right femoral artery with single 
stick and subsequently J-wire was advanced and 5-French OmniFlush 
catheter was advanced into the left iliac artery using exchange 
glidewire and the catheter tip was placed at the level of the common 
femoral artery.  Imaging was obtained at the external iliac artery and 
imaging was obtained with selective small contrast injections.  The 
entire extremity on the left side was imaged and on the right side 
imaging of the iliac vessel, femoral, and trifurcation was performed. 
No complications occurred.  A probe light was used for cautery device 
and the patient was sent to the recovery room. 

FINDINGS: 
1. The left lower extremity was visualized well and demonstrates the 
external iliac artery shows mild disease. 
2. The left common femoral artery is patent with mild to moderate 
plaque. 
3. The left common femoral artery/superficial femoral artery stent is 
widely patent.  This is an IDEV stent with excellent flow through it. 
4. The mid superficial femoral artery percutaneous transluminal 
angioplasty site is widely patent with less than 40% narrowing. 
5. The distal superficial femoral artery/popliteal percutaneous 
transluminal angioplasty site is widely patent.  This used to be a 
chronic occlusion, but excellent flow is noted through this vessel and 
flow into the popliteal artery is well preserved. 
6. The trifurcation shows occlusion of the anterior tibial artery, which 
is chronic. 
7. The 50% disease noted in the posterior tibial take off and the 
peroneal artery is a large vessel, which goes all the way to the distal 
foot above the ankle.  There is three vessel runoff in the foot with 
posterior tibial/anterior tibial reconstituting above the ankle and the 
peroneal artery. 
8. The right lower extremity was visualized only in the iliac and 
femoral vessels and appears to be intact.  There appears to be total 
occlusion of the distal superficial femoral artery, which is chronic and 
the trifurcation is diseased as previously reported. 

Based on these findings the patient has adequate flow and the previous 
stent and percutaneous transluminal angioplasty sites are widely patent. 
Therefore, the patient will continue with wound care as previously and 
followup with his podiatrist.  In addition, he will followup with his 
renal physician tomorrow for further recheck and evaluation.  The 
patient is advised to continue to encourage fluid PO intake.


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## dpeoples (Jul 21, 2011)

amym said:


> I need HELP! coding this!
> 
> PROTOCOL:  The patient underwent chemistry evaluation, which revealed a
> creatinine of 4.2.  Two weeks ago when the patient was admitted his
> ...



I see:
36245
75716

HTH


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