# Cath Lab Procedure



## sowmya (Nov 10, 2009)

Can any one help me in coding this cath report. I thank you in advance for your time taken in reading this report and helping me out. 

Diagnosis:
1. Critical limb ischemia with ischemic left big toe.
2. Severe peripheral vascular disease documented by arterial Doppler of lower extremities.

Procedures Performed:
1.	Aortogram with runoff.
2. Unsuccessful attempt at crossing a total occlusion involving distal left superficial femoral artery.
3. Selective arteriography of left popliteal artery.
4. Selective arteriography of right popliteal with sheath placement in right external iliac.
5. Intravenous conscious sedation.

Procedure in detail:
The patient was brought to catheterization lab after informed consent was obtained. The patient was prepped and draped in sterile fashion. Following administration of local anesthesia in the right groin, a 5-French sheath was inserted in the right femoral artery using modified Seldinger technique. A 5-French pigtail was advanced to the junction of L1-L2. After initial abdominal aortogram was obtained, we withdrew the tip of pigtail o the level of bifurcation and obtained further images. Following detection of total occlusion of distal left superficial femoral artery, we crossed over to the left superficial femoral using the pigtail and stiff angled Glide wire. Following this, selective images of the left superficial femoral artery were obtained by advancing a Quick-Cross catheter. Subsequent to this, we withdrew the Quick-Cross across the Glide wire again. At this time, the 5-French sheath was removed as well as the Quick-Cross. We advanced a 6-Fench Ansel sheath to the level of the proximal superficial femoral artery. At this time, we reinserted the Glide wire across the stiff angled Glide and we made attempts to cross the distal superficial femoral artery, which was totally occluded with the help of a Glide wire and a Quick-Cross catheter. Attempts were unsuccessful. Multiple attempts were made. At one point, it was felt that the tip of the Quick-Cross was in the lumen of the popliteal artery. Images obtained from that point revealed excellent images of popliteal artery and trifurcation; however the Glide wire was repetitively entering a side branch. Also noted at this point of time was perforation of one of the side branches with extravastion of the dye. At this point of time, a j-wire was brought in and the tip of the J-wire would not unfurl, confirming the presence of a dissection. Subsequent images did reveal a feeling of possible perforation. Final images did reveal a small passage across the popliteal above the bifurcation. I was of the opinion that further attempts at trying to cross the area in question would only propagate the dissection without getting into the true lumen. In view of this, we terminated attempts at revascularization at this point. Selective images of the right below-knee vasculature were completed via injection through the right-sided sheath. ( By withdrawal of the 6-French Ansel sheath tip to the right external iliac.) Towards the end, I withdrew the Ansel sheath completely over a guide wire and inserted a 6-French short sheath. ACT was noted to be 270; hence, we did not remove the sheath. The patient did have considerable pain and was somewhat uncooperative throughout the procedure, making the procedure somewhat difficult. A single complication of possible vessel perforation with extravasation f the above-mentioned possible perforation and absence of extravasation.

Findings:
1.	Right renal artery is a diffusely diseased vessel that demonstrates total occlusion in the distal portion.
2.	 Left renal artery is a diffusely diseased vessel that demonstrates total occlusion in the distal portion.
3.	 Abdominal aorta demonstrates mild atherosclerosis.
4. Left common iliac demonstrates mild atherosclerosis.
5. Left internal iliac demonstrates moderate atherosclerosis.
6. Moderate atherosclerosis of 50% is noted in the proximal left external iliac.
7. A long occlusion is noted in the distal left superficial femoral artery of 10 cm in length.
8. Left common femoral demonstrates mild atherosclerosis.
9. The left popliteal demonstrates good flow with no significant disease.
10. Left anterior tibial demonstrates severe proximal disease.
11. Left tibioperoneal trunk is normal.
12. Left posterior tibial demonstrates severe disease.
13. Left peroneal demonstrates moderate disease.
14. One vessel runoff is noted into the left foot via the anterior tibial.
15. The right common iliac does not demonstrate significant disease.
16. Mild disease noted in the right internal iliac.
17. Right external iliac demonstrates mild atherosclerosis.
18. Right superficial femoral artery demonstrates moderate atherosclerosis in the proximal portion. Focal critical stenosis as well as diffuse disease is noted at the junction of mid distal superficial femoral artery.
19. Right posterior tibial demonstrates severe diffuse disease.
20. Right peroneal demonstrates mild diffuse disease.
21. Right anterior tibial demonstrates moderate disease. One-vessel runoff is noted to the right foot via right anterior tibial.

Final Impression:

1.	Total occlusion of left superficial femoral artery with unsuccessful attempt at revascularization.
2.	 Severe disease involving the junction of the right mid to distal superficial femoral artery.
3.	 One-vessel runoff to the left foot.
4.	 One-vessel runoff to the right foot.

Plan:
In view of critical limb ischemia with the left big toe being blue, we will request surgical revascularization with a possible femoral-popliteal bypass. I discussed the case with cardiothoracic surgeon.

I coded this report as follows:
36200
75630-26
36245-lt.53
36246 rt.
36140 lt.
75716-26

Thank you,
skk


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## wwsteves (Nov 10, 2009)

It sounds to me like you have a bunch of extra codes in there. You don't code the needle introduction if you move beyond that. The same is true of cath placement in the aorta. Therefore, you would code the placement in the left SFA (36247-LT). The aortogram was done in multiple locations of the aorta, so that would be 75625-26. Finally, arteriograms were done to see bilateral lower extremities, so that is 75716-26.

So, all that together is:
36247-LT
75625-26
75716-26


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## sowmya (Nov 10, 2009)

Thank you
skk


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## sowmya (Nov 10, 2009)

wwsteves said:


> It sounds to me like you have a bunch of extra codes in there. You don't code the needle introduction if you move beyond that. The same is true of cath placement in the aorta. Therefore, you would code the placement in the left SFA (36247-LT). The aortogram was done in multiple locations of the aorta, so that would be 75625-26. Finally, arteriograms were done to see bilateral lower extremities, so that is 75716-26.
> 
> So, all that together is:
> 36247-LT
> ...



Thank you
skk


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