# iliofemoral coded?



## Robbin109 (May 14, 2012)

Can someone check this. I thought this iliofemoral would not be coded as it looks like it's part of the closure, but then towarde the end he says" the iliofemoral aniogram shows no high-grade stenosis....thanks!  

TITLE OF PROCEDURE:  Left and right heart catheterization; left               
ventriculogram; selective coronary arteriogram, right and left;  selective    
coronary bypass angiogram x 3; left internal mammary artery angiogram         
selective injection; right iliofemoral angiogram selective injection.         

TECHNIQUE:  Following preparation of the right groin, the right femoral vein  
and the right femoral artery were entered.  A 6 French sheath was placed in   
the artery, an 8 French sheath placed in the vein.  A Swan-Ganz catheter was  
advanced through the right heart into the left pulmonary artery.  Right heart 
pressures were obtained.  Cardiac output was determined after _____ technique.

The catheter was removed.  A pigtail catheter was advanced across the aortic  
valve retrograde into the left ventricle.  Left ventriculography was performed
in the RAO projection.                                                        

This catheter was exchanged for a JL4 catheter.  Left coronary arteriography  
performed.  Catheter exchanged for JR4 catheter.  Right coronary arteriography
performed.  Catheter placed into the left subclavian and exchanged for an IMT 
catheter and left internal mammary artery angiography performed.  Catheter    
exchanged for a left bypass catheter and selective injection of an obtuse     
marginal and diagonal bypass graft was obtained.  The catheter was pulled back
into the sheath and right iliofemoral angiography performed, 2 projections.   
The vein sheath was removed and direct compression applied.  The arterial     
sheath was removed and an Angio-Seal device was applied.  There was no        
immediate complication.                                                       

FINDINGS:                                                                     
Hemodynamics:  The right atrial pressure was 9.  Right ventricular pressure of
34/9.  Pulmonary artery pressure of 34/13 with a mean pressure of 21.         
Pulmonary capillary wedge pressure was 12.  Cardiac output was 3.67, for an   
index of 2.21.                                                                

Left ventricular end-diastolic pressure was 10.  There was no systolic        
gradient across the aortic valve.                                             

ANGIOGRAPHY:  The Left ventricular regional wall motion is abnormal and the   
left ventricle is dilated.  There is posterobasal and diaphragmatic akinesis. 
The apex is dyskinetic in a localized area and the anterolateral wall is      
hypokinetic.  Left ventricular ejection fraction is approximately 20%.        

There is no significant mitral insufficiency.  The aortic root is not dilated 
and the aortic leaflets are trileaflet.                                       

The left main coronary artery is relatively small, without high-grade         
stenosis.  The proximal circumflex is completely occluded.  The left anterior 
descending is completely occluded after the takeoff of 2 small septal         
branches.  There is a small, about 1.5 mm in diameter, median ramus that is   
patent.                                                                       

The native right coronary artery is small and nondominant without high-grade  
stenosis.                                                                     

There is a vein graft which is in the typical position for a right coronary   
artery graft, but this connects to the posterior descending artery, which is  
connected to the continuation circumflex (left  dominant system).             

The left internal mammary artery is patent to the LAD, without high-grade     
stenosis.  There is a vein graft to a small-sized 2 mm obtuse marginal branch 
that has no high-grade stenosis.  This goes towards the posterolateral wall.  
There is also patent vein graft to a small diagonal branch without high-grade 
stenosis.  The iliofemoral angiogram shows no high-grade stenosis.            

IMPRESSION:                                                                   
1.  Ischemic cardiomyopathy with markedly reduced left ventricular ejection   
fraction.  Patient already has an implantable defibrillator.                  
2  Occlusion of the circumflex and left anterior descending artery with a     
patent but small nondominant right coronary artery.                           
3.  Patent left internal mammary artery graft to the left anterior descending 
artery after the total occlusion.                                             
4.  Patent vein graft to an obtuse marginal branch, the posterior descending  
artery, and to a diagonal.


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## Robbin109 (May 14, 2012)

*another one..anyone?*

here's another one...different problem; Selective iliac in this case? 

TITLE:  Left and right heart catheterization, thermodilution cardiac output,  
selective coronary angiography, right and left via selective injection, left  
ventriculography, very selective injection and distal aortobiiliac aortogram. 

TECHNIQUE:  Following preparation of the right groin, the right femoral vein  
was entered by percutaneous Seldinger technique.  An 8-French sheath placed   
and then the right femoral artery was entered by percutaneous Seldinger       
technique and a 6-French sheath inserted.  A Swan-Ganz catheter was advanced  
through the femoral vein into the right heart and right heart pressures were  
obtained.  Then, AL2 catheter was advanced into the ascending aorta over a    
J-wire.  The wire was exchanged for a Glidewire and after probing for about 4 
minutes, the aortic valve was crossed in a retrograde fashion.  The Amplatz   
catheter was then exchanged for a double-lumen pigtail catheter.  Left        
ventricular pressure and aortic pressure was obtained.  Cardiac output was    
determined by thermodilution technique.  Left ventriculography was performed  
in the RAO projection.  There is an pulled back of the pigtail catheter.  The 
Swan-Ganz catheter was then removed.  The pigtail catheter was exchanged for a
left 4 Judkins catheter and left coronary arteriography performed selectively.
 This catheter was then exchanged for a right 4 Judkins catheters, did not    
seat well and was exchanged for a Williams right catheter and selective right 
coronary angiography performed.  A pigtail catheter was reinserted and distal 
aorta and bilateral iliac angiography performed to see if the patient's       
aortoiliac anatomy might be suitable to accept equipment for percutaneous     
aortic valve replacement.  The venous catheter was removed and direct         
compression applied and the arterial catheter removed and direct compression  
applied.  There was no immediate complication.                                

FINDINGS:  Hemodynamics:  Left ventricular end-diastolic pressure was 25.     
There is no diastolic gradient across the mitral valve.                       

There was a 43 mm peak gradient across the aortic valve with a calculated     
aortic valve area of 1.03 cm2.  The cardiac output was normal with calculated 
index of 3.26.  Oxygen saturation was 100%, left ventricular end-diastolic    
pressure repeat was 21, pulmonary capillary wedge pressure was 32.  Pulmonary 
pressure 54/15.                                                               

Left ventriculography shows normal regional wall motion.  Left ventricular    
ejection fraction 65%.                                                        

Selective left coronary arteriography demonstrated heavy calcification of the 
vessel as well as heavy calcification of the mitral annulus.  The left main   
coronary has no high-grade stenosis.  The left circumflex is the dominant     
vessel and has no high-grade stenosis.  Left anterior descending gives off a  
large first diagonal, which has no high-grade stenosis.  The LAD itself has an
80% relatively long stenosis in the mid portion of the vessel, approximately  
10-12 mm in length and starting just after the terminal diagonal branch of the
LAD.                                                                          

The right coronary artery is nondominant and has no high-grade stenosis.  The 
distal aorta is heavily calcified as are the proximal iliac vessels.  There   
appears to be a possible aortobifemoral graft.  The patient thought that she  
had stents in the legs, but I cannot identify these on screening angiography. 
Further angiography was not performed due to concerns about the patient having
a single transplanted kidney and contrast concerns.                           

IMPRESSION:                                                                   
1.  Moderately severe aortic stenosis.                                        
2.  Single-vessel coronary artery disease.                                    
3.  Additional comorbidities including history of peripheral arterial disease,
diabetes, hypertension, poor performance status.


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## dpeoples (May 15, 2012)

Robbin109 said:


> Can someone check this. I thought this iliofemoral would not be coded as it looks like it's part of the closure, but then towarde the end he says" the iliofemoral aniogram shows no high-grade stenosis....thanks!
> 
> TITLE OF PROCEDURE:  Left and right heart catheterization; left
> ventriculogram; selective coronary arteriogram, right and left;  selective
> ...



IMO, this is evaluation of the closure site, and I would not bill for ililac angiography.

HTH


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## dpeoples (May 15, 2012)

Robbin109 said:


> here's another one...different problem; Selective iliac in this case?
> 
> TITLE:  Left and right heart catheterization, thermodilution cardiac output,
> selective coronary angiography, right and left via selective injection, left
> ...



IMO, this case has medical necessity for aortoiliac angiography. I would code 75630 but a good case can be made for 75716(G0275) instead.

HTH


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## Robbin109 (May 15, 2012)

Thanks Danny...do you have any thougths on the second case:

"very selective injection and distal aortobiiliac aortogram"

'A pigtail catheter was reinserted and distal 
aorta and bilateral iliac angiography performed to see if the patient's 
aortoiliac anatomy might be suitable to accept equipment for percutaneous 
aortic valve replacement. "

"There 
appears to be a possible aortobifemoral graft. "


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## Robbin109 (May 15, 2012)

Thanks again!!


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