# need help with carotid coding



## bhargavi (Jun 28, 2018)

Indications 

Occlusion and stenosis of left carotid artery [I65.22 (ICD-10-CM)]
Atherosclerotic heart disease of native coronary artery without angina pectoris [I25.10 (ICD-10-CM)]
Swelling of limb [M79.89 (ICD-10-CM)]
Conclusion 

81-year-old male with symptomatic left sided high risk carotid stenosis referred for diagnostic carotid angiogram.  Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 5 French sheath was inserted in the right femoral artery.  Arch angiogram was performed with a pigtail.  A 5 French v TK catheter was used to perform the selective carotid angiogram finding:
1: Type I bovine aortic arch
2: Left common carotid artery is very tortuous.  There is severe more than 90% stenosis of the distal common carotid artery into the proximal left carotid bulb.  Cerebral angiogram showed poor flow into the anterior cerebral artery.
*
Impression: Severe stenosis in the distal left common carotid artery into the proximal left internal carotid artery as mentioned above
*
Plan: We will discussed with the patient medical management versus carotid stenting.  Patient was deemed high risk for carotid endarterectomy by vascular surgery consultation.
thank you in advance
I am thinking 36222 ?


----------



## jtuominen (Jun 28, 2018)

This is both a study of the cervical portion of the carotid artery and a study of the intracranial portion of the carotid artery from what appears to be the catheter at the level of the left common carotid. I'd go with 36223, defined as:

Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed

In this definition, when they discuss angiography of the intracranial carotid circulation--this is also known as views of "head"
the extracranial carotid portion in the definition here is referring to the "neck" views, or the portion of the carotid artery outside of the skull. (not to be confused with external carotid artery, see 36227 for that)


If this is the full note in its entirety, I would coach the provider to make sure to always add the following items:

* be specific about the vessel "selectively" catheterized. State whether the vessel is the subclavian, the left common carotid, or the left internal carotid, because specific catheter location makes a difference in your code choices. 

* state what type of views were taken, rather than leaving it up to remembering to do so via the findings section of the report. This could be easily satisfied by just writing that head and neck views were performed of the carotid artery, then following that up with supporting information in the findings portion of the note.

Here is a way to create a statement for the technique portion of the note that satisfies both of the above:

"I selectively engaged the left common carotid artery and performed carotid angiogram with head and neck views".


Here is what I am using in this report to arrive at 36223:

Indications 

Occlusion and stenosis of left carotid artery [I65.22 (ICD-10-CM)]
Atherosclerotic heart disease of native coronary artery without angina pectoris [I25.10 (ICD-10-CM)]
Swelling of limb [M79.89 (ICD-10-CM)]
Conclusion 

81-year-old male with symptomatic left sided high risk carotid stenosis referred for diagnostic carotid angiogram. Procedure, risks, benefits, alternative options were explained. Risks including bleeding, infection, cerebrovascular accident, myocardial infarction, death, and arrhythmia were all explained patient was agreeable. He was brought into the cardiac cath lab where Both groins were prepped and draped in the usual fashion. 2% lidocaine was used to anesthesize the skin. Using modified Seldinger technique, a 5 French sheath was inserted in the right femoral artery. Arch angiogram was performed with a pigtail. A 5 French v TK catheter was used to perform the *selective carotid angiogram *
_(While I know by reviewing findings that the vessel selected was the Left common carotid, your provider should specifically state this as a "selective left common carotid angiogram")_finding:
1: Type I bovine aortic arch

2: *Left common carotid artery is very tortuous. There is severe more than 90% stenosis of the distal common carotid artery into the proximal left carotid bulb.* _(this portion of the findings tells me he performed neck views of the carotid artery)_*Cerebral angiogram showed poor flow into the anterior cerebral artery.* _(this portion tells me he reviewed the intracranial or head portion of the circulation/artery)_

*
Impression: Severe stenosis in the distal left common carotid artery into the proximal left internal carotid artery as mentioned above
*
Plan: We will discussed with the patient medical management versus carotid stenting. Patient was deemed high risk for carotid endarterectomy by vascular surgery consultation.
thank you in advance


----------

