# Peripheral study/stenting...



## sslater (Jun 29, 2011)

*Peripheral study/stenting...NEED HELP*

Ok, this one is a new one for me.  i don't think i've ever had all of these in one procedure.  Just wanting to make sure I haven't missed anything.. so far i have:
37224
37221
71710-26
75650-26
36217-59
75625-26

Any help is very much appreciated!! 

PROCEDURES:  Aortic Root Angiography, Selective Right
Brachiocephalic Angiography, Selective Common Carotid
Angiography, Selective Left Vertebral Angiography. Selective
Abdominal Aortogram at the level of the renal arteries, Abdominal
Aortogram at the level of the Iliac Bifurcation, Selective Right
Common Iliac angiogram.

Angioplasty of the right common femoral, and Stenting of the
ostium of the right common iliac.

INDICATIONS: Claudication with ABI of .6 on the right.

History of brachiocephalic stenting in 2005, recent Doppler
revealing subclavian steal on the right and CTA revealing
significant stenosis of the right branchiocephalic stents.

No right femoral pulse could be felt.  We did feel the ridge,
which felt to be the artery and were able to cannulate the right
femoral even though no pulse could be felt.  We had to use a
glide wire to advance to the distal abdominal aorta. This was
achieved.  Angiograms subsequently of the abdominal aorta
revealed the abdominal aorta to be patent at the level of the
renal arteries.  There was a 30% or so left renal artery
stenosis. The right renal appeared okay but it was somewhat
obscured by the mesenteric artery. Below the renal arteries the
abdominal aorta had about a 30-40% area of narrowing. It was
focal and had about a 10mm gradient across this area.  The distal
aorta was patent and the left common iliac widely patent. The
right common iliac had a severe stenosis.  There appeared to be a
70% stenosis at the origin of the right common iliac and there
was a 40mm gradient across this lesion.  The external iliac had
no flow and the common femoral filled via internal iliac
collaterals to the profunda and SFA. The external iliac and the
common femoral were totally occluded with no flow on the right.


ACCESS: Access through the left femoral was also achieved.

A 6 French 55 Rabbe sheath placed.  Using crossover technique the
sheath was placed in the proximal iliac on the right.  Angiograms
were obtained and the lesion is again identified. The total
occlusion of the external iliac and common femoral was crossed.
The distal common femoral was difficult to cross but this was
finally achieved with the wire placed into the SFA.  A 4.0 X
150mm balloon was then utilized. Balloon was inflated up to 10
bars and finally to 14 bars, which is about a 4.4 size. The total
external iliac and common femoral stenosis was opened with
excellent results with 0% residual and excellent flow and return
of the pedal pulses.

The ostium of the right internal iliac did dissect with placement
with the crossover technique. This was at the side of the lesion.
This was subsequently stented with a 7 x 18 balloon expandible
bare metal stent.  There was 0% residual, excellent flow and
resolution of the dissection with the placement of the ostial
iliac stent on the right.  Post stent placement excellent results
were obtained with 0% residual and excellent flow.  No compromise
of the left iliac detected.

AORTIC ROOT ANGIOGRAPHY: Reveals total occlusion of the
branchiocephalic on the right with delayed collateral filling
from the subclavian, the subclavian via the basilar artery.  The
left common carotid and the left subclavian appeared normal.

SELECTIVE RIGHT BRACHIOCEPHALIC ANGIOGRAM: Reveals the proximal
ostial branchiocephalic stent to be totally occluded. There is no
filling of the brachiocephalic, carotid or subclavian noted by
antegrade flow.

LEFT COMMON CAROTID ANGIOGRAM: This reveals the common carotid to
be widely patent with no stenosis.  There is minimal stenosis or
irregularity at the origin  of the internal carotid. There is
excellent filling of the anterior middle cerebrals from the left
carotid.

LEFT VERTEBRAL ANGIOGRAPHY: This reveals the left vertebral to be
very large, widely patent and via the basilar artery. Retrograde
flow down the right vertebral filling the right subclavian with
retrograde flow back to the brachiocephalic and also filling the
right carotid. The basilar artery also supplies both posterior
cerebral arteries. There is again collateral flow from the
vertebral on the left to the right subclavian via the right
vertebral that supplies the right subclavian, also the right
carotid and the right carotid supplies the anterior middle
cerbral normally on the right by this collateral flow.

CONCLUSION:
  1. Total occlusion of the right brachiocephalic with total
     occlusion of previously placed right brachiocephalic stents
     (placed 2005).
  2. Collateral filling of the right common carotid and the right
     subclavian via subclavian steal mechanism via widely patent
     left vertebral basilar system.
  3. Left common carotid, internal carotid widely patent with
     minimal disease as described at the internal carotid origin.


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## dpeoples (Jun 30, 2011)

sslater said:


> Ok, this one is a new one for me.  i don't think i've ever had all of these in one procedure.  Just wanting to make sure I haven't missed anything.. so far i have:
> 37224
> 37221
> 71710-26
> ...



I have:
37221 R iliac stent
37224 R fem angioplasty
36215-59 R Brachiocephalic
36215-59 L com carotid
36216 L Vert
75650 Arch aorta
75658 Brachial
75625 Abd aorta
75676 L com carotid
75685 L Vert

HTH


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## sslater (Jun 30, 2011)

Thank you!!  I went back and redone it but i was still missing a couple!!  This one definitely overwhelmed me!! 

Thanks again!!


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## ksschroeder (Jul 27, 2011)

Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?

I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.  

What are your thoughts?


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## theresa.dix@tennova.com (Jul 28, 2011)

kcassidy said:


> Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?
> 
> I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.
> 
> What are your thoughts?



Here are my thoughts.

I see all the documentation for the peripheral PTA/Stent codes. Where is the cath placement documentation for the 36215,16? I dont see where it says the cath was placed in any of these vessels. I see the results only. I didn't think the word Selective was enough to use the cath placement codes. Even though the physician probably did place the cath's the docuementation doesn't prove it. For the abdominal angiogram at the level of the renals 75630 I believe is the code because it looks to me it was one shot at the level of the renals and the interpretation is of the renals,aorta and all the way down to the iliacs. What are your thoughts on this?

Am I not seeing this whole report?


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## dpeoples (Jul 29, 2011)

kcassidy said:


> Wouldn't 75710 be more appropriate for the brachiocephalic angiography instead of 75658 in this case?
> 
> I am thinking that since the access site is the femoral artery the brachiocephalic angiography would be done from an antegrade position and not retrograde, so would not fit the code description of 75658.
> 
> What are your thoughts?




hmmm...you're right, I had over looked the word "retrograde". Still, the angiography is not of the upper extremity (75710) so it doesn't meet that definition either. So, if I am to err on the side of caution, I would stick with 75658. The other choice is not to code that portion of the procedure. I will try to find some liturature on this, stay tuned...

ok, I don't have good information but I have read enough to admit I wrong. The industry standard seems to support 75710 for a brachiocephalic injection and angiography.  Please ignore my suggestion of 75658, that is reserved for a retrograde brachial angiography (36120/75658).


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## dpeoples (Jul 29, 2011)

theresa.dix@ethc.com said:


> Here are my thoughts.
> 
> I see all the documentation for the peripheral PTA/Stent codes. Where is the cath placement documentation for the 36215,16? I dont see where it says the cath was placed in any of these vessels. I see the results only. I didn't think the word Selective was enough to use the cath placement codes. Even though the physician probably did place the cath's the docuementation doesn't prove it. For the abdominal angiogram at the level of the renals 75630 I believe is the code because it looks to me it was one shot at the level of the renals and the interpretation is of the renals,aorta and all the way down to the iliacs. What are your thoughts on this?
> 
> Am I not seeing this whole report?



I would also prefer better documentation of catheter movement/placement. However, I am relying on the word "selective" to mean these vessels were "selected" in my coding choices.


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