# Arch aortogram with selective upper arteriogram



## claning (Jan 18, 2017)

Hello fellow coders!

Our hospital coder (coding for professional charges) wants to code both non-selective 36221 and selective 36216 for the arch aortogram...they also did an injection of nitriglycerin in the extremity. I'm thinking 36216, 75710, 96373 (??) & 75625? I need to do more Head & Neck!

Please see below report and share your thoughts, thanks!

Procedure: Arch aortogram, selective left upper extremity arteriogram with the catheter in the axillary artery, intra-arterial infusion of radioactive drug.

After full examination of risks and benefits of the procedure informed consent was obtained. Both groins were sterilely prepared and draped. The right common femoral artery was punctured under ultrasound guidance and a 5 French sheath was inserted. A pigtail catheter was advanced into the ascending aorta and an arch aortogram was done. The left subclavian artery was then selected and a Davis catheter advanced into the axillary artery. A left upper extremity arteriogram was done. 100 mcg of nitroglycerin was then injected intra-arterially and repeat angiogram of the hand was performed. Catheters and wires were removed and access site closed using an Angio-Seal device.

Findings: The arch aorta is widely patent with no evidence of atherosclerotic disease in the angiogram. The visualized portions of both common carotid arteries and the right subclavian artery are patent. Flow in both vertebral arteries is antegrade.

Selective left upper extremity arteriogram shows a patent left axillary, brachial, and radial artery as well as interosseous artery. The left ulnar artery is patent proximally but a filling defect is seen above the wrist consistent with thrombus. There is a 2 cm segment of the distal ulnar artery just below the wrist that is occluded. The palmar arch fills from the radial artery. Filling defects are seen in the digital arteries of second through fourth digits with poor flow distal to the third joint of the fourth finger.


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## Jim Pawloski (Jan 25, 2017)

claning said:


> Hello fellow coders!
> 
> Our hospital coder (coding for professional charges) wants to code both non-selective 36221 and selective 36216 for the arch aortogram...they also did an injection of nitriglycerin in the extremity. I'm thinking 36216, 75710, 96373 (??) & 75625? I need to do more Head & Neck!
> 
> ...



Hi,
I would bill the 36221 for the arch, 36216-xs for the selective catheter placement, 75710-lt-59 for the lt upper extremity arteriogram. I would not code 96373 for the nitro, because I think that was for vasospasm, and not a therapeutic procedure. 75625 code is for abdominal aortogram and is not used in this case.
HTH,
Jim Pawloski, CIRCC


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## mcauffman86 (Jan 30, 2020)

I was wondering why 36216 is coded for the selective catheter placement on the left side rather than 36215? Wasn't this done from a femoral contralateral approach?


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## Jim Pawloski (Jan 31, 2020)

36215 is from the origin of the left subclavian to the left vertebral artery. The catheter was in the axillary artery which is a 2nd order artery or 36216. It would not matter which femoral artery was accessed since the catheter passed thru the aorta then went selective above the diaphragm.


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## mcauffman86 (Feb 4, 2020)

Ok. That explanation makes sense to me. I have such a hard time with these cath placement codes sometimes. So with this below op report, I coded 37236-RT, 36215-RT, 75710-26-59-RT. Would you agree with this coding?

Procedure Ordered: 
Procedure(s):
SUBCLAVIAN ANGIOGRAM POSSIBLE PERCUTANEOUS ANGIOPLASTY 

Procedure Performed:
RADIAL ARTERY APPROACH PERIPHERAL ANGIOGRAM, SELECTIVE RIGHT INNOMINATE ARTERY ANGIOGRAM, ANGIOPLASTY AND STENT PLACEMENT REPORT.

Pre-Procedure Diagnosis: 
Severe bilateral subclavian artery stenosis.

Post-Procedure Diagnosis:
Same 

Indications:

Patient has long history of tobacco abuse and severe PVD and bilateral subclavian artery stenosis.
He had history of:
              - Cutting balloon angioplasty of R subclavian artery 
              - PTA & stenting of L subclavian artery 
              - PTA & stenting of R innominate artery 
              - CAS s/p L CCA stenting 
Recent peripheral angiogram showed 100% right innominate artery unable to open via the femoral artery approach.
He was hospitalized in 12/2019 with possible TIA and symptoms consistent with posterior circulation vertebral symptoms. He was seen recently by neurology and was recommended to be seen for his known history of subclavian steal syndrome & possible vascular intervention 
Attempt in PTA of the right innominate artery via the right brachial artery approach is recommended.

Nature of procedure, including benefits, alternative and risks, e.g. bleeding, CVA, MI, renal failure, infection, emergency CABG and even death explained.

Name of Procedure:
1. Arterial access via the right radial artery using Lumify US
2. Selective right innominate artery, right common carotid and right subclavian artery angiogram.
3. Right innominate artery angioplasty with a 7.0 mm balloon.
4. Right innominate artery stent placement with a 7.0 x 39 mm Omnilink stent.

Moderate sedation performed using IV Versed and Fentanyl.
Patient received continuous EKG, hemodynamic and oximetry monitoring.
The attending physician was present and/or scrubbed for the entire procedures.
Duration: 45 minutes.

Description of Procedure:
The patient was premedicated with Versed and fentanyl and was brought into the cath lab in a fasting state. Lidocaine 1% was used as a local anesthetic. After the right wrist, above the right radial artery was anesthetized, vascular access was achieved using the Lumify US system as follows:

Ultrasound guided vascular access was performed using the Lumify vascular system.
The right radial artery was identified by Ultrasound.
The radial artery is a very small vessel with poor flow on color flow and appears suitable for vascular access.
Real time live visualization of vascular needle entry and direct puncture into the right radial artery without double wall puncture.
Vascular access was achieved with a single puncture without difficulty.  A 6 french arterial sheath was introduced safely with Ultrasound guidance. There are no complications.

A 6-French Slender arterial sheath was advanced into the right radial artery. Subsequently, a  Multipurpose guide was advanced into the right innominate artery.  Selective right innominate artery  angiography was performed using the multipurpose catheter in multiple projections, 5000 units of heparin was given as an anticoagulant. 

Hemodynamics: 
Aortic pressure was:    10/11/2018    1/30/2020    1/30/2020
AO Systolic Pressure    104    94    100
AO Diastolic Pressure    70    58    59
AO Mean Pressure    86    70    76


LV pressure and LVEDP was:    6/19/2017
LV Systolic Pressure    166
LV Diastolic Pressure    14
LV End Diastolic Pressure    37
Some recent data might be hidden

Cine Interpretation: 

We were able to cross the 100% right innominate artery with a flexible guidewire.
The vessel was ballooned using a 7.0 mm balloon with inadequate result. The right innominate artery was stented using a 7.0 x 39 mm Omnilink stent. Residual 10% stenosis was seen post stent placement. 

Cine Interpretation: 

Right innominate artery 100% was reduced to 10% post stent placement.

The right Radial artery was closed with a radial artery compression band with good hemostasis without Complications.

Recommendation: 
Recommend Asa and plavix therapy. 

Case Classification:
Elective/Scheduled


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## Jim Pawloski (Feb 5, 2020)

The only code that I don't agree with is 36215. Since access was in the rt radial artery, and every thing is in a straight line (non selective), I would code 36140.
HTH,
Jim


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## mcauffman86 (Feb 5, 2020)

Yes it does help. I was viewing it from a femoral approach vs radial. Thanks Jim.


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## jadhavganesh345@gmail.com (Feb 12, 2020)

Agree with Jim for 1st scenario-36221, 36216, 75710


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