suela923@aol.com
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HELP! I am thinking 36223-50, 36225 but am being told 36223-50, 36225-50 is more appropriate. I feel that we saw what we needed to see from the right innominate catheter approach with the bp cuff for the vetebrals. If I bill 36225-50 aren't I overbilling because that would include two catheter placements when we only had the cath in the right innominate. Help I am very confused! Thanks!!
Right innominate arteriogram, left common carotid arteriogram, and left subclavian arteriogram for cervical and intracranial angiography on 5/30/2014.
Clinical indication: Abnormal distal vertebral arteries and basilar artery seen on CT angiogram. Probable cerebellar infarct.
Informed consent was obtained. The patient was prepped in a sterile fashion. The skin was anesthetized with 1% Xylocaine. Using the Seldinger technique the right common femoral artery was selectively catheterized. A 5-French Berenstein catheter was then advanced into the aortic arch. Several attempts were made to catheterize the left vertebral artery with a 5-French Berenstein catheter as well as a 4-French Berenstein catheter. These were unsuccessful due to marked vascular tortuosity and atherosclerotic disease. A 5-French Simmons 2 catheter was then placed into the right innominate artery. The right vertebral and common carotid arteries could not be selectively catheterized due to vascular tortuosity. Therefore right innominate arteriogram was performed with a blood pressure cuff inflated on the right arm to enhance intracranial opacification. The left common carotid artery was selectively catheterized with the Simmons 2 catheter and a selective left common carotid arteriogram was performed with cervical and intracranial angiography. The left subclavian artery was selectively catheterized with a 5-French Simmons 2 catheter and a left subclavian arteriogram was performed with a left arm blood pressure cuff inflated to enhance intracranial opacification.
The right innominate arteriogram shows mild diffuse atherosclerotic disease in the innominate artery as well as significant tortuosity. The right common carotid artery is widely patent. The right bifurcation is widely patent with only minimal atherosclerotic change at the origin of the ICA. The mid to distal cervical ICA is widely patent. The intracranial angiogram shows mild atherosclerotic disease in the Petrus ICA on the right as well as moderate atherosclerotic disease in the cavernous ICA. The supraclinoid ICA is widely patent. There is visualization of multiple widely patent right anterior and middle cerebral artery branches. There is a large right posterior communicating artery which fills the right posterior cerebral artery territory. There is some retrograde filling of a severely diseased distal basilar artery as well as a right superior cerebellar artery and small pontine artery collateral branches. There is very slow flow in the right vertebral artery. The right vertebral artery is occluded distally.
The left common carotid arteriogram in the neck shows mild atherosclerotic disease in the common carotid artery and in the carotid bulb and proximal internal carotid artery. The external carotid artery is patent. The ICA is widely patent. There is mild atherosclerotic disease in the Petrus and cavernous ICA segments. The supraclinoid ICA is widely patent. There is a large posterior communicating artery which is widely patent and which fills the posterior cerebral artery territory on the left. There is faint visualization of a severely diseased distal basilar artery and opacification of the left superior cerebellar artery branches. There is visualization of widely patent left anterior and middle cerebral artery branches.
The left subclavian arteriogram shows a patent cervical left vertebral artery which shows very slow flow. There is occlusion of the left vertebral artery at the origin of the posterior inferior cerebellar artery. There is opacification of the left posterior inferior cerebellar artery territory.
Result Impression
Occlusion of both distal vertebral arteries and basilar artery. I suspect these findings are due to atherosclerotic disease. Extensive calcification of both distal vertebral arteries is noted on the recent CT scan.
Widely patent anterior circulation vasculature. Large posterior communicating arteries are seen filling a severely diseased distal basilar artery and superior cerebellar arteries.
Right innominate arteriogram, left common carotid arteriogram, and left subclavian arteriogram for cervical and intracranial angiography on 5/30/2014.
Clinical indication: Abnormal distal vertebral arteries and basilar artery seen on CT angiogram. Probable cerebellar infarct.
Informed consent was obtained. The patient was prepped in a sterile fashion. The skin was anesthetized with 1% Xylocaine. Using the Seldinger technique the right common femoral artery was selectively catheterized. A 5-French Berenstein catheter was then advanced into the aortic arch. Several attempts were made to catheterize the left vertebral artery with a 5-French Berenstein catheter as well as a 4-French Berenstein catheter. These were unsuccessful due to marked vascular tortuosity and atherosclerotic disease. A 5-French Simmons 2 catheter was then placed into the right innominate artery. The right vertebral and common carotid arteries could not be selectively catheterized due to vascular tortuosity. Therefore right innominate arteriogram was performed with a blood pressure cuff inflated on the right arm to enhance intracranial opacification. The left common carotid artery was selectively catheterized with the Simmons 2 catheter and a selective left common carotid arteriogram was performed with cervical and intracranial angiography. The left subclavian artery was selectively catheterized with a 5-French Simmons 2 catheter and a left subclavian arteriogram was performed with a left arm blood pressure cuff inflated to enhance intracranial opacification.
The right innominate arteriogram shows mild diffuse atherosclerotic disease in the innominate artery as well as significant tortuosity. The right common carotid artery is widely patent. The right bifurcation is widely patent with only minimal atherosclerotic change at the origin of the ICA. The mid to distal cervical ICA is widely patent. The intracranial angiogram shows mild atherosclerotic disease in the Petrus ICA on the right as well as moderate atherosclerotic disease in the cavernous ICA. The supraclinoid ICA is widely patent. There is visualization of multiple widely patent right anterior and middle cerebral artery branches. There is a large right posterior communicating artery which fills the right posterior cerebral artery territory. There is some retrograde filling of a severely diseased distal basilar artery as well as a right superior cerebellar artery and small pontine artery collateral branches. There is very slow flow in the right vertebral artery. The right vertebral artery is occluded distally.
The left common carotid arteriogram in the neck shows mild atherosclerotic disease in the common carotid artery and in the carotid bulb and proximal internal carotid artery. The external carotid artery is patent. The ICA is widely patent. There is mild atherosclerotic disease in the Petrus and cavernous ICA segments. The supraclinoid ICA is widely patent. There is a large posterior communicating artery which is widely patent and which fills the posterior cerebral artery territory on the left. There is faint visualization of a severely diseased distal basilar artery and opacification of the left superior cerebellar artery branches. There is visualization of widely patent left anterior and middle cerebral artery branches.
The left subclavian arteriogram shows a patent cervical left vertebral artery which shows very slow flow. There is occlusion of the left vertebral artery at the origin of the posterior inferior cerebellar artery. There is opacification of the left posterior inferior cerebellar artery territory.
Result Impression
Occlusion of both distal vertebral arteries and basilar artery. I suspect these findings are due to atherosclerotic disease. Extensive calcification of both distal vertebral arteries is noted on the recent CT scan.
Widely patent anterior circulation vasculature. Large posterior communicating arteries are seen filling a severely diseased distal basilar artery and superior cerebellar arteries.