This cases present questions regarding coding for thoracic and abdominal aortagrams.
Questions arise in using the codes 36221,75605,75625 and 36200. I am not sure if there is redundancy between 36221,75605,75625 although there appear to be medical necessity and documentation for these codes. I do recieve a CCI edit for 36221 and 75605. Has any one come across this situation. Any guidance would be appreicated.
U/S Guidance is understood 76937
Below is procedure report.
PROCEDURE PERFORMED
1. Access via the right common femoral artery under ultrasound and
fluoroscopic guidance.
2. Diagnostic arch aortogram.
3. Descending thoracic aortogram.
4. Abdominal aortogram.
5. Conscious sedation for 1 hour.
The patient presents with asymptomatic high-
grade stenosis of left internal carotid artery as suggested by Duplex
ultrasound. presents today for arteriography to further evaluate
this.
PROCEDURE:
The patient had rather faint and deep femoral pulse. Xylocaine was used
for local anesthesia. I cannulated the artery without difficulty, but
could not pass the wire well. I decided to use an ultrasound. A SonoSite
Duplex ultrasound probe was placed in a sterile sleeve with gel. Under
ultrasound guidance, the common femoral artery was accessed without
difficulty. A guidewire was passed, and over this, a 5-French sheath was
placed. There is a hard copy of the ultrasound image scanned into the
chart.
As I passed the Glidewire, it was clear the patient had a thoracic
aneurysm which appeared to be quite large. There was possibly an
abdominal aortic aneurysm as well. I had to manipulate a pigtail
catheter through the chest to reach the aortic arch. The wire was passed
and then the tip of the pigtail catheter was positioned just above the
level of the aortic valve. Left anterior oblique view of the abdominal
aorta was obtained. I then attempted to cannulate the innominate artery
with a wire and catheter. Because of the amount of calcification and
occlusive disease, I decided to stop that. There was also the finding of
a thoracic aneurysm. Specifically, I attempted to pass a Sims catheter
with a 0.35 inch diameter Glidewire. Because of ectasia at the aortic
root, I was not able to J-up the catheter. Even J-ing the wire was
difficult. I then switched this to a JB3 catheter. With the JB3, I was
able to get the tip of the catheter into the origin of the innominate
artery. However, each time I tried to take the wire out, the catheter
flipped back into the arch. Considering the degree of calcification and
aneurysm, I decided not to pursue this any more. I was concerned that
further manipulation could potentially cause an embolus or stroke event.
Following this, the pigtail catheter was repositioned at the level of
the descending thoracic aorta. An anteroposterior view of this vessel
was obtained. Next, the catheter was positioned above the aortic
bifurcation in the pelvis. An anteroposterior view of the pelvic
arteries was obtained.At the conclusion of the procedure, the pigtail catheter was withdrawn
over a wire. The sheath was withdrawn beneath a Syvek pad. Pressure was
held for 10 minutes. There was no bleeding and no hematoma. The patient
was taken back to the outpatient department in good condition.
FINDINGS: The aortic arch is ectatic beginning at the aortic valve and
extending to just past the origin of the left subclavian artery. The
vessels are heavily calcified. Contrast selectively wants to go into the
aorta rather than to the great vessels. The best view of the great
vessels was obtained by placing a pigtail right at the origin of the
innominate and left common carotid artery. The origin of the great
vessels is either a bovine arch or an extremely close takeoff of the
left common carotid artery to the innominate. On some views it looks to
be bovine and on others, it looks to be somewhat separate. In any event,
there are heavy calcifications of both of those vessels and it is hard
to say what degree of stenosis might be present. The right internal
carotid artery is calcified but generally appears to be widely patent as
is the right vertebral. On the left side, there is heavy calcifications
in the aortic bulb, extending into the internal carotid artery. The
internal carotid artery looks to have a stenosis in the calcifications
which is severe. It is hard estimate precisely, but I would guess it to
be about 90%. Not enough contrast reached the intracranial vessels to
describe them anatomically. Left vertebral artery is patent.
There is an aneurysm which begins just to the left side of the
subclavian artery.The
descending thoracic aorta remains aneurysmal all the way to the
diaphragm. The artery does taper somewhat but is still ectatic at that
level. The celiac axis and superior mesenteric arteries are patent on
the anteroposterior view. The aorta is normal diameter at that level.
The single renal arteries are noted bilaterally. The left renal artery
appears to be quite calcified but I do not see any significant stenosis.
The infrarenal aorta is normal diameter, but somewhat calcified and
shows moderate atherosclerotic irregularities. The common iliac arteries
are widely patent. There is a small segment of the right common iliac
artery at its mid point which has a very localized aneurysm with a
diameter of about 2 cm. The internal iliac arteries are patent and
normal. The external iliac arteries are somewhat calcified but generally
normal. The legs were not imaged because of the amount of contrast that
it would require.
SUMMARY
1. Critical stenosis of about 90% at the level of the left internal
carotid artery.
2. Heavy calcifications of the great vessels with unknown degree
of stenosis.
3. Large descending thoracic aortic aneurysm.
Questions arise in using the codes 36221,75605,75625 and 36200. I am not sure if there is redundancy between 36221,75605,75625 although there appear to be medical necessity and documentation for these codes. I do recieve a CCI edit for 36221 and 75605. Has any one come across this situation. Any guidance would be appreicated.
U/S Guidance is understood 76937
Below is procedure report.
PROCEDURE PERFORMED
1. Access via the right common femoral artery under ultrasound and
fluoroscopic guidance.
2. Diagnostic arch aortogram.
3. Descending thoracic aortogram.
4. Abdominal aortogram.
5. Conscious sedation for 1 hour.
The patient presents with asymptomatic high-
grade stenosis of left internal carotid artery as suggested by Duplex
ultrasound. presents today for arteriography to further evaluate
this.
PROCEDURE:
The patient had rather faint and deep femoral pulse. Xylocaine was used
for local anesthesia. I cannulated the artery without difficulty, but
could not pass the wire well. I decided to use an ultrasound. A SonoSite
Duplex ultrasound probe was placed in a sterile sleeve with gel. Under
ultrasound guidance, the common femoral artery was accessed without
difficulty. A guidewire was passed, and over this, a 5-French sheath was
placed. There is a hard copy of the ultrasound image scanned into the
chart.
As I passed the Glidewire, it was clear the patient had a thoracic
aneurysm which appeared to be quite large. There was possibly an
abdominal aortic aneurysm as well. I had to manipulate a pigtail
catheter through the chest to reach the aortic arch. The wire was passed
and then the tip of the pigtail catheter was positioned just above the
level of the aortic valve. Left anterior oblique view of the abdominal
aorta was obtained. I then attempted to cannulate the innominate artery
with a wire and catheter. Because of the amount of calcification and
occlusive disease, I decided to stop that. There was also the finding of
a thoracic aneurysm. Specifically, I attempted to pass a Sims catheter
with a 0.35 inch diameter Glidewire. Because of ectasia at the aortic
root, I was not able to J-up the catheter. Even J-ing the wire was
difficult. I then switched this to a JB3 catheter. With the JB3, I was
able to get the tip of the catheter into the origin of the innominate
artery. However, each time I tried to take the wire out, the catheter
flipped back into the arch. Considering the degree of calcification and
aneurysm, I decided not to pursue this any more. I was concerned that
further manipulation could potentially cause an embolus or stroke event.
Following this, the pigtail catheter was repositioned at the level of
the descending thoracic aorta. An anteroposterior view of this vessel
was obtained. Next, the catheter was positioned above the aortic
bifurcation in the pelvis. An anteroposterior view of the pelvic
arteries was obtained.At the conclusion of the procedure, the pigtail catheter was withdrawn
over a wire. The sheath was withdrawn beneath a Syvek pad. Pressure was
held for 10 minutes. There was no bleeding and no hematoma. The patient
was taken back to the outpatient department in good condition.
FINDINGS: The aortic arch is ectatic beginning at the aortic valve and
extending to just past the origin of the left subclavian artery. The
vessels are heavily calcified. Contrast selectively wants to go into the
aorta rather than to the great vessels. The best view of the great
vessels was obtained by placing a pigtail right at the origin of the
innominate and left common carotid artery. The origin of the great
vessels is either a bovine arch or an extremely close takeoff of the
left common carotid artery to the innominate. On some views it looks to
be bovine and on others, it looks to be somewhat separate. In any event,
there are heavy calcifications of both of those vessels and it is hard
to say what degree of stenosis might be present. The right internal
carotid artery is calcified but generally appears to be widely patent as
is the right vertebral. On the left side, there is heavy calcifications
in the aortic bulb, extending into the internal carotid artery. The
internal carotid artery looks to have a stenosis in the calcifications
which is severe. It is hard estimate precisely, but I would guess it to
be about 90%. Not enough contrast reached the intracranial vessels to
describe them anatomically. Left vertebral artery is patent.
There is an aneurysm which begins just to the left side of the
subclavian artery.The
descending thoracic aorta remains aneurysmal all the way to the
diaphragm. The artery does taper somewhat but is still ectatic at that
level. The celiac axis and superior mesenteric arteries are patent on
the anteroposterior view. The aorta is normal diameter at that level.
The single renal arteries are noted bilaterally. The left renal artery
appears to be quite calcified but I do not see any significant stenosis.
The infrarenal aorta is normal diameter, but somewhat calcified and
shows moderate atherosclerotic irregularities. The common iliac arteries
are widely patent. There is a small segment of the right common iliac
artery at its mid point which has a very localized aneurysm with a
diameter of about 2 cm. The internal iliac arteries are patent and
normal. The external iliac arteries are somewhat calcified but generally
normal. The legs were not imaged because of the amount of contrast that
it would require.
SUMMARY
1. Critical stenosis of about 90% at the level of the left internal
carotid artery.
2. Heavy calcifications of the great vessels with unknown degree
of stenosis.
3. Large descending thoracic aortic aneurysm.