Wiki need help for cath placement for facility coding

[bhargavi]

INDICATION FOR THE PROCEDURE
1. Renovascular hypertension.
2. Renovascular disease.
3. Renal artery stenosis.

PROCEDURE
The procedure, risks, benefits and alternative options were explained. Risks
including bleeding, infection, distal embolization and vessel disruption and
most importantly dye induced nephropathy were all explained. Patient was
agreeable. She was brought into the cath lab where conscious sedation was
performed using Versed and fentanyl. Both groins were prepped and draped in
the usual fashion. Then 2% lidocaine was used to anesthetize the skin. Using
modified Seldinger technique, a 6-French sheath was inserted in the right
femoral artery with a micropuncture kit. A 6-French Press guiding catheter was
used to perform the diagnostic angiogram and the intervention.

FINDINGS
Severe 99% stenosis in the origin of the left renal artery.

Using an ATW marker wire I was able to cross the severe stenosis into the
distal vessel. The origin of the left renal artery was dilated with a 4 x 15
mm balloon followed by the insertion of a 5 x 15 mm Express SD renal stent with
excellent result and no residual stenosis.

IMPRESSION
1. There is 99% stenosis in the left renal artery in a patient with a known
occlusion of the right renal artery. This vessel was successfully treated with
a 5 x 15 mm balloon. After balloon angioplasty alone was not sufficient due to
resistance of the lesion.
2. Total of only 25 ml of contrast were used.

i am thinking of 37236 since i am billing for facility
or should i include 36251?

 

[deeva456]

Hello.

You can only bill for the stent placement. The physician did not state which kidney or renal artery the catheter was placed, was it left or right? It is implied that imaging was done but cannot bill on something that is implied or assumed.

Hope this has been of help to you.

Dolores