antoniamay
Networker
New to this and do not know where to begin! I am very confused on modifiers and how to best code these so any help would be greatly appreciated. 
Procedure: IR cerebral angiogram and left brachial angiogram for suspected vasculitis and prior history of left brachial thrombosis with thrombectomy and surgical reconstruction of the artery.
Indication: Left arm and forearm tingling with suspected cerebral arteritis.
Procedure:
Left brachial, forearm and hand angiogram
Right common femoral angiogram
Right common carotid and cerebral angiogram
Right internal carotid and cerebral angiogram
Right external carotid angiogram
Left common carotid and cerebral angiogram
Left internal carotid and cerebral angiogram
Left external carotid angiogram
Left vertebral angiogram
Access: The patient was brought to the radiography room and placed on the angiographic table. Both groins and right wrist were prepped and draped in the usual sterile fashion. After a hard stop confirming the patient and the procedure, the skin over the right radial was anesthetized. Using US guidance, a 21 G 3-inch needle was introduced into the right common femoral artery. A 0.014 microwire was inserted into the artery and a 6 F 11 cm sheath was threaded over it and made to rest into the common femoral artery and secured to the right groin.
Right common and cerebral angiogram: Using a angled glide catheter loaded over a 0.035 glidewire, the setup was advanced under fluoroscopy into the brachiocephalic and finally into the right common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right CCA: Smooth and unremarkable.
Right ECA: Smooth and unremarkable lumen. All major branches were identified.
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right internal carotid and cerebral angiogram: Using road-mapping technique, the cervical right ICA was selectively catheterized and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right external carotid angiogram: Using road-mapping technique, the cervical right ECA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP and lateral views and showed all major branches of the artery including superior thyroid, lingual, facial, ascending pharyngeal, occipital, superior temporal and posterior auricular arteries. The internal maxillary artery and its sub-branches were also seen. No beading/vasculitis, dural AV fistulae or other lesions were identified.
The catheter was withdrawn into the brachiocephalic artery.
Left common and cerebral angiogram: The angled glide catheter was advanced under fluoroscopy into the left common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left CCA: Smooth and unremarkable.
Left ECA: Smooth and unremarkable lumen. All major branches were identified.
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Minimal atherosclerosis seen in the petrocavernous segment.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush. The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the left CCA.
Left internal carotid and cerebral angiogram: Using road-mapping technique, the cervical left ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left external carotid angiogram: Using road-mapping technique, the cervical left ECA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP and lateral views and showed all major branches of the artery including superior thyroid, lingual, facial, ascending pharyngeal, occipital, superior temporal and posterior auricular arteries. The internal maxillary artery and its sub-branches were also seen. No beading/vasculitis, dural AV fistulae or other lesions were identified.
The catheter was withdrawn into the aortic arch.
Left vertebral angiogram: The angled glide catheter was manipulated into the left subclavian and then into the vertebral artery. Angiographic runs done in the AP, lateral and oblique projections showed:
Vertebral: Slight tortuosity of the V1 and normal V2 and V3 segments. The V4 segment appears normal and gives rise to a posterior inferior cerebellar artery which supplies the inferior portions of the posterior cerebellar lobes. It continues as a normal appearing basilar artery.
Basilar: The basilar artery appears unremarkable. Normal appearing anterior inferior cerebellar arteries are seen arising from its proximal 1/3 segment. Perforating pontine branches appear normal. The distal basilar artery is seen giving off normal appearing superior cerebellar arteries bilaterally. The terminal basilar is seen to end in normal appearing right and left posterior cerebral arteries, which run along a normal course supplying the ipsilateral occipital lobes.
The catheter was withdrawn into the left subclavian artery.
Left brachial, forearm and hand angiogram: The angle glide catheter was manipulated into the brachial artery above the level of surgical clips. Angiographic runs done in the AP view showed flow in the brachial artery with occlusion of the mid humeral level. Collateral flow was seen around the mid humerus filling the left intro she was artery. Sluggish flow was seen in the medial aspect of the distal forearm, consistent with left ulnar arterial flow. No flow was seen in the palmar arch or radial artery. No venous flow was seen.
The catheter was withdrawn into the aortic arch.
At this stage, all wires and catheters were removed from the body of the patient.
Closure: Right common femoral angiogram done through the 6F groin sheath showed adequate arteriotomy above its bifurcation into superficial femoral and profunda femoris arteries. A 6F Angioseal device was deployed after withdrawing the sheath over a J wire. Adequate hemostasis was achieved.
Complications: None. A brief neurological exam done at the end of the procedure showed normal vision, speech, right motor and sensory function.
Impression:
6 vessel cerebral angiogram appears unremarkable. No cerebral aneurysm, AVM/AVF, vasculitis, tumor blushes or other vascular pathology is seen.
Left brachial angiogram shows occlusion of the brachial artery in its mid humeral segment. Minimal flow is seen in the left forearm in the interosseous and ulnar arteries. No flow is seen in the palmar arch, radial artery or digital arteries.
These are the codes I am thinking I should start with but don't know exactly if I am right or how to go forward with modifiers and such
36215 - LT
36224 - 50
36227 - 50
36226 - 50
76937
Procedure: IR cerebral angiogram and left brachial angiogram for suspected vasculitis and prior history of left brachial thrombosis with thrombectomy and surgical reconstruction of the artery.
Indication: Left arm and forearm tingling with suspected cerebral arteritis.
Procedure:
Left brachial, forearm and hand angiogram
Right common femoral angiogram
Right common carotid and cerebral angiogram
Right internal carotid and cerebral angiogram
Right external carotid angiogram
Left common carotid and cerebral angiogram
Left internal carotid and cerebral angiogram
Left external carotid angiogram
Left vertebral angiogram
Access: The patient was brought to the radiography room and placed on the angiographic table. Both groins and right wrist were prepped and draped in the usual sterile fashion. After a hard stop confirming the patient and the procedure, the skin over the right radial was anesthetized. Using US guidance, a 21 G 3-inch needle was introduced into the right common femoral artery. A 0.014 microwire was inserted into the artery and a 6 F 11 cm sheath was threaded over it and made to rest into the common femoral artery and secured to the right groin.
Right common and cerebral angiogram: Using a angled glide catheter loaded over a 0.035 glidewire, the setup was advanced under fluoroscopy into the brachiocephalic and finally into the right common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right CCA: Smooth and unremarkable.
Right ECA: Smooth and unremarkable lumen. All major branches were identified.
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right internal carotid and cerebral angiogram: Using road-mapping technique, the cervical right ICA was selectively catheterized and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Right ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Right external carotid angiogram: Using road-mapping technique, the cervical right ECA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP and lateral views and showed all major branches of the artery including superior thyroid, lingual, facial, ascending pharyngeal, occipital, superior temporal and posterior auricular arteries. The internal maxillary artery and its sub-branches were also seen. No beading/vasculitis, dural AV fistulae or other lesions were identified.
The catheter was withdrawn into the brachiocephalic artery.
Left common and cerebral angiogram: The angled glide catheter was advanced under fluoroscopy into the left common carotid artery. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left CCA: Smooth and unremarkable.
Left ECA: Smooth and unremarkable lumen. All major branches were identified.
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Minimal atherosclerosis seen in the petrocavernous segment.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush. The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the left CCA.
Left internal carotid and cerebral angiogram: Using road-mapping technique, the cervical left ICA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP, lateral and oblique views and showed:
Left ICA: Smooth and unremarkable lumen. Cervical segment and bulb appear normal. Petrocavernous segment is normal.
Intracranial vasculature: Normal supraclinoid ICA bifurcates into normal appearing anterior and middle cerebral arteries. An Ophthalmic artery is seen traversing anteriorly, ending in a retinal blush.The secondary and tertiary branches of both cerebral arteries are unremarkable.
Tissue & venous phases: Unremarkable appearance.
No beading vasculitis, aneurysm, significant flow limiting stenoses, tumor blushes or other vascular lesions seen.
The catheter was withdrawn into the CCA.
Left external carotid angiogram: Using road-mapping technique, the cervical left ECA was selectively catheterized, and the wire was removed. Angiographic runs done from here in the AP and lateral views and showed all major branches of the artery including superior thyroid, lingual, facial, ascending pharyngeal, occipital, superior temporal and posterior auricular arteries. The internal maxillary artery and its sub-branches were also seen. No beading/vasculitis, dural AV fistulae or other lesions were identified.
The catheter was withdrawn into the aortic arch.
Left vertebral angiogram: The angled glide catheter was manipulated into the left subclavian and then into the vertebral artery. Angiographic runs done in the AP, lateral and oblique projections showed:
Vertebral: Slight tortuosity of the V1 and normal V2 and V3 segments. The V4 segment appears normal and gives rise to a posterior inferior cerebellar artery which supplies the inferior portions of the posterior cerebellar lobes. It continues as a normal appearing basilar artery.
Basilar: The basilar artery appears unremarkable. Normal appearing anterior inferior cerebellar arteries are seen arising from its proximal 1/3 segment. Perforating pontine branches appear normal. The distal basilar artery is seen giving off normal appearing superior cerebellar arteries bilaterally. The terminal basilar is seen to end in normal appearing right and left posterior cerebral arteries, which run along a normal course supplying the ipsilateral occipital lobes.
The catheter was withdrawn into the left subclavian artery.
Left brachial, forearm and hand angiogram: The angle glide catheter was manipulated into the brachial artery above the level of surgical clips. Angiographic runs done in the AP view showed flow in the brachial artery with occlusion of the mid humeral level. Collateral flow was seen around the mid humerus filling the left intro she was artery. Sluggish flow was seen in the medial aspect of the distal forearm, consistent with left ulnar arterial flow. No flow was seen in the palmar arch or radial artery. No venous flow was seen.
The catheter was withdrawn into the aortic arch.
At this stage, all wires and catheters were removed from the body of the patient.
Closure: Right common femoral angiogram done through the 6F groin sheath showed adequate arteriotomy above its bifurcation into superficial femoral and profunda femoris arteries. A 6F Angioseal device was deployed after withdrawing the sheath over a J wire. Adequate hemostasis was achieved.
Complications: None. A brief neurological exam done at the end of the procedure showed normal vision, speech, right motor and sensory function.
Impression:
6 vessel cerebral angiogram appears unremarkable. No cerebral aneurysm, AVM/AVF, vasculitis, tumor blushes or other vascular pathology is seen.
Left brachial angiogram shows occlusion of the brachial artery in its mid humeral segment. Minimal flow is seen in the left forearm in the interosseous and ulnar arteries. No flow is seen in the palmar arch, radial artery or digital arteries.
These are the codes I am thinking I should start with but don't know exactly if I am right or how to go forward with modifiers and such
36215 - LT
36224 - 50
36227 - 50
36226 - 50
76937