Wiki Can I bill anything here?

amym

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Please help. Not sure if I can bill anything here.
SUMMARY:

-- CORONARY CIRCULATION:
-- The right brachial artery was cannulated and a 5 fr sheath was
advanced across the vessel. Following this, a cather was advanced and the
right sublcavian was noted to be severely stenotic. Case was aborted at
this time.

PROCEDURES PERFORMED:

-- Case Cancelled.

HEMODYNAMICS: Hemodynamic assessment demonstrates normal hemodynamics.

CORONARY VESSELS: The right brachial artery was cannulated and a 5 fr
sheath was advanced across the vessel. Following this, a cather was
advanced and the right sublcavian was noted to be severely stenotic. Case
was aborted at this time.

PROCEDURE: The risks and alternatives of the procedures and conscious
sedation were explained to the patient and informed consent was obtained.
The patient was brought to the cath lab and placed on the table. The
planned puncture sites were prepped and draped in the usual sterile
fashion.

-- Right radial artery access. The puncture site was infiltrated with
local anesthetic. The vessel was accessed using the modified Seldinger
technique, a wire was threaded into the vessel, and a catheter was
advanced over the wire into the vessel.

-- Case Cancelled..

COMPLICATIONS:
None occurred during the cath lab visit.
PROCEDURE COMPLETION: The patient tolerated the procedure well. TIMING:
Test started at 13:28. Test concluded at 14:08. RADIATION EXPOSURE:
Fluoroscopy time: 3 min.
HEMOSTASIS:
The sheath was removed. The site was compressed manually. Hemostasis was
successful.
MEDICATIONS GIVEN:
Nitroglycerin, 200 mcg, IA, at 13:39.
Heparin, 2500 units, IV, last dose at 13:39.
1% Lidocaine, 10 ml, subcutaneously, at 13:32.
CONTRAST GIVEN:
Omnipaque 5 ml.


STUDY DIAGRAM

HEMODYNAMIC TABLES

Pressures: Baseline
Pressures: - HR: 77
Pressures: - Rhythm:
Pressures: -- Aortic Pressure (S/D/M): 155/73/93

Outputs: Baseline
Outputs: -- CALCULATIONS: Age in years: 81.33
Outputs: -- CALCULATIONS: Body Surface Area: 1.73
Outputs: -- CALCULATIONS: Height in cm: 180.00
Outputs: -- CALCULATIONS: Sex: Female
Outputs: -- CALCULATIONS: Weight in kg: 57.30
 
I'm debating if you can bill the brachial cath placment only? Because MD states cath was advanced and the RT subclavian was found to be stenotic. I'm not sure if you can bill the subclavian cath placement because it would be an assumption that the cath made it that far? Can you query the physician and see if he/she did place the cath in the subclavian. Then I would bill for that and the 75710-26 as well.
 
You can bill for the cath placement with a 52, 73, or 74 modifier for reduced services since the surgeon did document that procedure the procedure was aborted as well as the reason.
 
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