Tonyj
True Blue
I'm new to coding NS and CV and I'm scratching my head with the code selection for the OP note below.
We coded it as;
36224-50
36228-LT
61630
61650
61651
I'm getting stuck in edits due to 36224,36228, 61630 being inclusive to 61650 & 61651.
I believe I can code as such according to the OP note. Please review and advise.
Thanks in advance.
PREOPERATIVE DIAGNOSIS: *SYMPTOMATIC VASOSPASM
*
POSTOPERATIVE DIAGNOSIS: *SYMPTOMATIC VASOSPASM: MODERATE FOCAL LEFT
M1 MIDDLE SEGMENT AND MODERATE RIGHT DISTAL ICA AND PROXIMAL M1
*
OPERATION: FEMORAL CEREBRAL ANGIOGRAM WITH INTRA-ARTERIAL VERAPAMIL
INJECTION AND ANGIOPLASTY
*
ANESTHESIA: General anesthesia
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *LESS THAN 50 CC
*
INDICATIONS: XXXXXXXX is a 54 years year old Female who is day 4
of a HH3, mF1 subarachnoid hemorrhage, secondary to a ruptured left
ophthalmic artery aneurysm, that has been successfully coiled. Her
course has been complicated by severe vasospasm for which she
underwent angioplasty of left M1 with IA verapamil injection on day 2
and verapamil injection on day 3. Her neurological exam is
significant for lethargy and left sided weakness and her MRI was
performed and reveals extensive areas of infarction in the left MCA
territory and smaller areas in the right MCA territory.
*
PROCEDURE: * *Following explanation of the benefits, risks and
alternatives for the procedure, consent was obtained from the *
family. *The risks including but not limited to stroke, intracranial
hemorrhage, vascular injury to the cervical or femoral vessels and
groin hematoma were discussed with the family. *The patient was
brought to the Angiographic Suite and cardiopulmonary monitoring was
placed. *Pateint was placed under general anesthesia. *A time-out was
performed. *Her previously inserted 6-Fr short long arrow sheath was
sterilized and accessed and was continued to be maintained on
heparinized flush. *
*
Using coaxial technique, a 5-Fr Envoy catheter was advanced into the
descending aorta, back-bled, and flushed in the usual fashion. *Using
coaxial technique, the catheter was advanced into the aortic arch,
and with the aid of the roadmapping, digital fluoroscopy, and careful
guidewire manipulation, the right common and internal carotid and the
left common and internal carotid arteries were selectively
catheterized. *Upon each successive selective catheterization,
digital subtraction angiography using the appropriate rate and volume
of contrast in multiple projections was performed.
*
INTERVETNION
Based on the findings of the angiograms (detailed below), the
decision was made to treat with IA Verapamil injection. Upon
catheterization of each vessel, a baseline diagnostic angiogram was
obtained. Verapamil was slowly injected in 20 mg increments at a rate
of 1 mg/minute with vigilant BP monitoring; maintaining it at the
pre-specified range. Vasopressor medications were used whenever
necessary. After each 20 mg injection, a repeat angiogram of the
vessel was obtained.
*
50 mg of Verapamil were injected in the right ICA.
There was remarkable improvement in vessel caliber and good perfusion
in the capillary phase in all the vessels treated, but persistent
spasm in the distal right ICA and proximal M1. The decision was made
to perform angioplasty on those segments.
*
A 3 x 10 compliant Transform balloon-catheter was advanced over a
Synchro 14 micro guidewire. The 5-Fr Envoy was then advanced into the
petrous ICA. Using roadmapping, digital fluoroscopy and careful micro
guidewire manipulation, the 3x10 transform balloon was used to
perform angioplasty of the distal internal carotid artery and the M1
segment of the middle cerebral artery. Repeat angiographic runs
(detailed below) revealed significant improvement in vessel caliber.
The balloon-catheter was removed.
*
10 additional mgs of verapamil were injected in the right ICA. Follow
up angiographic run demonstrated excellent vessel caliber and
improvement in perfusion of the right ICA circulation.
*
The catheter was withdrawn and used to select the left internal
carotid artery. An exchange length Amplatz wire was used to exchange
the catheter and the sheath for a NeuronMax and a DDC catheter, for
better support in preparation for angioplasty. Injection run
demonstrated improvement in vessel caliber compared to the initial
runs of the case. The decision was made to inject verapamil instead.
*
Verapamil was slowly injected in 20 mg increments at a rate of 1
mg/minute with vigilant BP monitoring; maintaining it at the
pre-specified range. Vasopressor medications were used whenever
necessary. After each 20 mg injection, a repeat angiogram of the
vessel was obtained. A total of 60 mg of IA verapamil were injected
with remarkable improvement in vessel caliber and distal perfusion.
*
The catheter was removed. *Angiographic run of the right internal
iliac and common/superficial femoral arteries was performed. *The
femoral sheath was removed; and hemostasis achieved with a Perclose
vascular closure device.. The patient tolerated the procedure well
and was transported from the angio suite in unchanged neurological
status, without groin hematoma, and with good distal lower extremity
pulses. *The patient was transferred neuroscience intensive care unit.
*
FINDINGS:
RIGHT COMMON CAROTID ARTERY
The internal and external carotid artery origins are normal in
contour and calibre with no evidence of significant plaque formation
or stenosis. *
*
RIGHT INTERNAL CAROTID ARTERY
BASELINE
There is evidence of significant vasospasm in the distal supraclinoid
ICA and the MCA throughout its course. There is no aneurysm, vascular
malformation or evidence of arteriovenous shunting. *No significant
intracranial atheromatous disease is present. The capillary phase
demonstrated perfusion delay especially in the watershed territories.
No abnormality is present in the major cortical and deep draining
veins and dural venous sinuses which are present with normal flow and
calibre.
*
AFTER INJECTION OF 20 MG OF VERAPAMIL
There is significant improvement in vessel caliber with improvement
in the capillary phase.
*
AFTER INJECTION OF 40 MG OF VERAPAMIL
There is improvement in vessel caliber with further improvement in
the capillary phase, but a persistent area of hypoperfusion in the
ACA/MCA watershed territory.
*
AFTER INJECTION OF 50 MG OF VERAPAMIL
There is improvement in vessel caliber with further improvement in
the capillary phase, but a persistent area of hypoperfusion in the
ACA/MCA watershed territory.
*
AFTER ANGIOPLASTY OF DISTAL ICA AND PROXIMAL MCA
There is remarkable improvement in vessel caliber with further
improvement in the capillary phase.
*
AFTER INJECTION OF 60 MG OF VERAPAMIL
There is excellent restoration of proximal vessel caliber with
further improvement in the capillary phase.
*
LEFT COMMON CAROTID ARTERY
The internal and external carotid artery origins are normal in
contour and calibre with no evidence of significant plaque formation
or stenosis.
*
REPEAT INJECTION AFTER INTERVENTION
No interval change in vessel caliber or supply. No evidence of
dissection or other untoward events.
*
LEFT INTERNAL CAROTID ARTERY
BASELINE
There is evidence of moderate focal vasospasm in the mid-M1 segment
of the MCA, in the area that has not been previously angioplastied.
Additionally, the vessel calibers in distal cortical branches are
exhibiting diffuse mild to moderate spasm. The previously coiled
ophthalmic artery aneurysm is completely occluded. There is no
vascular malformation or evidence of arteriovenous shunting. *No
significant intracranial atheromatous disease is present. The
capillary phase demonstrated slow perfusion in the ACA/MCA watershed
territory. No abnormality is present in the major cortical and deep
draining veins and dural venous sinuses which are present with normal
flow and calibre.
*
REPEAT ANGIOGRAM VIA DDC CATHETER (AFTER 60 MG IA VERAPAMIL ON THE
CONTRALATERAL SIDE)
There is significant improvement in the caliber of the M1 segment
with improvement in the focal area of mid-M1 spasm and mild
persistent distal M3 and M4 spasm.
*
AFTER INJECTION OF 20 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase.
*
AFTER INJECTION OF 40 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase. There remains a persistent area of hypoperfusion in
the MCA/ACA watershed territory, correlating with her known fixed
ischemic strokes seen on MRI.
*
AFTER INJECTION OF 60 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase. There remains a persistent area of hypoperfusion in
the MCA/ACA watershed territory, correlating with her known fixed
ischemic strokes seen on MRI.
*
RIGHT COMMON FEMORAL ARTERY
Normal caliber and puncture above the bifurcation. *
*
SUPERVISION AND INTERPRETATION:
1. *Angiographic study demonstrates significant vasospasm involving:
right supraclinoid ICA, right MCA and left mid-M1 focal segment with
diffuse cortical mild spasm.
2. *Underwent IA verapamil injection of right ICA, with 60 mg, left
ICA with 60 mg.
3. *Underwent right sided angioplasty of supraclinoid ICA and right
M1 with excellent results.
4. *No immediate complications.
*
VESSELS STUDIED:
1. *Right common carotid artery
2. *Right internal carotid artery
3. *Left common carotid artery
4. *Left internal carotid artery
5. *Left internal carotid intracranial injections x2
6. *Right common femoral artery
*
MATERIALS EMPLOYED:
1. *5-Fr Envoy catheter.
2. *Bentson guidewire
3. *0.035 Terumo LT guidewire.
4. *Transform 3x10 compliant.
5. *Synchro 14 micro-wire.
6. *NeuronMax 088.
7. *DDC catheter.
8. *Exchange length Amplatz wire.
9. *Perclose vascular closure device.
10. *Verapamil total dose: 120 mg.
We coded it as;
36224-50
36228-LT
61630
61650
61651
I'm getting stuck in edits due to 36224,36228, 61630 being inclusive to 61650 & 61651.
I believe I can code as such according to the OP note. Please review and advise.
Thanks in advance.
PREOPERATIVE DIAGNOSIS: *SYMPTOMATIC VASOSPASM
*
POSTOPERATIVE DIAGNOSIS: *SYMPTOMATIC VASOSPASM: MODERATE FOCAL LEFT
M1 MIDDLE SEGMENT AND MODERATE RIGHT DISTAL ICA AND PROXIMAL M1
*
OPERATION: FEMORAL CEREBRAL ANGIOGRAM WITH INTRA-ARTERIAL VERAPAMIL
INJECTION AND ANGIOPLASTY
*
ANESTHESIA: General anesthesia
*
COMPLICATIONS: NONE
*
ESTIMATED BLOOD LOSS: *LESS THAN 50 CC
*
INDICATIONS: XXXXXXXX is a 54 years year old Female who is day 4
of a HH3, mF1 subarachnoid hemorrhage, secondary to a ruptured left
ophthalmic artery aneurysm, that has been successfully coiled. Her
course has been complicated by severe vasospasm for which she
underwent angioplasty of left M1 with IA verapamil injection on day 2
and verapamil injection on day 3. Her neurological exam is
significant for lethargy and left sided weakness and her MRI was
performed and reveals extensive areas of infarction in the left MCA
territory and smaller areas in the right MCA territory.
*
PROCEDURE: * *Following explanation of the benefits, risks and
alternatives for the procedure, consent was obtained from the *
family. *The risks including but not limited to stroke, intracranial
hemorrhage, vascular injury to the cervical or femoral vessels and
groin hematoma were discussed with the family. *The patient was
brought to the Angiographic Suite and cardiopulmonary monitoring was
placed. *Pateint was placed under general anesthesia. *A time-out was
performed. *Her previously inserted 6-Fr short long arrow sheath was
sterilized and accessed and was continued to be maintained on
heparinized flush. *
*
Using coaxial technique, a 5-Fr Envoy catheter was advanced into the
descending aorta, back-bled, and flushed in the usual fashion. *Using
coaxial technique, the catheter was advanced into the aortic arch,
and with the aid of the roadmapping, digital fluoroscopy, and careful
guidewire manipulation, the right common and internal carotid and the
left common and internal carotid arteries were selectively
catheterized. *Upon each successive selective catheterization,
digital subtraction angiography using the appropriate rate and volume
of contrast in multiple projections was performed.
*
INTERVETNION
Based on the findings of the angiograms (detailed below), the
decision was made to treat with IA Verapamil injection. Upon
catheterization of each vessel, a baseline diagnostic angiogram was
obtained. Verapamil was slowly injected in 20 mg increments at a rate
of 1 mg/minute with vigilant BP monitoring; maintaining it at the
pre-specified range. Vasopressor medications were used whenever
necessary. After each 20 mg injection, a repeat angiogram of the
vessel was obtained.
*
50 mg of Verapamil were injected in the right ICA.
There was remarkable improvement in vessel caliber and good perfusion
in the capillary phase in all the vessels treated, but persistent
spasm in the distal right ICA and proximal M1. The decision was made
to perform angioplasty on those segments.
*
A 3 x 10 compliant Transform balloon-catheter was advanced over a
Synchro 14 micro guidewire. The 5-Fr Envoy was then advanced into the
petrous ICA. Using roadmapping, digital fluoroscopy and careful micro
guidewire manipulation, the 3x10 transform balloon was used to
perform angioplasty of the distal internal carotid artery and the M1
segment of the middle cerebral artery. Repeat angiographic runs
(detailed below) revealed significant improvement in vessel caliber.
The balloon-catheter was removed.
*
10 additional mgs of verapamil were injected in the right ICA. Follow
up angiographic run demonstrated excellent vessel caliber and
improvement in perfusion of the right ICA circulation.
*
The catheter was withdrawn and used to select the left internal
carotid artery. An exchange length Amplatz wire was used to exchange
the catheter and the sheath for a NeuronMax and a DDC catheter, for
better support in preparation for angioplasty. Injection run
demonstrated improvement in vessel caliber compared to the initial
runs of the case. The decision was made to inject verapamil instead.
*
Verapamil was slowly injected in 20 mg increments at a rate of 1
mg/minute with vigilant BP monitoring; maintaining it at the
pre-specified range. Vasopressor medications were used whenever
necessary. After each 20 mg injection, a repeat angiogram of the
vessel was obtained. A total of 60 mg of IA verapamil were injected
with remarkable improvement in vessel caliber and distal perfusion.
*
The catheter was removed. *Angiographic run of the right internal
iliac and common/superficial femoral arteries was performed. *The
femoral sheath was removed; and hemostasis achieved with a Perclose
vascular closure device.. The patient tolerated the procedure well
and was transported from the angio suite in unchanged neurological
status, without groin hematoma, and with good distal lower extremity
pulses. *The patient was transferred neuroscience intensive care unit.
*
FINDINGS:
RIGHT COMMON CAROTID ARTERY
The internal and external carotid artery origins are normal in
contour and calibre with no evidence of significant plaque formation
or stenosis. *
*
RIGHT INTERNAL CAROTID ARTERY
BASELINE
There is evidence of significant vasospasm in the distal supraclinoid
ICA and the MCA throughout its course. There is no aneurysm, vascular
malformation or evidence of arteriovenous shunting. *No significant
intracranial atheromatous disease is present. The capillary phase
demonstrated perfusion delay especially in the watershed territories.
No abnormality is present in the major cortical and deep draining
veins and dural venous sinuses which are present with normal flow and
calibre.
*
AFTER INJECTION OF 20 MG OF VERAPAMIL
There is significant improvement in vessel caliber with improvement
in the capillary phase.
*
AFTER INJECTION OF 40 MG OF VERAPAMIL
There is improvement in vessel caliber with further improvement in
the capillary phase, but a persistent area of hypoperfusion in the
ACA/MCA watershed territory.
*
AFTER INJECTION OF 50 MG OF VERAPAMIL
There is improvement in vessel caliber with further improvement in
the capillary phase, but a persistent area of hypoperfusion in the
ACA/MCA watershed territory.
*
AFTER ANGIOPLASTY OF DISTAL ICA AND PROXIMAL MCA
There is remarkable improvement in vessel caliber with further
improvement in the capillary phase.
*
AFTER INJECTION OF 60 MG OF VERAPAMIL
There is excellent restoration of proximal vessel caliber with
further improvement in the capillary phase.
*
LEFT COMMON CAROTID ARTERY
The internal and external carotid artery origins are normal in
contour and calibre with no evidence of significant plaque formation
or stenosis.
*
REPEAT INJECTION AFTER INTERVENTION
No interval change in vessel caliber or supply. No evidence of
dissection or other untoward events.
*
LEFT INTERNAL CAROTID ARTERY
BASELINE
There is evidence of moderate focal vasospasm in the mid-M1 segment
of the MCA, in the area that has not been previously angioplastied.
Additionally, the vessel calibers in distal cortical branches are
exhibiting diffuse mild to moderate spasm. The previously coiled
ophthalmic artery aneurysm is completely occluded. There is no
vascular malformation or evidence of arteriovenous shunting. *No
significant intracranial atheromatous disease is present. The
capillary phase demonstrated slow perfusion in the ACA/MCA watershed
territory. No abnormality is present in the major cortical and deep
draining veins and dural venous sinuses which are present with normal
flow and calibre.
*
REPEAT ANGIOGRAM VIA DDC CATHETER (AFTER 60 MG IA VERAPAMIL ON THE
CONTRALATERAL SIDE)
There is significant improvement in the caliber of the M1 segment
with improvement in the focal area of mid-M1 spasm and mild
persistent distal M3 and M4 spasm.
*
AFTER INJECTION OF 20 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase.
*
AFTER INJECTION OF 40 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase. There remains a persistent area of hypoperfusion in
the MCA/ACA watershed territory, correlating with her known fixed
ischemic strokes seen on MRI.
*
AFTER INJECTION OF 60 MG OF VERAPAMIL
There is further improvement in vessel caliber with some in the
capillary phase. There remains a persistent area of hypoperfusion in
the MCA/ACA watershed territory, correlating with her known fixed
ischemic strokes seen on MRI.
*
RIGHT COMMON FEMORAL ARTERY
Normal caliber and puncture above the bifurcation. *
*
SUPERVISION AND INTERPRETATION:
1. *Angiographic study demonstrates significant vasospasm involving:
right supraclinoid ICA, right MCA and left mid-M1 focal segment with
diffuse cortical mild spasm.
2. *Underwent IA verapamil injection of right ICA, with 60 mg, left
ICA with 60 mg.
3. *Underwent right sided angioplasty of supraclinoid ICA and right
M1 with excellent results.
4. *No immediate complications.
*
VESSELS STUDIED:
1. *Right common carotid artery
2. *Right internal carotid artery
3. *Left common carotid artery
4. *Left internal carotid artery
5. *Left internal carotid intracranial injections x2
6. *Right common femoral artery
*
MATERIALS EMPLOYED:
1. *5-Fr Envoy catheter.
2. *Bentson guidewire
3. *0.035 Terumo LT guidewire.
4. *Transform 3x10 compliant.
5. *Synchro 14 micro-wire.
6. *NeuronMax 088.
7. *DDC catheter.
8. *Exchange length Amplatz wire.
9. *Perclose vascular closure device.
10. *Verapamil total dose: 120 mg.