# Peripheral Angiography/Right Radial revascularizaion & Mechanical Thrombectomy



## Cardio403 (Apr 16, 2019)

Good Afternoon,

I am looking for some help with this upper extremity Procedure.  I do not have these procedures very often & I am not 100% sure on my code selection.
If someone could take a look & let me know if I chose the correct codes & if not which codes should I have chosen.

Thank you so much for your help   

These are the codes I submitted:
37184
36217
37211-59
75710-26,59
75774-26,59
99152

The carrier is denying 75710 & 75774 as well as 37211.  

PROCEDURES PERFORMED:
1.  Percutaneous revascularization of the right radial artery.
2.  Intraarterial TPA infusion of the right radial artery.
3.  Selective right brachial artery angiogram with distal runoff.
4.  Selective right radial artery angiogram of distal runoff.
*
BRIEF HISTORY:  This is a 46-year-old morbidly obese female initially
presented to our clinic for evaluation of symptoms of dyspnea on exertion and
abnormal stress test.  The patient subsequently underwent a coronary angiogram
on 10/15/2018 via right radial arterial approach.  The patient then underwent
a successful percutaneous revascularization of the right coronary artery and
LAD utilizing drug-eluting stents.  She was subsequently seen as an outpatient
on 10/24/2018 in our clinic where she noted symptoms of right arm swelling as
well as significant discomfort of her right wrist and the right arm.  She
subsequently underwent an arterial duplex ultrasound of the right upper
extremity revealing an occlusion of the right radial artery with maintenance
of patency of the right ulnar artery.  However, due to significant discomfort,
the patient was brought urgently on 10/25/2018 for selective right brachial
artery angiogram with possibility of endovascular revascularization.
*
PROCEDURE DESCRIPTION:  Conscious sedation was performed by registered nurse
under the supervision of Dr..  A 6 x 23 sheath was placed in the
left common femoral artery.  A 5-French LIMA diagnostic catheter was utilized
to engage the right innominate artery.  The LIMA diagnostic catheter was
subsequently advanced into the distal segment of the right brachial artery. 
Selective right brachial artery angiogram with distal runoff was performed via
hand injection of contrast through the LIMA diagnostic catheter.  This
confirmed a proximal thrombotic occlusion of the right radial artery with
maintenance of patency of the right ulnar artery as well as a right
interosseous artery.  Then, we proceeded to exchange the 5-French LIMA
diagnostic catheter for a 0.035 Quick-Cross catheter over a 0.035 Versacore
guidewire.  Then, we proceeded across the proximally occluded right radial
artery using a 0.014 Whisper guidewire.  The Quick-Cross catheter was advanced
into the proximal segment of the right radial artery.  Selective right radial
artery angiogram confirmed extensive thrombus within the right radial artery. 
At this point, we proceeded to perform a mechanical thrombectomy of the right
radial artery using CAT6 Penumbra aspiration catheter.  Multiple runs were
performed.  This did result in a significant aspiration of the thrombus
burden.  However, the flow within the right radial artery was still sluggish
with a significant residual thrombus throughout the mid and distal segments. 
As a result, we proceeded to give 10 mg IV push of intraarterial TPA through
the Quick-Cross catheter placed in the right radial artery.  The TPA was given
over 25 minutes.  This resulted in a palpable right radial pulse.  There was
still a significant amount of thrombus burden within the mid and distal
segment of the right radial artery.  As a result, we proceeded to leave the
Quick-Cross catheter in the proximal segment of the right radial artery with a
continuous infusion of TPA overnight at 0.5 mg per hour.  The patient will be
brought back electively tomorrow afternoon for recheck right radial artery
angiogram.
*
TECHNICAL FACTORS:  Omnipaque 275 mL.  Angiomax 0.75 mg IV push followed by
Angiomax infusion drip at 1.75 mg/kg per hour.  TPA 10 mg IV push time once
followed by TPA infusion drip at 0.5 mg per hour.
*
POSTOPERATIVE DIAGNOSES:
1.  Mechanical thrombectomy of the right radial artery using a CAT6 Penumbra
aspiration catheter.
2.  Intraarterial TPA infusion via 0.035 Quick-Cross catheter placed in the
proximal segment of the right radial artery.
3.  Proximal thrombotic occlusion of the right radial artery with continued
patency of the right ulnar artery and right interosseous arteries.
*
PLAN:  The patient does appear to have manually palpable right radial pulses
at this time.  We will continue infusing the TPA infusion overnight to further
diminish the thrombus burden in mid and distal segments.  The patient will be
brought back electively tomorrow for recheck right radial artery angiogram.
*
*


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## Cardio403 (Apr 24, 2019)

*Peripheral Angiography/Right Radial revasc & Mech Thrombectomy **Still need Help***

Hello Again.
Any help with this would be greatly appreciated.  Need to know if my coding is way off or in the ball park.
Thank you so much!!!


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## Jim Pawloski (Apr 24, 2019)

Cardio403 said:


> Hello Again.
> Any help with this would be greatly appreciated.  Need to know if my coding is way off or in the ball park.
> Thank you so much!!![/QUOT
> 
> ...


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## Cardio403 (Jun 13, 2019)

Jim,  Thank you so much for your help.  The payor did reprocess with your suggestions. 
 Cardio403


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## Jim Pawloski (Jun 17, 2019)

Thanks for letting me know what happened!
Jim


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