suela923@aol.com
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I billed 36223-50, 36223-50, 36225, 36226 for this case but am being advised to bill 75710 for left subclavian but I disagree. I billed 36225 for the left subclavian cath placement and angiogram which I believe the cath was in the subclavian because the left vertebral was occluded. I don't think I should bill for an additional angiogram. I feel that we saw subclavian at the same time we saw the vertebral. Any thoughts???? Thanks, Sue
Arch and cerebral arteriogram
History: Dizziness. Left vertebral artery occlusion.
Technique: Timeout performed. Skin over right groin prepped and draped sterilely. 2% lidocaine used as local anesthetic. Moderate sedation also administered. Micropuncture needle used to access right common femoral artery. 6-French sheath placed. Pigtail catheter advanced into the ascending aorta. Biplane aortography performed. Berenstein catheter used to select the brachiocephalic artery. Arteriogram performed. Catheter further advanced into the right vertebral artery. Diagnostic cervical and cerebral arteriogram performed. Right common carotid artery selected. Cervical and cerebral arteriogram performed. Left common carotid artery selected. Cervical and cerebral arteriogram performed. Left subclavian artery selected. Arteriogram performed. Catheter and sheath removed. Hemostasis achieved. Angio-Seal closure device deployed. No complications.
Findings: Arch aortogram shows no proximal great vessel stenosis. There may be a bovine arch. There is a cervical fusion plate and screws present. Right vertebral artery is widely patent. No left vertebral artery demonstrated. Antegrade flow in the subclavian and carotid arteries. Normal caliber transverse aorta.
Brachiocephalic artery arteriogram shows filling of the brachiocephalic artery, right common carotid artery, right subclavian artery, and right vertebral artery all of which are patent.
Right vertebral artery arteriogram shows a dominant widely patent right vertebral artery. The basilar artery appears normal. Cerebellar arteries appear normal. There is reflux into a small but patent distal left vertebral artery. Left PICA is patent. Intracranial views show filling of the posterior cerebral arteries bilaterally. No intracranial aneurysm, stenosis, or vascular malformation. Normal venous drainage.
Right common carotid arteriogram shows a widely patent common carotid artery and carotid bifurcation, at the C3-C4 level. ECA and proximal branches are patent. ICA is patent. Intracranial views show filling of the right MCA and ACA territories. No intracranial aneurysm, stenosis, or vascular malformation. Normal venous drainage.
Left common carotid arteriogram shows a widely patent common carotid artery, carotid bifurcation, ICA, and ECA. No stenosis. Intracranial views show filling of the left MCA, PCA, ACA territories. No intracranial aneurysm, stenosis, or vascular malformation. Posterior communicating artery on the left is patent. Normal venous drainage.
Left subclavian artery arteriogram shows a widely patent left subclavian artery. Left vertebral artery is occluded at its origin. No subclavian artery stenosis or dissection. Visualized axillary artery is patent.
Result Impression
The right vertebral artery is widely patent and appears dominant supplying the entire posterior circulation and refluxing into a small distal left vertebral artery.
The left vertebral artery appears small and occluded at its origin. As there is a widely patent posterior circulation supplied by the right vertebral artery, there would be no benefit from recanalization. No subclavian artery stenosis.
Widely patent carotid arteries bilaterally. No intracranial abnormality.
Arch and cerebral arteriogram
History: Dizziness. Left vertebral artery occlusion.
Technique: Timeout performed. Skin over right groin prepped and draped sterilely. 2% lidocaine used as local anesthetic. Moderate sedation also administered. Micropuncture needle used to access right common femoral artery. 6-French sheath placed. Pigtail catheter advanced into the ascending aorta. Biplane aortography performed. Berenstein catheter used to select the brachiocephalic artery. Arteriogram performed. Catheter further advanced into the right vertebral artery. Diagnostic cervical and cerebral arteriogram performed. Right common carotid artery selected. Cervical and cerebral arteriogram performed. Left common carotid artery selected. Cervical and cerebral arteriogram performed. Left subclavian artery selected. Arteriogram performed. Catheter and sheath removed. Hemostasis achieved. Angio-Seal closure device deployed. No complications.
Findings: Arch aortogram shows no proximal great vessel stenosis. There may be a bovine arch. There is a cervical fusion plate and screws present. Right vertebral artery is widely patent. No left vertebral artery demonstrated. Antegrade flow in the subclavian and carotid arteries. Normal caliber transverse aorta.
Brachiocephalic artery arteriogram shows filling of the brachiocephalic artery, right common carotid artery, right subclavian artery, and right vertebral artery all of which are patent.
Right vertebral artery arteriogram shows a dominant widely patent right vertebral artery. The basilar artery appears normal. Cerebellar arteries appear normal. There is reflux into a small but patent distal left vertebral artery. Left PICA is patent. Intracranial views show filling of the posterior cerebral arteries bilaterally. No intracranial aneurysm, stenosis, or vascular malformation. Normal venous drainage.
Right common carotid arteriogram shows a widely patent common carotid artery and carotid bifurcation, at the C3-C4 level. ECA and proximal branches are patent. ICA is patent. Intracranial views show filling of the right MCA and ACA territories. No intracranial aneurysm, stenosis, or vascular malformation. Normal venous drainage.
Left common carotid arteriogram shows a widely patent common carotid artery, carotid bifurcation, ICA, and ECA. No stenosis. Intracranial views show filling of the left MCA, PCA, ACA territories. No intracranial aneurysm, stenosis, or vascular malformation. Posterior communicating artery on the left is patent. Normal venous drainage.
Left subclavian artery arteriogram shows a widely patent left subclavian artery. Left vertebral artery is occluded at its origin. No subclavian artery stenosis or dissection. Visualized axillary artery is patent.
Result Impression
The right vertebral artery is widely patent and appears dominant supplying the entire posterior circulation and refluxing into a small distal left vertebral artery.
The left vertebral artery appears small and occluded at its origin. As there is a widely patent posterior circulation supplied by the right vertebral artery, there would be no benefit from recanalization. No subclavian artery stenosis.
Widely patent carotid arteries bilaterally. No intracranial abnormality.
