smiller
Networker
Hello everyone - we need help with coding a peripheral case - we're trying to help a co-worker understand better how to code the lower extremity studies (particularly when the report says "I did not perform a runoff further down the right lower extremity because of the patient's renal insufficiency") - Here's a copy of the report:
Any help is appreciated.
PROCEDURES:
1. Right femoral arteriotomy.
2. Abdominal aortogram below the level of the renal arteries.
3. Selective angiography of the left common femoral artery with
runoff down the left lower extremity to the level of the left ankle.
4. Atherectomy to the left superficial femoral artery using a
TurboHawk LX-M device with a Spider 6.0 filter for distal embolic
protection.
5. Balloon angioplasty to the left superficial femoral artery.
6. Closure of the arterial puncture site using a Mynx closure device.
ENTRY SITE: Right femoral artery.
TOTAL CONTRAST ADMINISTERED: 70 mL of Visipaque contrast.
ESTIMATED BLOOD LOSS: Less than 5 cc.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the
patient. The patient was taken to the cardiac catheterization suite
and prepped and draped in the usual sterile fashion. 1% lidocaine was
used for local anesthesia and Versed and fentanyl were administered
intravenously for sedation. A modified Seldinger technique was used
to access the right femoral artery and a 5-French sheath was placed in
the vessel and secured in the usual fashion. A 5-French OmniFlush
catheter was advanced to the infrarenal abdominal aorta. An
infrarenal abdominal aortogram was performed. Following this, the
catheter was advanced to the left common femoral artery. Selective
angiography was performed of the left common femoral artery with
runoff down the left lower extremity to the level of the left ankle.
The decision was made to proceed with percutaneous intervention. The
patient was given intravenous heparin for anticoagulation. The
5-French short sheath and the 5-French OmniFlush catheter were
exchanged over a wire for a 7-French Terumo Destination sheath. The
tip of the Terumo Destination sheath was placed in the left common
femoral artery. The Glidewire Advantage wire was advanced down the
left superficial femoral artery, beyond the lesion of interest. A
NaviCross catheter was then advanced into the left popliteal artery.
A Spider 6.0 filter was then advanced to the left popliteal artery
through the NaviCross catheter. The Spider filter was deployed in the
distal portion of the left popliteal artery.
A TurboHawk LX-M device was then advanced to the left superficial
femoral artery. Atherectomy was performed in multiple different
planes. After multiple passes in multiple different planes, the
TurboHawk device was removed from the body over the wire. Following
this, balloon angioplasty was performed in the left superficial
femoral artery. Repeat angiography demonstrated minimal residual
stenosis and excellent flow going down the left superficial femoral
artery. There was markedly improved flow going to the left foot.
The NaviCross catheter was used to retrieve the Spider filter. The
7-French Terumo Destination sheath was exchanged over a wire for a
7-French short sheath. Position of the sheath in the right femoral
artery was confirmed with fluoroscopy. A Mynx closure device was used
to seal the arterial puncture site. Hemostasis was achieved and there
was no residual bleeding, oozing or hematoma.
COMPLICATIONS: None.
FINDINGS:
1. The infrarenal abdominal aorta is patent. There are minimal
irregularities in the vessel that are less than 10%.
2. Right lower extremity: The right common iliac artery is widely
patent with minimal irregularities that are less than 10%. The right
internal iliac artery and the right external iliac artery are widely
patent with mild irregularities that are less than 10%. The right
common femoral artery is widely patent with minimal irregularities
that are less than 10%. I did not perform a runoff further down the
right lower extremity because of the patient's renal insufficiency.
3. Left lower extremity: The left common iliac artery is widely
patent with minimal irregularities that are less 10%. The left
internal and external iliac arteries are both widely patent with
minimal irregularities that are less than 10%. The left common
femoral artery is widely patent with mild irregularities that are less
than 10%. The left profunda femoral artery is widely patent with mild
irregularities that are less than 20%. The left superficial femoral
artery has a severe 95% area of stenosis in the mid portion of the
vessel. This was treated with atherectomy and balloon angioplasty
with a decrease in percent stenosis from about 95% to 10%. The left
popliteal artery has minimal irregularities that are less 10%. The
left anterior tibial artery is diffusely diseased with maximal
stenosis of about 90%. There is diffuse disease at the level of the
left ankle and this will be treated conservatively with medical
therapy. The left tibioperoneal trunk is patent with mild
irregularities that are less than 30%. The left posterior tibial
artery and the left peroneal artery are both widely patent to the
level of the left ankle. There are mild irregularities in both these
vessels that are less than 30%. The patient has three-vessel runoff
to the level of the left ankle.
RECOMMENDATIONS:
1. Standard observation status post peripheral angiography and
percutaneous intervention.
2. Patient will be continued on aspirin and Plavix for peripheral
artery disease. The patient does not need to be continued on Plavix
for any specific amount of time because no stent was placed.
3. The patient will be hydrated status post peripheral angiography
and percutaneous intervention. Only 70 cc of contrast were used for
the procedure. The patient will be admitted to the hospital overnight
for observation. Nephrology will be consulted to assist in management
of the patient. The patient's renal function will be closely
monitored.
4. Continue wound care.
5. Continue to optimize the patient's volume status.
6. Continue medical therapy for the patient's known coronary artery
disease.
Thank you
Any help is appreciated.
PROCEDURES:
1. Right femoral arteriotomy.
2. Abdominal aortogram below the level of the renal arteries.
3. Selective angiography of the left common femoral artery with
runoff down the left lower extremity to the level of the left ankle.
4. Atherectomy to the left superficial femoral artery using a
TurboHawk LX-M device with a Spider 6.0 filter for distal embolic
protection.
5. Balloon angioplasty to the left superficial femoral artery.
6. Closure of the arterial puncture site using a Mynx closure device.
ENTRY SITE: Right femoral artery.
TOTAL CONTRAST ADMINISTERED: 70 mL of Visipaque contrast.
ESTIMATED BLOOD LOSS: Less than 5 cc.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the
patient. The patient was taken to the cardiac catheterization suite
and prepped and draped in the usual sterile fashion. 1% lidocaine was
used for local anesthesia and Versed and fentanyl were administered
intravenously for sedation. A modified Seldinger technique was used
to access the right femoral artery and a 5-French sheath was placed in
the vessel and secured in the usual fashion. A 5-French OmniFlush
catheter was advanced to the infrarenal abdominal aorta. An
infrarenal abdominal aortogram was performed. Following this, the
catheter was advanced to the left common femoral artery. Selective
angiography was performed of the left common femoral artery with
runoff down the left lower extremity to the level of the left ankle.
The decision was made to proceed with percutaneous intervention. The
patient was given intravenous heparin for anticoagulation. The
5-French short sheath and the 5-French OmniFlush catheter were
exchanged over a wire for a 7-French Terumo Destination sheath. The
tip of the Terumo Destination sheath was placed in the left common
femoral artery. The Glidewire Advantage wire was advanced down the
left superficial femoral artery, beyond the lesion of interest. A
NaviCross catheter was then advanced into the left popliteal artery.
A Spider 6.0 filter was then advanced to the left popliteal artery
through the NaviCross catheter. The Spider filter was deployed in the
distal portion of the left popliteal artery.
A TurboHawk LX-M device was then advanced to the left superficial
femoral artery. Atherectomy was performed in multiple different
planes. After multiple passes in multiple different planes, the
TurboHawk device was removed from the body over the wire. Following
this, balloon angioplasty was performed in the left superficial
femoral artery. Repeat angiography demonstrated minimal residual
stenosis and excellent flow going down the left superficial femoral
artery. There was markedly improved flow going to the left foot.
The NaviCross catheter was used to retrieve the Spider filter. The
7-French Terumo Destination sheath was exchanged over a wire for a
7-French short sheath. Position of the sheath in the right femoral
artery was confirmed with fluoroscopy. A Mynx closure device was used
to seal the arterial puncture site. Hemostasis was achieved and there
was no residual bleeding, oozing or hematoma.
COMPLICATIONS: None.
FINDINGS:
1. The infrarenal abdominal aorta is patent. There are minimal
irregularities in the vessel that are less than 10%.
2. Right lower extremity: The right common iliac artery is widely
patent with minimal irregularities that are less than 10%. The right
internal iliac artery and the right external iliac artery are widely
patent with mild irregularities that are less than 10%. The right
common femoral artery is widely patent with minimal irregularities
that are less than 10%. I did not perform a runoff further down the
right lower extremity because of the patient's renal insufficiency.
3. Left lower extremity: The left common iliac artery is widely
patent with minimal irregularities that are less 10%. The left
internal and external iliac arteries are both widely patent with
minimal irregularities that are less than 10%. The left common
femoral artery is widely patent with mild irregularities that are less
than 10%. The left profunda femoral artery is widely patent with mild
irregularities that are less than 20%. The left superficial femoral
artery has a severe 95% area of stenosis in the mid portion of the
vessel. This was treated with atherectomy and balloon angioplasty
with a decrease in percent stenosis from about 95% to 10%. The left
popliteal artery has minimal irregularities that are less 10%. The
left anterior tibial artery is diffusely diseased with maximal
stenosis of about 90%. There is diffuse disease at the level of the
left ankle and this will be treated conservatively with medical
therapy. The left tibioperoneal trunk is patent with mild
irregularities that are less than 30%. The left posterior tibial
artery and the left peroneal artery are both widely patent to the
level of the left ankle. There are mild irregularities in both these
vessels that are less than 30%. The patient has three-vessel runoff
to the level of the left ankle.
RECOMMENDATIONS:
1. Standard observation status post peripheral angiography and
percutaneous intervention.
2. Patient will be continued on aspirin and Plavix for peripheral
artery disease. The patient does not need to be continued on Plavix
for any specific amount of time because no stent was placed.
3. The patient will be hydrated status post peripheral angiography
and percutaneous intervention. Only 70 cc of contrast were used for
the procedure. The patient will be admitted to the hospital overnight
for observation. Nephrology will be consulted to assist in management
of the patient. The patient's renal function will be closely
monitored.
4. Continue wound care.
5. Continue to optimize the patient's volume status.
6. Continue medical therapy for the patient's known coronary artery
disease.
Thank you
