amym
Guest
Indication: Severe bilateral claudication, left greater than right.
Ankle brachial index was less than 0.5. The patient has a prior
history of stenting to the right superficial femoral artery.
Protocol: The patient brought to the endovascular laboratory after
written informed consent was taken. Right groin is prepped and
draped in usual fashion. Xylocaine was infiltrated. A 5-French
sheath was placed. A 5-French OmniFlush catheter was advanced to
the level of L1. Imaging was obtained of the aorta and subsequently
catheter pulled back above the bifurcation and bolus chases
performed using 80 mL of contrast. Total contrast used was 100 mL.
No complications occurred. The sheath was removed with manual
compression at the end.
Findings:
1. The visualized portions of the aorta are normal.
2. Bilateral renal artery show only mild disease.
3. Common iliac, external iliac, and internal iliac arteries
showing mild disease bilaterally.
4. Right superficial femoral artery demonstrates presence of a
stent beginning in the middle third and lower third of the
vessel. There are three separate stents and all three of them
are occluded with reconstitution of the vessel at the level of
the popliteal artery and subsequent circulation below the knee
demonstrates good flow with only mild disease with all three
vessels being patent. Good three vessel runoff is noted into
the right foot.
5. Left circulation revealed superficial femoral artery showing
mild disease up to 20% plaque and then subsequently popliteal
arteries without any significant disease.
6. Left infrapopliteal circulation shows severe disease. Left
anterior tibial artery has 100% stenosis with presence of
collateral with a short occlusion reconstituting and supplying
the foot. The peroneal artery has 99% stenosis and the left
posterior tibial artery is totally occluded. There is presence
of three vessel runoff into the foot.
Impression:
1. High-grade stenosis bilaterally with intrastent restenosis and
total occlusion of the right superficial femoral artery.
2. Total occlusion of all three vessels with two vessel runoff in
the left foot.
Plan: Based on these findings, recommend that left anterior tibial
artery can be revascularized with atherectomy and balloon approach
and staged process. The patient will be scheduled in two weeks.
Does this report constitute billing 3620, 75716-26, 75625-26?
Ankle brachial index was less than 0.5. The patient has a prior
history of stenting to the right superficial femoral artery.
Protocol: The patient brought to the endovascular laboratory after
written informed consent was taken. Right groin is prepped and
draped in usual fashion. Xylocaine was infiltrated. A 5-French
sheath was placed. A 5-French OmniFlush catheter was advanced to
the level of L1. Imaging was obtained of the aorta and subsequently
catheter pulled back above the bifurcation and bolus chases
performed using 80 mL of contrast. Total contrast used was 100 mL.
No complications occurred. The sheath was removed with manual
compression at the end.
Findings:
1. The visualized portions of the aorta are normal.
2. Bilateral renal artery show only mild disease.
3. Common iliac, external iliac, and internal iliac arteries
showing mild disease bilaterally.
4. Right superficial femoral artery demonstrates presence of a
stent beginning in the middle third and lower third of the
vessel. There are three separate stents and all three of them
are occluded with reconstitution of the vessel at the level of
the popliteal artery and subsequent circulation below the knee
demonstrates good flow with only mild disease with all three
vessels being patent. Good three vessel runoff is noted into
the right foot.
5. Left circulation revealed superficial femoral artery showing
mild disease up to 20% plaque and then subsequently popliteal
arteries without any significant disease.
6. Left infrapopliteal circulation shows severe disease. Left
anterior tibial artery has 100% stenosis with presence of
collateral with a short occlusion reconstituting and supplying
the foot. The peroneal artery has 99% stenosis and the left
posterior tibial artery is totally occluded. There is presence
of three vessel runoff into the foot.
Impression:
1. High-grade stenosis bilaterally with intrastent restenosis and
total occlusion of the right superficial femoral artery.
2. Total occlusion of all three vessels with two vessel runoff in
the left foot.
Plan: Based on these findings, recommend that left anterior tibial
artery can be revascularized with atherectomy and balloon approach
and staged process. The patient will be scheduled in two weeks.
Does this report constitute billing 3620, 75716-26, 75625-26?