Hello,
I am fairly new and I need a second opinion on my coding. My docs like to debate and I need help explaining why the codes changed. particularly on the provider selection 36225/bilateral, but I got 36225/RT.
Provider selection:
My Finding
POSTOPERATIVE DIAGNOSIS: Right posterior communicating artery aneurysm status
post coil embolization, with recurrence.
NAME OF PROCEDURES:
1. Introduction of needle catheter into right proximal radial artery under
continuous ultrasound guidance with storage of an image.
2. Left subclavian arteriogram.
3. Left common carotid arteriogram.
4. Right internal carotid arteriogram.
5. Rotational angiogram, right internal carotid, with 3D reconstruction
performed on additional workstation with direct physician involvement.
6. Right internal carotid arteriogram magnified working angles in the A plane
RAO 32, caudal 22, in the B plane RAO 90, cranial 0.
7. Right middle cerebral artery arteriogram.
8. Transcatheter permanent embolization of the central nervous system, Pipeline
embolization of right posterior communicating artery aneurysm.
9. Right internal carotid arteriogram, mid embolization.
10. Right internal carotid arteriogram, post embolization.
11. Right subclavian angiogram.
INDICATIONS FOR PROCEDURE: A 59-year-old female, history of a ruptured right
posterior communicating artery aneurysm, initially treated with coil
embolization. She has a known residual at the base and the plan was for cerebral
angiogram with planned flow diversion therapy. Risks and benefits of the
procedure were discussed with the patient prior to the procedure. These risks
include but are not limited to vessel injury, hematoma, hemorrhage, stroke, and
death. We discussed alternatives of conservative management, microsurgical
treatment, and coil embolization. The patient understands the risks and
benefits of the procedure and elects to proceed. All her questions were
answered. Informed consent was obtained. No guarantees were made.
DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite,
positioned supine on the angiography table. The right radial region was prepped
and draped in the usual sterile fashion. Following induction of general
anesthesia, the patient was endotracheally intubated. SSEP and EEG monitoring
were established and remained at baseline throughout the procedure. A timeout
was performed in accordance with the hospital protocol. Using modified Seldinger
technique and a micropuncture needle, access was obtained to the right proximal
radial artery and a 7-French sheath was placed under continuous ultrasound
guidance with storage of an image. We then infused the radial artery cocktail.
We prepped and advanced a 7-French BMX over a select Sim 2 and 0.035 Glidewire.
Wire catheter combination was tracked to the arch, reformatted. We catheterized
the left subclavian and left common carotid artery. Selective injection was
performed with catheter positioned in each of these vessels, filming in the PA,
lateral and oblique views using digital reconstruction. We catheterized the
right subclavian artery and angiography was performed. At this point, we
attempted to catheterize the right common carotid, but we were unable to do so
due to the angulation and the kink of our Simmons catheter. Therefore, it was
removed. We prepped and advanced and set a select Berenstein over an 0.035 glide
and this wire catheter combination was used to catheterize the right internal
carotid artery. The wire was removed. Selective injection was performed, PA and
lateral views. We then performed a rotational angiogram, right internal carotid
with 3D reconstruction, performed on additional workstation with direct
physician involvement. At this point, we elected to proceed with embolization.
We administered 5 mg of verapamil to the internal carotid. We administered
heparin to maintain an ACT of greater than 200. Throughout the course of the
procedure, the patient had been started on aspirin and Plavix beforehand and was
respondent of Plavix. We tracked the BMX to the distal cervical carotid. We then
prepped and advanced an Esperance 5-French over a Phenom 27 and a Synchro. Wire
catheter combination was used to cross the aneurysm, position of the
microcatheter in the distal middle superior artery. The wire was removed. We
performed a microcatheter angiogram. We then prepped and advanced a 4.0 x 12 mm
Pipeline Flexor Shield Technology device. This was deployed beginning at the
level of the carotid terminus. We pushed the device out across the aneurysm. We
performed control angiography during deployment. We then recaptured the wire.
Follow-up angiogram was performed and we turned our attention to closure. BMX
was removed from the patient. A 7-French sheath was removed. TR band was
applied, achieving excellent hemostasis. The patient was then extubated and
transported to the ICU in stable condition, having tolerated the procedure well.
It should be noted, I was present throughout the procedure, puncture and final
closure, present for the critical portions including but not limited to vessel
catheterization, angiography, image interpretation, embolization, and final
closure. Immediately available for all non-critical portion. No backup surgery
was necessary as this was a single case.
ANGIOGRAPHIC FINDINGS:
1. Right radial ultrasound: Right radial ultrasonography demonstrates pulsatile
patent radial artery. This was used to guide placement of the sheath under
continuous ultrasound guidance with storage of an image.
2. Left subclavian arteriogram: Selective injection demonstrates filling of the
vertebral along its extracranial and intracranial course, basilar artery and
distal branches including bilateral superior cerebellar arteries are well
visualized. The left PICF fills well and is free of pathology. Neither P1
segment is noted, given the fetal origin of these vessels. No evidence of
intracranial aneurysm, vascular malformation, arteriovenous shunting. No
abnormalities of the venous phase. Arterial venous transit is normal.
3. Left common carotid arteriogram: Selective injection demonstrates filling of
the internal along the cervical, petrous, cavernous and supraclinoid segment.
The medial cerebral artery distal branches fill out well. The anterior cerebral
artery distal branches fill out well with rapid washout due to competitive flow.
Large caliber fetal-type posterior communicating artery was noted. External
carotid artery and branches were superimposed on this injection. No evidence of
intracranial aneurysm, vascular malformation, arteriovenous shunting. No
abnormalities of the venous phase. Arteriovenous transit is normal.
4. Right subclavian arteriogram: Selective injection demonstrates the
subclavian fills without evidence of hemodynamically significant stenosis.
Costocervical, thyroid, cervical trunks, and distal branches are well
visualized. The common carotid artery is visualized and no evidence of cervical
carotid artery stenosis is noted. The vertebral artery fills along its
extracranial course without evidence of pathology.
5. Right internal carotid arteriogram: Selective injection demonstrates filling
of the internal along the cervical, petrous, cavernous, supraclinoid segment.
Middle cerebral artery distal branches fill out well. Anterior cerebral artery
distal branches fill out well. Bilateral anterior cerebral arteries fill on this
injection. There is a small amount of residual filling at the base of the
previously coiled aneurysm. This residual/recurrent aneurysm measures 1.8 x 2.1
mm. Fetal type posterior communicating artery is noted. There is an infundibular
origin of an anterior cerebral artery branch at the level of the anterior
communicating artery, stable from prior. Careful analysis of three-dimensional
reconstructed images demonstrates the anatomy of the residual aneurysm in
relationship to the parent artery to advantage and the presence of a small
artery originating from the peak of the infundibulum at the anterior
communicating artery complex. No evidence of additional intracranial aneurysm,
vascular malformation, arteriovenous shunting. No abnormalities of the venous
phase. Arteriovenous transit is normal.
6. Right middle cerebral arteriogram: Selective injection demonstrates the
intraluminal position of the microcatheter. Patency of distal branches. No
contrast extravasation. No other untoward findings.
7. Right internal carotid artery mid embolization. During embolization, the
distal aspect of the device is open at the level of the carotid terminus. The
proximal device remains restrained within the microcatheter. No contrast
extravasation or other untoward findings.
8. Right internal carotid arteriogram post embolization: Following
embolization, internal carotid, middle cerebral artery, anterior cerebral
artery, distal branches fill out well. Excellent apposition of the device both
distal and proximal and across the neck of the posterior communicating artery.
There is some stagnation of contrast within the aneurysm.
IMPRESSION: Angiography with uncomplicated flow diversion therapy for a residual
previously ruptured right posterior communicating artery aneurysm.
I am fairly new and I need a second opinion on my coding. My docs like to debate and I need help explaining why the codes changed. particularly on the provider selection 36225/bilateral, but I got 36225/RT.
Provider selection:
- 36223/unilateral
- 36224/unilateral
- 36225/ bilateral
- 36228/ unilateral
- 61624 X1 unit
- 75894 X 1 unit
- 76898 X2 units
- 76937 X1 unit
- 76377 X1 unit
My Finding
- 76937/26
- 36223/59, LT
- 36224/RT
- 36225/RT
- 76377/26
- 36228/RT
- 61624
- 75894/26
- 75898 X2 UNITs
POSTOPERATIVE DIAGNOSIS: Right posterior communicating artery aneurysm status
post coil embolization, with recurrence.
NAME OF PROCEDURES:
1. Introduction of needle catheter into right proximal radial artery under
continuous ultrasound guidance with storage of an image.
2. Left subclavian arteriogram.
3. Left common carotid arteriogram.
4. Right internal carotid arteriogram.
5. Rotational angiogram, right internal carotid, with 3D reconstruction
performed on additional workstation with direct physician involvement.
6. Right internal carotid arteriogram magnified working angles in the A plane
RAO 32, caudal 22, in the B plane RAO 90, cranial 0.
7. Right middle cerebral artery arteriogram.
8. Transcatheter permanent embolization of the central nervous system, Pipeline
embolization of right posterior communicating artery aneurysm.
9. Right internal carotid arteriogram, mid embolization.
10. Right internal carotid arteriogram, post embolization.
11. Right subclavian angiogram.
INDICATIONS FOR PROCEDURE: A 59-year-old female, history of a ruptured right
posterior communicating artery aneurysm, initially treated with coil
embolization. She has a known residual at the base and the plan was for cerebral
angiogram with planned flow diversion therapy. Risks and benefits of the
procedure were discussed with the patient prior to the procedure. These risks
include but are not limited to vessel injury, hematoma, hemorrhage, stroke, and
death. We discussed alternatives of conservative management, microsurgical
treatment, and coil embolization. The patient understands the risks and
benefits of the procedure and elects to proceed. All her questions were
answered. Informed consent was obtained. No guarantees were made.
DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite,
positioned supine on the angiography table. The right radial region was prepped
and draped in the usual sterile fashion. Following induction of general
anesthesia, the patient was endotracheally intubated. SSEP and EEG monitoring
were established and remained at baseline throughout the procedure. A timeout
was performed in accordance with the hospital protocol. Using modified Seldinger
technique and a micropuncture needle, access was obtained to the right proximal
radial artery and a 7-French sheath was placed under continuous ultrasound
guidance with storage of an image. We then infused the radial artery cocktail.
We prepped and advanced a 7-French BMX over a select Sim 2 and 0.035 Glidewire.
Wire catheter combination was tracked to the arch, reformatted. We catheterized
the left subclavian and left common carotid artery. Selective injection was
performed with catheter positioned in each of these vessels, filming in the PA,
lateral and oblique views using digital reconstruction. We catheterized the
right subclavian artery and angiography was performed. At this point, we
attempted to catheterize the right common carotid, but we were unable to do so
due to the angulation and the kink of our Simmons catheter. Therefore, it was
removed. We prepped and advanced and set a select Berenstein over an 0.035 glide
and this wire catheter combination was used to catheterize the right internal
carotid artery. The wire was removed. Selective injection was performed, PA and
lateral views. We then performed a rotational angiogram, right internal carotid
with 3D reconstruction, performed on additional workstation with direct
physician involvement. At this point, we elected to proceed with embolization.
We administered 5 mg of verapamil to the internal carotid. We administered
heparin to maintain an ACT of greater than 200. Throughout the course of the
procedure, the patient had been started on aspirin and Plavix beforehand and was
respondent of Plavix. We tracked the BMX to the distal cervical carotid. We then
prepped and advanced an Esperance 5-French over a Phenom 27 and a Synchro. Wire
catheter combination was used to cross the aneurysm, position of the
microcatheter in the distal middle superior artery. The wire was removed. We
performed a microcatheter angiogram. We then prepped and advanced a 4.0 x 12 mm
Pipeline Flexor Shield Technology device. This was deployed beginning at the
level of the carotid terminus. We pushed the device out across the aneurysm. We
performed control angiography during deployment. We then recaptured the wire.
Follow-up angiogram was performed and we turned our attention to closure. BMX
was removed from the patient. A 7-French sheath was removed. TR band was
applied, achieving excellent hemostasis. The patient was then extubated and
transported to the ICU in stable condition, having tolerated the procedure well.
It should be noted, I was present throughout the procedure, puncture and final
closure, present for the critical portions including but not limited to vessel
catheterization, angiography, image interpretation, embolization, and final
closure. Immediately available for all non-critical portion. No backup surgery
was necessary as this was a single case.
ANGIOGRAPHIC FINDINGS:
1. Right radial ultrasound: Right radial ultrasonography demonstrates pulsatile
patent radial artery. This was used to guide placement of the sheath under
continuous ultrasound guidance with storage of an image.
2. Left subclavian arteriogram: Selective injection demonstrates filling of the
vertebral along its extracranial and intracranial course, basilar artery and
distal branches including bilateral superior cerebellar arteries are well
visualized. The left PICF fills well and is free of pathology. Neither P1
segment is noted, given the fetal origin of these vessels. No evidence of
intracranial aneurysm, vascular malformation, arteriovenous shunting. No
abnormalities of the venous phase. Arterial venous transit is normal.
3. Left common carotid arteriogram: Selective injection demonstrates filling of
the internal along the cervical, petrous, cavernous and supraclinoid segment.
The medial cerebral artery distal branches fill out well. The anterior cerebral
artery distal branches fill out well with rapid washout due to competitive flow.
Large caliber fetal-type posterior communicating artery was noted. External
carotid artery and branches were superimposed on this injection. No evidence of
intracranial aneurysm, vascular malformation, arteriovenous shunting. No
abnormalities of the venous phase. Arteriovenous transit is normal.
4. Right subclavian arteriogram: Selective injection demonstrates the
subclavian fills without evidence of hemodynamically significant stenosis.
Costocervical, thyroid, cervical trunks, and distal branches are well
visualized. The common carotid artery is visualized and no evidence of cervical
carotid artery stenosis is noted. The vertebral artery fills along its
extracranial course without evidence of pathology.
5. Right internal carotid arteriogram: Selective injection demonstrates filling
of the internal along the cervical, petrous, cavernous, supraclinoid segment.
Middle cerebral artery distal branches fill out well. Anterior cerebral artery
distal branches fill out well. Bilateral anterior cerebral arteries fill on this
injection. There is a small amount of residual filling at the base of the
previously coiled aneurysm. This residual/recurrent aneurysm measures 1.8 x 2.1
mm. Fetal type posterior communicating artery is noted. There is an infundibular
origin of an anterior cerebral artery branch at the level of the anterior
communicating artery, stable from prior. Careful analysis of three-dimensional
reconstructed images demonstrates the anatomy of the residual aneurysm in
relationship to the parent artery to advantage and the presence of a small
artery originating from the peak of the infundibulum at the anterior
communicating artery complex. No evidence of additional intracranial aneurysm,
vascular malformation, arteriovenous shunting. No abnormalities of the venous
phase. Arteriovenous transit is normal.
6. Right middle cerebral arteriogram: Selective injection demonstrates the
intraluminal position of the microcatheter. Patency of distal branches. No
contrast extravasation. No other untoward findings.
7. Right internal carotid artery mid embolization. During embolization, the
distal aspect of the device is open at the level of the carotid terminus. The
proximal device remains restrained within the microcatheter. No contrast
extravasation or other untoward findings.
8. Right internal carotid arteriogram post embolization: Following
embolization, internal carotid, middle cerebral artery, anterior cerebral
artery, distal branches fill out well. Excellent apposition of the device both
distal and proximal and across the neck of the posterior communicating artery.
There is some stagnation of contrast within the aneurysm.
IMPRESSION: Angiography with uncomplicated flow diversion therapy for a residual
previously ruptured right posterior communicating artery aneurysm.
It's best to start a fresh thread if you have a new case. And we like it when you provide how you would code it. In other words we don't want to do your coding for you but help confirm / clarify.
