# Common Carotid Stent Placement with Angioplasty



## imoore65 (Jan 13, 2015)

Good Afternoon,

Is the following report all bundled into 37218 or can we code for each selective cath placement/Radiology S+I in addition to stent/angioplasty? 

Procedure steps:
?         Percutaneous access right common femoral artery
?         Arch aortogram
?         Selective brachiocephalic arteriogram
?         Sub-selective common carotid arteriogram
?         Sub-selective right subclavian arteriogram
?         Percutaneous transluminal angioplasty with stenting of the right common carotid artery
?         Post stenting angioplasty.
?         Follow-up arteriogram.

Description: Using Seldinger technique, the* right common femoral artery is percutaneously accessed *followed by placement of a 5-French sheath. Over a guidewire, a 5-French pigtail catheter is passed into the *aortic arch followed by power injection of contrast for digital arteriogram.* Catheter was then exchanged for a 5-French KMP catheter, which was used to select the origin of the brachiocephalic artery. *The catheter was advanced into the brachiocephalic artery followed by power injection of contrast for a digital brachiocephalic arteriogram. The catheter is then further sub-selectively placed in the proximal right subclavian artery followed by hand injection of contrast for a digital arteriogram.* The images were than evaluated.

An arterio-venous fistula was seen arising off the base of the right common carotid artery extending over to the right internal jugular vein. The catheter was *sub-selectively placed in the origin of this fistula to demonstrate this fistulous connection with hand injection of contrast. The catheter was then re-directed into the right common carotid artery.* A 0.035 inch guidewire was passed distally. Over this, the catheter and sheath were exchanged for a 6-French sheath. Coaxially, a 6 x 22 mm *atrium covered stent was passed and positioned across the base of the right common carotid artery*. This was subsequently *deployed with balloon angioplasty*. Repeat balloon angioplasty was then performed using an 8 mm balloon to expand the stent tighter against the Bessel wall. The balloon catheter was then removed. The sheath was then exchanged for a long 90 cm Brite Tip sheath was positioned at the level of the brachiocephalic artery. Injection of contrast was then carried out showing unsuccessful occlusion of the arteriovenous fistula.

It was decided that the patient would be operatively treated at that point. The sheath was then removed and exchanged for a short 6-French sheath. This was sutured in place to the skin and a sterile dressing was applied. 

Thanks for all of your help,

Ingrid Moore, CPC, RCC


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## Amy Pritchett (Jan 14, 2015)

ranscatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation 
Notes:
(37218 includes all ipsilateral extracranial intrathoracic selective innominate and carotid catheterization, all diagnostic imaging for ipsilateral extracranial intrathoracic innominate and/or carotid artery stenting, and all related radiologic supervision and interpretation. Report 37218 when the ipsilateral extracranial intrathoracic carotid arteriogram (including imaging and selective catheterization) confirms the need for stenting. If stenting is not indicated, report the appropriate codes for selective catheterization and imaging) 

(Do not report 37218 in conjunction with 36222, 36223, 36224 for the treated carotid artery) 

(For open or percutaneous transcatheter placement of intravascular cervical carotid artery stent, see 37215, 37216) 

(For open or percutaneous transcatheter placement of extracranial vertebral artery stent, see 0075T, 0076T) 

(For transcatheter placement of intracranial stent, use 61635)

2015 Advice
The 2015 code update adds 37218 for placement of one or more stents in the common carotid artery or innominate artery using a catheter. The code applies whether the provider uses an open or percutaneous antegrade approach. Note that the code includes, but does not require, related angioplasty. Keep in mind that 37218 applies to antegrade approach, meaning going in the normal direction of flow. Be sure not to confuse it with the similar code for a retrograde approach, meaning against the normal direction of flow: 37217, Transcatheter placement of intravascular stents, intrathoracic common carotid artery or innominate artery by retrograde treatment, open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation.  Hope this helps you


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## imoore65 (Jan 14, 2015)

Thanks, that does help a lot. I was confused as the brachiocephalic, right subclavian and right common carotid were all in the same vascular family in this ipsilateral approach. Have a great day!


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