Cardiology Coding Alert

When billing vascular procedures, coders need to be able to visualize the route the cardiologist took in the cardiovascular system, so clarity should be a top priority when describing these procedures in operative reports.

You need a clear picture when you code for vascular, says Rebecca Sanzone, CPC, assistant billing manager with Mid-Atlantic Cardiology, a 45-member cardiology practice in Baltimore. You need to be able to close your eyes and see where the cardiologist started, where they ended, and any bumps in the road. If you cant visualize what they did, you cant code it.

In the following op note, the cardiologist carefully and clearly describes a series of vascular procedures, including diagnostic angiography (pictures of the blood vessels) as well as interventional procedures to correct the circulatory function.

Operative Report

Procedures: Bilateral renal angiography, left subclavian angiography, angioplasty of the left subclavian artery, angioplasty of the left vertebral artery.

Conclusions: There is no evidence of renal artery stenosis bilaterally. There is 90 percent left subclavian artery stenosis and a 90 percent vertebral artery stenosis. The 90 percent stenoses of the left subclavian and vertebral arteries were successfully dilated, leaving behind good flow and a 40 percent gradual stenosis in the subclavian with brisk distal flow.

Protocol: After informed consent, the patient was brought to the cath lab in the fasting state. She has a history of recent uncontrolled hypertension in spite of medication. She also has a history of angioplasty in the left subclavian artery. She has been having symptoms of pain in the left arm as well as occasional dizzy spells. Non-invasive studies revealed subclavian steal consistent with subclavian stenosis.

Right femoral artery was cannulated with SF sheath. A right Judkins catheter was used to cannulate the renal arteries. Selective angiography was performed of the left and right renal arteries. There was no gradient at the ostium of the renal arteries.

The right Judkins catheter was then advanced to the aortic arch and the left subclavian artery cannulated. Digital angiography was performed in multiple projections to obtain an overview of the left subclavian artery stenosis.

After reviewing the angiograms, preparations were made for angioplasty. The 5F sheath was removed and replaced with a 6F sheath. We advanced a Terumo wire across the lesion without too much difficulty and placed it in the distal axillary artery. We then took an 8F ... sheath in place of the earlier sheath and positioned the tip of the sheath into the left subclavian artery.

An 8-mm-by-4-cm Meditech balloon was prepped and advanced over the Terumo wire. There was no significant difficulty crossing the lesion. The lesion in the left subclavian was dilated to two atmospheres. It seemed that the balloon was [...]