Jami Posted Mon 08th of January, 2018 15:22:27 PM
This is how I coded the procedure; 36215,75710,76937
Description of Procedure: After the patient was appropriately consented and all the risks and benefits of the procedure are explained to the patient, the patient's groins are prepped and draped in the standard surgical fashion.
The right groin is assessed with ultrasound and 1% lidocaine plain is injected into the skin and subcutaneous tissues in the amount of 20 ml. Under ultrasound guidance the right CFA is accessed with an 18 gauge needle. Then using a 0.035 angled access wire through the needle, the wire was introduced into the aorta followed by placement of a 5 fr sheath after removal of the needle. The sheath was flushed with heparinized saline solution. The patient was given 2000 units of heparin IV. At that point a 5 fr NEFF catheter was placed into the Aortic arch in a with 3rd order selection and the C-Arm is placed in a 25 degree LAO and angiography was performed.
Findings: Type III arch with high grade stenosis of the left subclavian artery. The BCT is patent and the left CCA is patent.
there in a 4th order selection the NEFF was placed into the proximal left subclavian artery and angiography was performed.
Findings: High grade stenosis is noted in the subclavian artery about 90%. The proximal/origin of the LSCA measures 11 mm and the proximal 7 mm.
Then the NEFF catheter was placed beyond the stenosis and angiography was performed.
Findings: The vertebral artery is patent, the TCT is patent. No disease is noted distally in the subclavian artery.
The patient was then given 3000 units of heparin in planning to stent. Due to the mismatch in size the stent needs to be flared to meet the proximal end of the LSCA size. We did not have a stent large enough to post dilate the iCast stent 7 mm x 38 mm stent.
The case was stopped and the patient was given 40 units of Protamine. The sheath was pulled and pressure was applied.
Good hemostasis was obtained, Mupirocin ointment and sterile occlusive dressings were applied. US was used to access the common femoral artery flow. The flow is patent and good hemostasis.
SuperCoder Answered Tue 09th of January, 2018 04:08:38 AM
AAE does not provide coding for operative reports and chart notes. SuperCoder offers SuperCoding on Demand (SOD)
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