# 36251, 36252 VS 36245 Renal Angiograms



## HEMINGWAYT (Mar 18, 2013)

Since the addition of the 36251,36252 is there an instance when you would use the 36245?  I think I am overthinking this and getting myself confused.

My situations would always be in conjunction with a cath procedure.

Thank you in advance


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## Jim Pawloski (Mar 18, 2013)

HEMINGWAYT said:


> Since the addition of the 36251,36252 is there an instance when you would use the 36245?  I think I am overthinking this and getting myself confused.
> 
> My situations would always be in conjunction with a cath procedure.
> 
> Thank you in advance



For Celiac, SMA, IMA and lower extremity arteriograms ( non interventional study)
HTH,
Jim Pawloski, CIRCC


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## kmuerth (Jun 19, 2013)

Jim, 

I just coded a right femoral artery catheterization with abdominal aortography, selective right and left renal angiography, selective right and left common iliac artery angiography and runoffs. I came up with 36252, 36246 RT, 36246 LT, and 75616. 

Am I correct?

Also, Supercoder instructs to add on -59 to the 36246. Is that because the cath is entering a different area? Wouldnt that be implied in the CPT code?


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## Jim Pawloski (Jun 19, 2013)

kmuerth said:


> Jim,
> 
> I just coded a right femoral artery catheterization with abdominal aortography, selective right and left renal angiography, selective right and left common iliac artery angiography and runoffs. I came up with 36252, 36246 RT, 36246 LT, and 75616.
> 
> ...



Can you post the report?  With what you coded, were both femoral arteries accessed?
Thanks,
Jim Pawloski, CIRCC


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## kmuerth (Jun 19, 2013)

PROCEDURES:  Right femoral artery catheterization with abdominal aortography, selective right and left renal angiography and selective right and left common iliac artery angiography and runoffs.  

PROCEDURE:    The patient was premedicated with diphenhydramine and diazepam and brought to the catheterization laboratory with an IV placed in the left arm.  The right groin was prepped and draped in the usual fashion and infiltrated with 1% Xylocaine.  A 5 French sheath was positioned in the right common femoral artery.  She received Versed 2 mg IV.  Abdominal aortography was performed using a using a 5 French pigtail catheter with 30 cc of Isovue injected at 10 cc per second.  Selective angiography was performed using the IMA catheter.  Right and left common iliac artery angiography was performed using 30 cc of Isovue injected at 10 cc per second.  Following this, all catheters and sheaths were removed and hemostasis was achieved with direct pressure.  The patient experienced no complications. 

RESULTS: 
Hemodynamics:  All pressures are in mmHg, means are in parentheses.  

	Heart rate: 		68 beats per minute
	Aorta: 			169/65 (105) 

The rhythm throughout the procedure was normal sinus.  

Angiography: 

Abdominal Aorta:  Abdominal aortography demonstrates no significant abnormalities or stenoses.  

Left Renal Artery:  Selective injection of the left renal artery demonstrates no significant stenoses.

Right Renal Artery:  Selective injection of the right renal artery demonstrates no significant stenoses.  

Right Common Iliac Artery:  Selective injection of the right common iliac artery demonstrates no significant stenoses of the iliac system.  The common femoral artery is also free of significant disease.  There is 30% narrowing at the ostium of the profunda.  The common femoral artery shows minor 20% irregularities in its mid portion.  However, at the distal end of the abductor canal is a focal area of 70-80% stenosis.  There is at least two-vessel runoff present.  The anterior tibial artery was not well visualized.  

Left Common Iliac Artery:  Selective injection of the left common iliac artery demonstrates 10% irregularities of the common iliac artery.  The external and internal iliac arteries are free of significant disease.  .10% irregularity is noted of the common femoral artery.  There is 30% narrowing at the ostium of the superficial femoral artery with an area of 50% narrowing at the abductor canal.  The popliteal artery has 50% stenosis.  Two-vessel runoff is noted.  The anterior tibial artery is either vestigial or totally occluded . 

CONCLUSIONS:  
PERIPHERAL VASCULAR DISEASE - SEVERE, INVOLVING THE RIGHT AND LEFT SUPERFICIAL FEMORAL ARTERIES AND THE LEFT POPLITEAL ARTERY.

RECOMMENDATIONS:  Mrs. Wilson has significant disease involving the right superficial femoral artery at the abductor canal.  There is borderline significant disease involving the left superficial femoral and popliteal arteries.  Her symptoms involve her right leg exclusively.  If an aggressive walking program does not give her sufficient improvement, I would recommend intervention of the right superficial femoral artery.


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## kmuerth (Jun 19, 2013)

*Another but more intensive renal procedure. Help!*

PROCEDURES:  Right femoral artery catheterization with abdominal aortography with selective right and left renal artery angiography and percutaneous transluminal angioplasty and arterial stenting of the left renal artery.  

PROCEDURE:    The patient was premedicated with diphenhydramine, diazepam and Prasugrel brought to the catheterization laboratory with an IV placed in the left arm.  The right groin was prepped and draped in the usual fashion and infiltrated with 1% Xylocaine.  A 6 French sheath was positioned in the right common femoral artery.  Through this, a 6 French LIMA renal angioplasty guide was inserted and angiography performed.  After careful review of the cineangiograms and discussion with the patient, it was decided to proceed with PTA.  She received 3000 units of heparin  IV and aspirin 325 mg plus Versed 2 mg IV.  A 0.14 Spartacore angioplasty wire was advanced fluoroscopically across the renal artery stenosis.  Over this guidewire, a 5.0 x 20 mm Viatrac catheter was inserted and positioned across the stenosis and inflated to 12 atmospheres for 30 seconds.  There appeared to be a distal filling defect present prior to angioplasty that was still present and there was still 40% narrowing within the renal artery itself.  Because of this, a decision will be made to proceed with arterial stenting.  A 5 mm x 18 mm Herculink stent was inserted and deployed at 14 atmospheres for 30 seconds.  The original Viatrac balloon was also reinserted for post stent dilatation to 18 atmospheres for 15 seconds. Repeat angiography demonstrated excellent results.  All catheters and sheaths were removed and hemostasis was achieved with direct pressure.  The patient experienced no complications.  

RESULTS: 
Hemodynamics:  All pressures are in mmHg, means are in parentheses.  

	Heart rate: 		79 beats per minute
	Aorta: 			155/73 (108) 

Angiography: 

Abdominal Aorta:  
Abdominal aortography demonstrates 20% narrowing of the aorta just below the renal arteries.  No other significant stenoses are seen.  

Right Renal Artery:
Selective injection of the right renal artery demonstrates no significant stenoses.  

Left Renal Artery:  
Selective injection of the left renal artery demonstrates 90% in-stent restenosis.  At the distal end of the stent is what appears to be a small edge dissection or filling defect.  This stent appears to be under deployed also.  

Post PTA:
Following initial angioplasty, the edge dissection is still present with persistent 30-40% narrowing.   

Following arterial stenting, the vessel is widely patent without evidence of stenosis, dissection or thrombus.  

CONCLUSIONS: 
1.  PERIPHERAL VASCULAR DISEASE -- SEVERE INVOLVING THE LEFT RENAL ARTERY REPRESENTING IN-STENT RESTENOSIS.  

2.  PTA OF THE LEFT RENAL ARTERY -- SUCCESSFUL BUT WITH PERSISTENT EDGE DISSECTION/FILLING DEFECT.  

3.  ARTERIAL STENTING OF THE LEFT RENAL ARTERY -- SUCCESSFUL WITH TOTAL RESOLUTION OF DISSECTION/FILLING DEFECT.  


I came up with 37205,75960. 36252. 35471 LT with the 75966.  Am I getting it? lol


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## Jim Pawloski (Jun 20, 2013)

kmuerth said:


> PROCEDURES:  Right femoral artery catheterization with abdominal aortography, selective right and left renal angiography and selective right and left common iliac artery angiography and runoffs.
> 
> PROCEDURE:    The patient was premedicated with diphenhydramine and diazepam and brought to the catheterization laboratory with an IV placed in the left arm.  The right groin was prepped and draped in the usual fashion and infiltrated with 1% Xylocaine.  A 5 French sheath was positioned in the right common femoral artery.  She received Versed 2 mg IV.  Abdominal aortography was performed using a using a 5 French pigtail catheter with 30 cc of Isovue injected at 10 cc per second.  Selective angiography was performed using the IMA catheter.  Right and left common iliac artery angiography was performed using 30 cc of Isovue injected at 10 cc per second.  Following this, all catheters and sheaths were removed and hemostasis was achieved with direct pressure.  The patient experienced no complications.
> 
> ...



I would use your codes, but only 36245-lt for your selectivity.  The right side is bundled into the selective lt iliac because that was the access side.
HTH,
Jim Pawloski, CIRCC


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## Jim Pawloski (Jun 20, 2013)

kmuerth said:


> PROCEDURES:  Right femoral artery catheterization with abdominal aortography with selective right and left renal artery angiography and percutaneous transluminal angioplasty and arterial stenting of the left renal artery.
> 
> PROCEDURE:    The patient was premedicated with diphenhydramine, diazepam and Prasugrel brought to the catheterization laboratory with an IV placed in the left arm.  The right groin was prepped and draped in the usual fashion and infiltrated with 1% Xylocaine.  A 6 French sheath was positioned in the right common femoral artery.  Through this, a 6 French LIMA renal angioplasty guide was inserted and angiography performed.  After careful review of the cineangiograms and discussion with the patient, it was decided to proceed with PTA.  She received 3000 units of heparin  IV and aspirin 325 mg plus Versed 2 mg IV.  A 0.14 Spartacore angioplasty wire was advanced fluoroscopically across the renal artery stenosis.  Over this guidewire, a 5.0 x 20 mm Viatrac catheter was inserted and positioned across the stenosis and inflated to 12 atmospheres for 30 seconds.  There appeared to be a distal filling defect present prior to angioplasty that was still present and there was still 40% narrowing within the renal artery itself.  Because of this, a decision will be made to proceed with arterial stenting.  A 5 mm x 18 mm Herculink stent was inserted and deployed at 14 atmospheres for 30 seconds.  The original Viatrac balloon was also reinserted for post stent dilatation to 18 atmospheres for 15 seconds. Repeat angiography demonstrated excellent results.  All catheters and sheaths were removed and hemostasis was achieved with direct pressure.  The patient experienced no complications.
> 
> ...



Looks like your getting it.  May want to add a modifier-59 to the 36252 to get paid for the diagnostic exam.
Thanks,
Jim Pawloski, CIRCC


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## kmuerth (Jun 20, 2013)

Jim, you rock by the way  Thank you for helping everybody on here!

Im not grasping the 36245-LT unfortunately.   Darn brain. 

I will hit the books and the web to try to figure it out and paint myself a mental picture to get it. Feel free to be the artist!


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## kmuerth (Jun 20, 2013)

OK. I think I got it! So Dr. started in the right common femoral, went all the way up to the abdominal aorta, injected, took pictures, turned around, came back down, injected from the abdominal aorta area into the left and right renal arteries, took pictures, then went down to right common iliac, injected, took pictures, CROSSED OVER to left common iliac, injected took pictures. So because the femoral access to the selective renal angiography includes all the things along the way, we wouldnt code the 36245 RT, but we can code the 36245 -LT because we are leaving the original pathway and crossing over to the a left first order of the common iliac?? Did I get it??


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## kmuerth (Jun 20, 2013)

some coders are questioning a use of the 75774 code? Please review the op report and give your opinion. Thanks!


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## Jim Pawloski (Jun 20, 2013)

kmuerth said:


> OK. I think I got it! So Dr. started in the right common femoral, went all the way up to the abdominal aorta, injected, took pictures, turned around, came back down, injected from the abdominal aorta area into the left and right renal arteries, took pictures, then went down to right common iliac, injected, took pictures, CROSSED OVER to left common iliac, injected took pictures. So because the femoral access to the selective renal angiography includes all the things along the way, we wouldnt code the 36245 RT, but we can code the 36245 -LT because we are leaving the original pathway and crossing over to the a left first order of the common iliac?? Did I get it??



Yep! You got it!
Jim Pawloski, CIRCC


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## Jim Pawloski (Jun 20, 2013)

kmuerth said:


> some coders are questioning a use of the 75774 code? Please review the op report and give your opinion. Thanks!



Only if your in the same vascular family, and the catheter is moved from one vessel to another.
Thanks,
Jim


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## kmuerth (Jun 25, 2013)

Jim, 

I would to learn from you as this is a new field for me. Would you be so kind enough as to provide an email address where I can reach you?

Thanks, 

Kmuerth@flaheart.com


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