# carotid stent placement



## prabha

Can anyone please confirm me whether we can code the following report with 37216 alone or with 37216,36217,36218 & 75650-26?

Also let me know if I have missed any CPT's.

procedure performed: left carotid cervicocerebral angiogram and left internal carotid artery stent supported angioplasty with distal protection device; right femoral angiogram; Angioseal closure, right common femoral arteriotomy.
*
Indication of procedure: patient with left hemispheric stroke found to have moderate to high-grade stenosis of the left internal carotid artery and considered high risk for surgical endarterectomy. 
**
Vessels catheterized: Right common femoral artery, right external iliac artery, right common iliac artery, abdominal aorta, descending thoracic aorta, aortic arch, left common carotid artery.
*
Description of procedure: After informed consent was obtained the patient was brought to the angiography suite where she was placed on the table supine. Ongoing anesthesia and sedation was provided by the Department of anesthesiology. 

After identifying anatomical landmarks the right femoral artery was palpated and accessed using an 18-gauge single wall puncture needle. This was exchanged for a 4 French introducer sheath through which femoral angiography was performed focal stenosis was identified at the port near the point of catheter entry. The 4 French sheath was withdrawn and a 6 French Cook shuttle catheter was attempted to be placed however difficulty was encountered in doing this. The Cook shuttle catheter was then withdrawn and a 5 French dilator was placed following this another 6 French dilator was placed. The Cook shuttle catheter was still unable to be advanced. Therefore this was withdrawn and a 7 French introducer sheath was placed. Heparin 5000 units IV was administered. A 5 French Davis catheter was prepared and advanced over a 35 Glidewire into the aortic arch with the catheter was back bled and double flushed. Here it was connected to Visipaque contrast material via a power injector. All subsequent vessel selection was under fluoroscopy and final ultrasound images were obtained using digital subtraction angiography. Left common carotid artery was selected. Cervical cerebral angiography was performed and measurements were obtained. This demonstrated irregularity and stenosis as noted on prior imaging. The catheter was then placed in the external carotid artery an exchange length wire was placed in the ascending pharyngeal artery. The 5 French Davis catheter was withdrawn and this is exchanged for a 7 French MPA catheter. Additional doses of heparin were administered throughout the case to maintain a maximal ACT of approximately 312 seconds. Next a 5 French Angioguard filter device was advanced through the shuttle catheter under road mapping with direct visualization of the internal carotid artery when the distal and proximal markers of the Angioguard were found to be placed in the distal most segment of the internal carotid artery the outer sheath was removed allowing the filter device to open up. Next a 7 x 40 mm Precise Cordis stent was advanced over the wire. It was brought into the region of the stenosis of the internal carotid artery. Additional runs were obtained to confirm adequate placement of this stent device overlying the region of stenosis then the stent was deployed in standard fashion. Post stent upon the runs were obtained which still showed some residual stenosis.

 Next the 5 x 20 mm aviator balloon was again brought up to the region of stenosis and angioplasty was again performed to 10 atmosphere pressure. Subsequent runs showed good resolution of the stenosis. The balloon was removed. Intracranial angiography was performed to determine that there was no evidence of occlusion. Then the filter device was recaptured using the capture sheet. This was removed and a final postangioplasty cervical internal carotid artery runs and intracranial post internal carotid artery run in the AP and lateral positions was obtained. Then the catheter was removed. Final angiography was performed through the groin sheath. Then the introducer sheath was exchanged using the modified Seldinger technique for an 8 French Angio-Seal device which was deployed in standard fashion to achieve vessel hemostasis.
*
Interpretation:
Left common carotid artery: the left common carotid artery is seen to bifurcate into the internal external carotid artery. There is irregularity of the internal carotid origin in the region of the carotid bulb causing a stenosis of approximately 50-60%. The area of stenosis is irregular and appears to have ulcerated plaque. Intracranially the internal carotid artery is seen to give rise to the ophthalmic artery as well as a posterior to indicating artery prior to its bifurcation into the anterior and middle cerebral arteries. The posterior indicating artery is seen to continue as the posterior cerebral artery and is larger in caliber at this point where it continues as a PCA. There is intracranial atherosclerosis and areas of ectasia at the M1 M2 junction of the superior division. There is a stenosis of the proximal left pericallosal artery. There is also some intracranial atherosclerosis involving the ICA and left A1 junctions. Status post stent supported angioplasty the stenosis is resolved to a moderate degree stenosis with no residual stenosis. 
**
Summary:
1. successful stent supported angioplasty using distal protection device of the left internal carotid artery origin, preintervention there is approximately 50-60% stenosis with a very irregular ulcerated plaque of the left ICA origin by NASCET criteria; status post intervention this is reduced to nil.
*
2. Irregularity of the right common femoral artery and focal stenosis near the point of sheath insertion.
*
3. Angio-Seal closure right common femoral arteriotomy.


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## Jim Pawloski

prabha said:


> Can anyone please confirm me whether we can code the following report with 37216 alone or with 37216,36217,36218 & 75650-26?
> 
> Also let me know if I have missed any CPT's.
> 
> procedure performed: left carotid cervicocerebral angiogram and left internal carotid artery stent supported angioplasty with distal protection device; right femoral angiogram; Angioseal closure, right common femoral arteriotomy.
> *
> Indication of procedure: patient with left hemispheric stroke found to have moderate to high-grade stenosis of the left internal carotid artery and considered high risk for surgical endarterectomy.
> **
> Vessels catheterized: Right common femoral artery, right external iliac artery, right common iliac artery, abdominal aorta, descending thoracic aorta, aortic arch, left common carotid artery.
> *
> Description of procedure: After informed consent was obtained the patient was brought to the angiography suite where she was placed on the table supine. Ongoing anesthesia and sedation was provided by the Department of anesthesiology.
> 
> After identifying anatomical landmarks the right femoral artery was palpated and accessed using an 18-gauge single wall puncture needle. This was exchanged for a 4 French introducer sheath through which femoral angiography was performed focal stenosis was identified at the port near the point of catheter entry. The 4 French sheath was withdrawn and a 6 French Cook shuttle catheter was attempted to be placed however difficulty was encountered in doing this. The Cook shuttle catheter was then withdrawn and a 5 French dilator was placed following this another 6 French dilator was placed. The Cook shuttle catheter was still unable to be advanced. Therefore this was withdrawn and a 7 French introducer sheath was placed. Heparin 5000 units IV was administered. A 5 French Davis catheter was prepared and advanced over a 35 Glidewire into the aortic arch with the catheter was back bled and double flushed. Here it was connected to Visipaque contrast material via a power injector. All subsequent vessel selection was under fluoroscopy and final ultrasound images were obtained using digital subtraction angiography. Left common carotid artery was selected. Cervical cerebral angiography was performed and measurements were obtained. This demonstrated irregularity and stenosis as noted on prior imaging. The catheter was then placed in the external carotid artery an exchange length wire was placed in the ascending pharyngeal artery. The 5 French Davis catheter was withdrawn and this is exchanged for a 7 French MPA catheter. Additional doses of heparin were administered throughout the case to maintain a maximal ACT of approximately 312 seconds. Next a 5 French Angioguard filter device was advanced through the shuttle catheter under road mapping with direct visualization of the internal carotid artery when the distal and proximal markers of the Angioguard were found to be placed in the distal most segment of the internal carotid artery the outer sheath was removed allowing the filter device to open up. Next a 7 x 40 mm Precise Cordis stent was advanced over the wire. It was brought into the region of the stenosis of the internal carotid artery. Additional runs were obtained to confirm adequate placement of this stent device overlying the region of stenosis then the stent was deployed in standard fashion. Post stent upon the runs were obtained which still showed some residual stenosis.
> 
> Next the 5 x 20 mm aviator balloon was again brought up to the region of stenosis and angioplasty was again performed to 10 atmosphere pressure. Subsequent runs showed good resolution of the stenosis. The balloon was removed. Intracranial angiography was performed to determine that there was no evidence of occlusion. Then the filter device was recaptured using the capture sheet. This was removed and a final postangioplasty cervical internal carotid artery runs and intracranial post internal carotid artery run in the AP and lateral positions was obtained. Then the catheter was removed. Final angiography was performed through the groin sheath. Then the introducer sheath was exchanged using the modified Seldinger technique for an 8 French Angio-Seal device which was deployed in standard fashion to achieve vessel hemostasis.
> *
> Interpretation:
> Left common carotid artery: the left common carotid artery is seen to bifurcate into the internal external carotid artery. There is irregularity of the internal carotid origin in the region of the carotid bulb causing a stenosis of approximately 50-60%. The area of stenosis is irregular and appears to have ulcerated plaque. Intracranially the internal carotid artery is seen to give rise to the ophthalmic artery as well as a posterior to indicating artery prior to its bifurcation into the anterior and middle cerebral arteries. The posterior indicating artery is seen to continue as the posterior cerebral artery and is larger in caliber at this point where it continues as a PCA. There is intracranial atherosclerosis and areas of ectasia at the M1 M2 junction of the superior division. There is a stenosis of the proximal left pericallosal artery. There is also some intracranial atherosclerosis involving the ICA and left A1 junctions. Status post stent supported angioplasty the stenosis is resolved to a moderate degree stenosis with no residual stenosis.
> **
> Summary:
> 1. successful stent supported angioplasty using distal protection device of the left internal carotid artery origin, preintervention there is approximately 50-60% stenosis with a very irregular ulcerated plaque of the left ICA origin by NASCET criteria; status post intervention this is reduced to nil.
> *
> 2. Irregularity of the right common femoral artery and focal stenosis near the point of sheath insertion.
> *
> 3. Angio-Seal closure right common femoral arteriotomy.





You can only bill for the stent, since everything else is bundled into the stent charge.  So your only code is 37216.

HTH
Jim Pawloski, CIRCC


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## prabha

Thanks Jim..


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## donnajrichmond

*carotid stent*

The correct code is 37215, NOT 37216.  A distal embolic device was used: " Next a 5 French Angioguard filter device was advanced through the shuttle catheter under road mapping with direct visualization of the internal carotid artery when the distal and proximal markers of the Angioguard were found to be placed in the distal most segment of the internal carotid artery the outer sheath was removed allowing the filter device to open up."


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## Jim Pawloski

donnajrichmond said:


> The correct code is 37215, NOT 37216.  A distal embolic device was used: " Next a 5 French Angioguard filter device was advanced through the shuttle catheter under road mapping with direct visualization of the internal carotid artery when the distal and proximal markers of the Angioguard were found to be placed in the distal most segment of the internal carotid artery the outer sheath was removed allowing the filter device to open up."



Oops, your right!  I was going off Prabha's codes.  

Thanks,
Jim


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