margaret fahy
Guru
Opinion on this one. NOTE: Just because dr. has the angiographies in question broken out in separate paragraphs, etc., does not mean he performed them prior to intervention. I oftentimes have difficulties with his documentation.. Also note that two days prior, these Carotid angios were done, but there was a change in pt.'s condition which necessitated this intervention, thus rendering them codaable.
We are coding......36012, 76860,37248, 61624, 76894, 75898 (recommended by Dr. Z.), 76937, and do you feel the Carotid Angios should be coded as having been done prior to intervention, or included in 75898? There is a disagreement as to the coding of these. If they are to be part of 75898, how many 75898's do you see? Thanks so much for taking the time to look at this......Margie
PROCEDURE: The skin of the right groin was prepped and draped in
sterile fashion. After local anesthesia, a 21-gauge needle was
inserted into the right common femoral vein with ultrasound
guidance. Once blood return was obtained a, 0.018" mandril wire
was placed in the artery and advanced under fluoroscopic guidance
to the aorta. The needle was removed and a 4 F micropuncture
sheath was placed over the wire into the artery and utilized to
exchange for a 0.035" Bentson wire. Over this wire, a 6 French
sheath was advanced into the artery and connected to a continuous
infusion of heparinized saline. Through the sheath, a 6 French
Sophia catheter was advanced and used to select the left jugular………………..36012 & 75860
vein. Biplane DSA run was performed. After interventions, the…………………..AFTER INTERVENTIONS
catheter was then advanced to the left transverse and then right
transverse sinus. Biplane DSA was performed. At the conclusion of
the case, the catheter was then removed and manual compression
was applied until hemostasis was achieved. A sterile occlusive
dressing was placed over the site.
During the procedure, the right radial artery was also accessed…………………During the procedure
using ultrasound guidance. After local anesthesia, a 21-gauge
needle was inserted into the right radial artery with ultrasound
guidance. Once blood return was obtained a, 0.018" mandril wire
was placed in the artery and advanced under fluoroscopic guidance
to the aorta. The needle was removed and a 5 French sheath was
advanced into the artery and connected to a continuous infusion
of heparinized saline. Through the sheath, a 5 French sim1
catheter was advanced and used to select the right external and
internal carotid arteries. Biplane DSA run was performed.
Pulse oximetry in the right foot and right wrist remained normal
and stable throughout the procedure. No immediate complications
were experienced and the patient left the IR suite in stable
condition. Dr. was present for the entire procedure.
FINDINGS:
Ultrasound demonstrated an anechoic and pulsatile right common…………………..76937
femoral vein, suitable for arterial access.
Ultrasound demonstrated an anechoic and pulsatile right radial
artery, suitable for arterial access
RIGHT JUGULAR VEIN: Occlusion of the jugular vein at the bulb.
RIGHT COMMON, INTERNAL AND EXTERNAL CAROTID: Arteriovenous
fistula with feeders arising from the right MMA and right
occipital artery as well as the recurrent meningeal artery.
Otherwise unremarkable angiographic appearance of the right
supraclinoid internal carotid artery, right middle cerebral
artery, and right anterior cerebral artery.
RIGHT RADIAL ARTERY: Normal appearance of the right radial
artery. Suitable for arterial access.
INTERVENTION: Through the existing sheath in the left internal……………………………37248…..stent used during procedure but not left in place, right?
jugular vein, a combination of devices was used to recanalize the
occluded left jugular bulb/sigmoid sinus. This included
angioplasty x4 (see Epic for device type), direct aspiration with
a Sophia catheter, and deployment of a 6 x 40 mm Solitaire
stentretriever. Once recanalization of the sigmoid/jugular bulb
was complete, attention was then removed to the right sided dural………………..61624, 75894, 75898
arteriovenous fistula. The Sophia catheter was navigated from the
left jugular sheath into into the right transverse sinus venous
pouch and multiple coils were deployed until there was no
residual arteriovenous shunting. Intermittent right external
carotid artery arteriograms were performed to assess for residual
shunting. At the completion of the procedure, the venous
catheters were removed and a right common carotid artery
arteriogram demonstrated no residual arterial venous shunting
with normal intracranial arterial vasculature. The right vein of
Labbe was still patent and draining into the patent right
transverse sinus. The right sigmoid sinus and jugular bulb
remained occluded.
IMPRESSION:
Extensive left-sided sigmoid/jugular thrombosis with successful
recanalization.
Right-sided external carotid artery to transverse sinus dural
arteriovenous fistula with successful transvenous embolization as
above. No residual fistula at the completion of the procedure.
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We are coding......36012, 76860,37248, 61624, 76894, 75898 (recommended by Dr. Z.), 76937, and do you feel the Carotid Angios should be coded as having been done prior to intervention, or included in 75898? There is a disagreement as to the coding of these. If they are to be part of 75898, how many 75898's do you see? Thanks so much for taking the time to look at this......Margie
PROCEDURE: The skin of the right groin was prepped and draped in
sterile fashion. After local anesthesia, a 21-gauge needle was
inserted into the right common femoral vein with ultrasound
guidance. Once blood return was obtained a, 0.018" mandril wire
was placed in the artery and advanced under fluoroscopic guidance
to the aorta. The needle was removed and a 4 F micropuncture
sheath was placed over the wire into the artery and utilized to
exchange for a 0.035" Bentson wire. Over this wire, a 6 French
sheath was advanced into the artery and connected to a continuous
infusion of heparinized saline. Through the sheath, a 6 French
Sophia catheter was advanced and used to select the left jugular………………..36012 & 75860
vein. Biplane DSA run was performed. After interventions, the…………………..AFTER INTERVENTIONS
catheter was then advanced to the left transverse and then right
transverse sinus. Biplane DSA was performed. At the conclusion of
the case, the catheter was then removed and manual compression
was applied until hemostasis was achieved. A sterile occlusive
dressing was placed over the site.
During the procedure, the right radial artery was also accessed…………………During the procedure
using ultrasound guidance. After local anesthesia, a 21-gauge
needle was inserted into the right radial artery with ultrasound
guidance. Once blood return was obtained a, 0.018" mandril wire
was placed in the artery and advanced under fluoroscopic guidance
to the aorta. The needle was removed and a 5 French sheath was
advanced into the artery and connected to a continuous infusion
of heparinized saline. Through the sheath, a 5 French sim1
catheter was advanced and used to select the right external and
internal carotid arteries. Biplane DSA run was performed.
Pulse oximetry in the right foot and right wrist remained normal
and stable throughout the procedure. No immediate complications
were experienced and the patient left the IR suite in stable
condition. Dr. was present for the entire procedure.
FINDINGS:
Ultrasound demonstrated an anechoic and pulsatile right common…………………..76937
femoral vein, suitable for arterial access.
Ultrasound demonstrated an anechoic and pulsatile right radial
artery, suitable for arterial access
RIGHT JUGULAR VEIN: Occlusion of the jugular vein at the bulb.
RIGHT COMMON, INTERNAL AND EXTERNAL CAROTID: Arteriovenous
fistula with feeders arising from the right MMA and right
occipital artery as well as the recurrent meningeal artery.
Otherwise unremarkable angiographic appearance of the right
supraclinoid internal carotid artery, right middle cerebral
artery, and right anterior cerebral artery.
RIGHT RADIAL ARTERY: Normal appearance of the right radial
artery. Suitable for arterial access.
INTERVENTION: Through the existing sheath in the left internal……………………………37248…..stent used during procedure but not left in place, right?
jugular vein, a combination of devices was used to recanalize the
occluded left jugular bulb/sigmoid sinus. This included
angioplasty x4 (see Epic for device type), direct aspiration with
a Sophia catheter, and deployment of a 6 x 40 mm Solitaire
stentretriever. Once recanalization of the sigmoid/jugular bulb
was complete, attention was then removed to the right sided dural………………..61624, 75894, 75898
arteriovenous fistula. The Sophia catheter was navigated from the
left jugular sheath into into the right transverse sinus venous
pouch and multiple coils were deployed until there was no
residual arteriovenous shunting. Intermittent right external
carotid artery arteriograms were performed to assess for residual
shunting. At the completion of the procedure, the venous
catheters were removed and a right common carotid artery
arteriogram demonstrated no residual arterial venous shunting
with normal intracranial arterial vasculature. The right vein of
Labbe was still patent and draining into the patent right
transverse sinus. The right sigmoid sinus and jugular bulb
remained occluded.
IMPRESSION:
Extensive left-sided sigmoid/jugular thrombosis with successful
recanalization.
Right-sided external carotid artery to transverse sinus dural
arteriovenous fistula with successful transvenous embolization as
above. No residual fistula at the completion of the procedure.
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