Rita Bartholomew
Guru
Need help with IR codes here. I got 76937, 36251, 37205, 75960 and 75710. I'm being told to remove 76937, 36251 & 75710 and add 36245, 36247, 75625 and 75716. Where am I going wrong in my thinking?
PREOPERATIVE DIAGNOSES:
1. Atherosclerosis with nonhealing ulcer, left foot.
2. Chronic renal insufficiency.
POSTOPERATIVE DIAGNOSES:
1. Atherosclerosis with nonhealing ulcer, left foot.
2. Chronic renal insufficiency.
NAME OF PROCEDURE:
1. Angiogram of the left lower extremity.
2. Angiogram of the abdominal aorta and left renal artery.
3. Left renal artery stent placement.
SURGEON: Xxxx Xxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
ACCESS: A 6-French sheath, left renal artery.
CLINICAL HISTORY: This 61-year-old woman with diabetes mellitus and end-stage renal disease now has a nonhealing ulcer at the left fourth toe amputation site, comes for revascularization. After personal communication with her nephrologist and her baseline creatinine of 3.9, we have decided that she is so close to needing hemodialysis that we will plan that this will be the ultimate event which results in her needing dialysis and give her intravenous contrast, understanding that there will be contrast-induced nephropathy.
The patient indicates that she understands the risks and benefits of this procedure and agreed to proceed. On the table, when I discussed her severe left renal artery stenosis, she agree to left renal artery stent placement in an attempt to avoid hemodialysis.
OPERATIVE FINDINGS:
1. The abdominal aorta was patent. There were multiple right renal arteries, all of which were stenotic. Approximately 3 renal arteries were noted. All of these were small and had stenotic origins. On the left side, a solitary left renal artery was present and the nephrogram on the left was better than that on the right. The left renal artery stenosis was approximately 98% of the origin and 90% throughout a 1 cm length. The artery then became more patent distally.
2. The right and left common iliac arteries were patent. The distal left common iliac artery had a 50% stenosis. The right renal artery had significant calcification but no obvious stenosis. The left external iliac artery and right external iliac artery were patent. On the left side, the common femoral artery had significant atherosclerotic occlusive disease. This gave rise to a totally occluded superficial femoral artery and a diseased-appearing profunda femoris artery. The superficial femoral artery was totally occluded until the behind the knee popliteal artery, which then reconstituted by unnamed collaterals.
3. The popliteal artery was patent throughout its length but had a 50% stenosis below the knee. The below the knee popliteal artery then became more patent with a stenotic-appearing common tibioperoneal trunk. The anterior tibial artery was patent for approximately 4 cm and then became totally occluded. The common tibioperoneal trunk then gave rise to a reasonably robust-appearing peroneal artery. This gave flow to the foot via collaterals. The dorsal pedal artery did reconstitute on the dorsal foot, however, proximally it appeared to be diseased at approximately 2 mm and distally it was at approximately 3 mm. The posterior tibial artery was heavily diseased and gave rise to a very diseased-appearing plantar artery.
4. The left lower extremity was considered to be inoperable or operable with very poor durability, given an endovascular procedure and open surgery was planned. I then proceeded with left renal artery stent placement. The left renal artery was selectively catheterized and successfully stented with a Boston Scientific stainless steel stent measuring 6 mm x 18 mm. Widely patent flow was then noted in the left kidney.
PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in a dorsal recumbent position. After excellent moderate sedation, the skin of the groin areas was prepared and draped in a standard sterile fashion. The patient had a large panniculus and access was difficult. The right common femoral artery pulse was not palpable. Ultrasound guidance was then used. Using color flow duplex ultrasound guidance I first called a time-out for correct patient and procedural identification per Mercy Hospital protocol. Then, under local anesthesia and ultrasound guidance, I accessed the right common femoral artery in the retrograde direction. A 0.018-inch guidewire advanced easily. Over the 0.018-inch guidewire I advanced the 5-French sheath into the common femoral artery. Then 3000 units of unfractionated heparin was then administered IV. Next, through the sheath, I advanced an 0.035-inch guidewire into the abdominal aorta. The Omni Flush catheter was then advanced into the abdominal aorta and fashioned at the L2 vertebral body position. An AP angiogram of the abdominal aorta was obtained. Severe left and right renal artery stenoses were identified. Multiple renal arteries were noted on the right, where as a severely diseased single artery was noted on the left.
The right renal arteries were considered to be too small to intervene upon.
I then had a conversation with the patient regarding her renal artery stenosis and her nearly end-stage renal disease and she agreed to proceed with left renal artery stent placement if needed. Next, I pulled the catheter down to the aortic bifurcation where a single AP image of the iliofemoral and pelvic runoff was obtained. I then selectively catheterized the left common femoral artery from the right side. Serologically, the left lower extremity then proceeded to the level of the ankle. The findings are noted above. Next, I pulled the catheter back to the abdominal aorta and placed a 0.035-inch guidewire into the abdominal aorta. A total of 70 mg/kg of unfractionated heparin was administered IV. Next an Ansel-2 sheath was advanced into the abdominal aorta. A Mickelson catheter was advanced into the abdominal aorta. Using the Mickelson catheter in conjunction with the Ansel-2 sheath, I selectively catheterized the left renal artery. A 0.014-inch guidewire was advanced. Next, I was able to perform balloon angioplasty of the left renal artery. The 3 mm balloon was used. Next, after a period of dilatation, I advanced the sheath to the ostium of the left renal artery and a 4 mm x 20 mm balloon was used. Next, I advanced the sheath tip to the ostium of the left renal artery and a stent measuring 6 mm x 18 mm was then passed into the left renal artery beyond the area of stenosis. The back end of the stent was positioned into the abdominal aorta. Multiple images were obtained with breath-hold to confirm positioning and the sheath was then backed away from the end of the balloon. The balloon was then inflated, inflating the stent. Full effacement of the balloon was noted. A completion angiogram was then performed demonstrating wide patency of the stent.
I accepted tissue result. The right lower extremity was imaged and common femoral artery was patent and the superficial femoral and profunda femoris arteries, while diseased, were both patent. The proximal right superficial femoral artery had an 80% stenosis.
I then used a Mynx closure device to close the puncture site in the right groin area. There were no complications. Dry sterile was applied. Ms. Xxxxxx tolerated the procedure well. Sponge and needle counts following the case were correct x2. Contrast used and fluoroscopy time as noted in the nurse's notes.
PREOPERATIVE DIAGNOSES:
1. Atherosclerosis with nonhealing ulcer, left foot.
2. Chronic renal insufficiency.
POSTOPERATIVE DIAGNOSES:
1. Atherosclerosis with nonhealing ulcer, left foot.
2. Chronic renal insufficiency.
NAME OF PROCEDURE:
1. Angiogram of the left lower extremity.
2. Angiogram of the abdominal aorta and left renal artery.
3. Left renal artery stent placement.
SURGEON: Xxxx Xxxx, M.D.
ANESTHESIA: Local with moderate sedation.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
ACCESS: A 6-French sheath, left renal artery.
CLINICAL HISTORY: This 61-year-old woman with diabetes mellitus and end-stage renal disease now has a nonhealing ulcer at the left fourth toe amputation site, comes for revascularization. After personal communication with her nephrologist and her baseline creatinine of 3.9, we have decided that she is so close to needing hemodialysis that we will plan that this will be the ultimate event which results in her needing dialysis and give her intravenous contrast, understanding that there will be contrast-induced nephropathy.
The patient indicates that she understands the risks and benefits of this procedure and agreed to proceed. On the table, when I discussed her severe left renal artery stenosis, she agree to left renal artery stent placement in an attempt to avoid hemodialysis.
OPERATIVE FINDINGS:
1. The abdominal aorta was patent. There were multiple right renal arteries, all of which were stenotic. Approximately 3 renal arteries were noted. All of these were small and had stenotic origins. On the left side, a solitary left renal artery was present and the nephrogram on the left was better than that on the right. The left renal artery stenosis was approximately 98% of the origin and 90% throughout a 1 cm length. The artery then became more patent distally.
2. The right and left common iliac arteries were patent. The distal left common iliac artery had a 50% stenosis. The right renal artery had significant calcification but no obvious stenosis. The left external iliac artery and right external iliac artery were patent. On the left side, the common femoral artery had significant atherosclerotic occlusive disease. This gave rise to a totally occluded superficial femoral artery and a diseased-appearing profunda femoris artery. The superficial femoral artery was totally occluded until the behind the knee popliteal artery, which then reconstituted by unnamed collaterals.
3. The popliteal artery was patent throughout its length but had a 50% stenosis below the knee. The below the knee popliteal artery then became more patent with a stenotic-appearing common tibioperoneal trunk. The anterior tibial artery was patent for approximately 4 cm and then became totally occluded. The common tibioperoneal trunk then gave rise to a reasonably robust-appearing peroneal artery. This gave flow to the foot via collaterals. The dorsal pedal artery did reconstitute on the dorsal foot, however, proximally it appeared to be diseased at approximately 2 mm and distally it was at approximately 3 mm. The posterior tibial artery was heavily diseased and gave rise to a very diseased-appearing plantar artery.
4. The left lower extremity was considered to be inoperable or operable with very poor durability, given an endovascular procedure and open surgery was planned. I then proceeded with left renal artery stent placement. The left renal artery was selectively catheterized and successfully stented with a Boston Scientific stainless steel stent measuring 6 mm x 18 mm. Widely patent flow was then noted in the left kidney.
PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in a dorsal recumbent position. After excellent moderate sedation, the skin of the groin areas was prepared and draped in a standard sterile fashion. The patient had a large panniculus and access was difficult. The right common femoral artery pulse was not palpable. Ultrasound guidance was then used. Using color flow duplex ultrasound guidance I first called a time-out for correct patient and procedural identification per Mercy Hospital protocol. Then, under local anesthesia and ultrasound guidance, I accessed the right common femoral artery in the retrograde direction. A 0.018-inch guidewire advanced easily. Over the 0.018-inch guidewire I advanced the 5-French sheath into the common femoral artery. Then 3000 units of unfractionated heparin was then administered IV. Next, through the sheath, I advanced an 0.035-inch guidewire into the abdominal aorta. The Omni Flush catheter was then advanced into the abdominal aorta and fashioned at the L2 vertebral body position. An AP angiogram of the abdominal aorta was obtained. Severe left and right renal artery stenoses were identified. Multiple renal arteries were noted on the right, where as a severely diseased single artery was noted on the left.
The right renal arteries were considered to be too small to intervene upon.
I then had a conversation with the patient regarding her renal artery stenosis and her nearly end-stage renal disease and she agreed to proceed with left renal artery stent placement if needed. Next, I pulled the catheter down to the aortic bifurcation where a single AP image of the iliofemoral and pelvic runoff was obtained. I then selectively catheterized the left common femoral artery from the right side. Serologically, the left lower extremity then proceeded to the level of the ankle. The findings are noted above. Next, I pulled the catheter back to the abdominal aorta and placed a 0.035-inch guidewire into the abdominal aorta. A total of 70 mg/kg of unfractionated heparin was administered IV. Next an Ansel-2 sheath was advanced into the abdominal aorta. A Mickelson catheter was advanced into the abdominal aorta. Using the Mickelson catheter in conjunction with the Ansel-2 sheath, I selectively catheterized the left renal artery. A 0.014-inch guidewire was advanced. Next, I was able to perform balloon angioplasty of the left renal artery. The 3 mm balloon was used. Next, after a period of dilatation, I advanced the sheath to the ostium of the left renal artery and a 4 mm x 20 mm balloon was used. Next, I advanced the sheath tip to the ostium of the left renal artery and a stent measuring 6 mm x 18 mm was then passed into the left renal artery beyond the area of stenosis. The back end of the stent was positioned into the abdominal aorta. Multiple images were obtained with breath-hold to confirm positioning and the sheath was then backed away from the end of the balloon. The balloon was then inflated, inflating the stent. Full effacement of the balloon was noted. A completion angiogram was then performed demonstrating wide patency of the stent.
I accepted tissue result. The right lower extremity was imaged and common femoral artery was patent and the superficial femoral and profunda femoris arteries, while diseased, were both patent. The proximal right superficial femoral artery had an 80% stenosis.
I then used a Mynx closure device to close the puncture site in the right groin area. There were no complications. Dry sterile was applied. Ms. Xxxxxx tolerated the procedure well. Sponge and needle counts following the case were correct x2. Contrast used and fluoroscopy time as noted in the nurse's notes.