# 36222 or 36223 ??



## MELJNBBRB (Apr 7, 2014)

I have got all of the the other codes I need, but ever since the codes were revised I get confused :/ Would you code 36222 OR 36223? 
Thanks in advance,
Melissa Bedford,CCS,CPC


INDICATION: Left upper extremity ischemia. Asymmetric upper extremity blood pressures with 40 mm Hg decreased on the left. Dizziness.

PROCEDURE:
1. Arch aortogram.
2. Selective bilateral common carotid artery catheterization and angiography.
3. Selective left subclavian artery catheterization and angiography.
4. Left subclavian artery angioplasty followed by left subclavian artery stent placement.
5. Right common femoral artery Starclose deployment.


OPERATORS: Dr.

MEDICATIONS: 1% lidocaine local anesthesia; fentanyl 150 mcg IV; Versed 3 mg IV; heparin 5000 units IA; Ancef 2 g IV. 

CONTRAST: 108 mL Omnipaque-300.

FLUOROSCOPY TIME: 8.9 minutes.

COMPLICATIONS: None immediately evident.

DESCRIPTION: After the procedure including indication and potential complications had been discussed with the patient and all questions answered, written informed consent was obtained. The patient was then taken to the interventional suite and placed on 
the table in supine position where skin of the bilateral groins was prepped and draped sterilely. A time-out was performed. Pre angiography pulses: right CFA, DPA and PTA palpable; Left CFA, PTA and DPA dopplerable.

After achieving 1% lidocaine local anesthesia, the right common femoral artery was accessed with a 21 gauge single wall needle using ultrasound guidance. After placing a 0.018 guidewire, a micropuncture introducer was placed. The micropuncture introducer
was exchanged for a 0.035 Bentson guidewire. A 5 French hemostatic vascular sheath was then inserted into the right common femoral artery. A 5 French pigtail catheter was advanced over a Bentson guidewire into the thoracic aorta where flush aortic 
digital subtraction arch angiography was performed.

The 5 French pigtail catheter was exchanged for a 5 French JB1 catheter. The catheter was used to select the left subclavian artery. Using a Glidewire, access to the left axillary and left brachial artery was obtained. The JB1 catheter was used to 
exchange for a 0.035 Versa core guidewire. Using the Versa core guidewire, the 5 French sheath was exchanged for a 6 French by 65 cm length hemostatic sheath positioned at the ostia of the left subclavian artery. Hemodynamic gradient of 40 mm of Hg 
between aorta and left subclavian artery demonstrated. Initial angioplasty was performed using a Sterling 4.0 mm x 20 mm length balloon catheter, inflated to 20 atmospheres. This was followed with placement of a balloon expandable stent. A 7 mm diameter 
by 29 mm length Omnilink Elite balloon mounted stent was deployed with 10 atmospheres pressure. Complete stent expansion was achieved. The sheath was used for followup digital subtraction angiography which demonstrated restoration of lumen caliber 
diameter with improved antegrade flow, restoration of antegrade vertebral artery flow, and no evidence of pseudoaneurysm, fistula, or thromboembolism. Hemodynamics revealed less than 10 mm gradient residual.

The JB1 catheter, and Glidewire was then used to select the right common carotid artery. Multiplanar digital subtraction angiography of the extracranial right carotid artery, and cerebral internal carotid artery was then performed. Cerebral arteriography
through venous phase was obtained. 

The JB1 catheter, and Glidewire was then used to select the left common carotid artery. Multiplanar digital subtraction angiography of the extracranial right carotid artery, and cerebral internal carotid artery was then performed Cerebral arteriography
through venous phase was obtained. 


Angiography of the right external iliac artery demonstrates access above the common femoral artery bifurcation.
The right common femoral artery sheath was removed and hemostasis obtained a Starclose device was deployed. Hemostasis was obtained, without hematoma. Common femoral artery pulses are 2+ and stable. Stable post catheterization peripheral pulses, 
bilateral DPA and PTA dopplerable. Stable neurologic exam.

Patient tolerated the procedure well. The patient was hemodynamically stable and discharged from interventional radiology. The patient was monitored by an independent radiology nurse. 

FINDINGS:
1. Aortic arch is unremarkable for dissection or aneurysmal dilatation. Type I aortic arch. There is subtotal stenosis at the origin of left subclavian artery extending for 2 cm length. The origin of left subclavian artery is densely calcified. There is 
a vertebral steal syndrome with retrograde flow within the vertebral artery.
2. Patent and unremarkable innominate artery, and right subclavian artery. The remainder of the left subclavian artery, and left axillary artery are unremarkable. 
3. Right common carotid, external carotid and internal carotid artery are patent and unremarkable for significant stenosis, occlusion, or aneurysm. No evidence of FMD or dissection.
4. Left common carotid, external carotid and internal carotid artery are patent and unremarkable for significant stenosis, occlusion, or aneurysm. No evidence of FMD or dissection. There is a focal hypoattenuating at the proximal left internal carotid 
artery approximately 3 cm from the origin. No evidence of hemodynamic significance of the focal kinking likely related to ectasia.
5. Cerebral venous phase and dural sinuses are unremarkable. 
6. Unremarkable right common iliac, internal and external iliac artery.
7. Post left subclavian artery angioplasty and stent placement result in restoration of left subclavian artery lumen caliber diameter without significant residual recoil stenosis. There is restoration of antegrade left vertebral artery flow.
. 

Impression: IMPRESSION:

1. Focal subtotal stenosis at the origin of left subclavian artery with resultant left vertebral steal syndrome.
2. Successful left subclavian artery angioplasty and stent placement without residual or recurrent stenosis.
3. No significant carotid artery stenosis. Focal extracranial left internal carotid artery kink is likely related to ectasia without evidence of hemodynamically significance.


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## Jim Pawloski (Apr 8, 2014)

SASSYLDY27 said:


> I have got all of the the other codes I need, but ever since the codes were revised I get confused :/ Would you code 36222 OR 36223?
> Thanks in advance,
> Melissa Bedford,CCS,CPC
> 
> ...



I would code 36223-rt, 36223-lt, 36215-lt, 75710-lt-59, 37236.
Thank you,
Jim Pawloski, CIRCC


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