# carotid stenting w.innominate stenting



## mabar1571 (May 10, 2012)

I do primarily card.cath.coding, but sometimes our drs.branch out.  Here is the note on this pt--

TECHNIQUE
Under Lidocaine 1% local anesthesia a 6F sheath was placed in the 
right radial artery using the Seldinger technique and the patient was 
given verapamil 2.5mg x1 through the sheath (to decrease the risk of 
spasm).  The patient was then given an intrarterial heparin bolus of 
1000 U.  A 6F JR4 diagnostic catheter was advanced through the radial 
sheath into the aortic arch over a 0.035 J-wire and angiography of the 
proximal subclavian/ Innominate artery performed. Since flow was 
present in the carotid artery, a decision was made to attempt 
stenting. Under Lidocaine 1% local anesthesia a 7F introducer was 
placed in the right femoral artery using a modified Seldinger 
technique.  Via the JR4 catheter in the subclavian artery, a 0.014 
GrandSlam 300cm coronary wire was advanced into the aorta.  
Angiography revealed severe compromise  of the innominate artery with 
near ostial-proximal occlusion of the right common carotid artery, 
with associated decreased flow.  A 6F JR 4 guide catheter was then 
advanced through the 7F right femoral artery sheath into the aortic 
arch over a 0.035 J-wire.  The wire was removed after engaging the 
innomiate artery, and a 0.035 Glide wire was advanced into the right 
common carotid artery (A Wholey wire could not be negotiated into the 
CCA).  A 4F straight Glidecath was introduced over the Wholey wire, at 
which point the wire was removed and angiography of the right common 
carotid artery was performed verifying true intraluminal position . A 
heparin bolus of 5000 Units was given and subsequent boluses were 
administered to achieve and maintain an ACT >200 for the remainder of 
the procedure (a total of 12,000 units was given).  The Glidcath was 
removed and a Wholey wire placed in the ICA. An Absolute Pro 10.0 x 60 
x 135 was advanced to the right common carotid artery and the self-
expanding stent was deployed.  Subsequent angiography revealed 
improved carotid flow.  Attention was then turned to the innominate 
artery given the patient's known dissection from the aortic arch to 
the carotid.  An Express OTW 10.0 x 37 was advanced to the innominate 
artery and was deployed at 6atm.  A short gap was left between the 
right common carotid stent and the innominate artery stent for 
potential graft anastomosis during surgery.  Subsequent angiography of 
the innominate artery revealed good balloon expansion and flow, but it 
was noted that the distal common carotid artery (including the distal 
stent) was being compressed by an expanding false lumen.  
Consequently, the 0.035 Wholey wire was advanced into the internal 
carotid artery and an Absolute Pro 7.0 x 40 x 135 stent was advanced 
to the distal right common carotid artery (overlapping with the 
previously placed stent, extending into the bulb), and was deployed 
(self-explanding).  An EverCross 5mm x 30mm x 135cm was advanced to 
the stent overlap and was inflated up to 6atm.  Final angiography 
revealed 30% narrowing of the distal right common carotid artery from 
compression by the false lumen.  The flow was significantly improved 
and cerebral angiography ( single AP projection injection) revealed 
normal flow in the right anterior cerebral artery and the right middle 
cerebral artery.  Following the procedure, the right femoral sheath 
was sutured in place, to be removed once ACT <180.  The right radial 
sheath was removed and hemostasis was achieved with a radial (Tuomo) 
band.

ok, I know I can only bill the 37216 for the carotid stenting w/o embolic protection as that code includes the cath.and angiograms, but could I separately bill for the innominate stenting (37205) w.the cath.code (36215) and an aortic arch study (75650)?

thanks.


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## dpeoples (May 11, 2012)

mabar1571 said:


> I do primarily card.cath.coding, but sometimes our drs.branch out.  Here is the note on this pt--
> 
> TECHNIQUE
> Under Lidocaine 1% local anesthesia a 6F sheath was placed in the
> ...





Yes, you can, IMO, bill for the innominate stent. I would not code the catheter placement of the innominate since that is proximal portion of the same vessel included with 37216. As for the arch study, yes, that is separately billable but your carrier may require a modifier 
59.

HTH


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## mabar1571 (May 11, 2012)

thinking it over and reading the note again i believe you are right in not billing for the cath since it was on the way to the carotid and the cath.is included in 37216.  Though, I was speculating that maybe a 36200 could be billed w.the aortic arch study seeing that it was done through the radial and both stents (carotid and innominate) were done through a femoral approach.  Any thoughs anyone?


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## dpeoples (May 11, 2012)

mabar1571 said:


> thinking it over and reading the note again i believe you are right in not billing for the cath since it was on the way to the carotid and the cath.is included in 37216.  Though, I was speculating that maybe a 36200 could be billed w.the aortic arch study seeing that it was done through the radial and both stents (carotid and innominate) were done through a femoral approach.  Any thoughs anyone?



I had to take another look but yes, that is correct. Because they were performed through two different access points, it is appropriate to bill for cath placement in the aorta for arch aortography. Just be sure to append mofifier 59 to 36200.

HTH


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