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Bilateral renal artery angio and stent placement

Michelle Posted Thu 04th of February, 2016 11:09:09 AM

Hello, I am fairly new to vascular coding and I want to make sure I code this correct. I am thinking 36252 (bilat)and 37236, 37237. From what I have read angio is included in stent placement so I would not use 35471. I attached the op note below.

THanks for any help with this.

Procedure:
1. Right femoral access.
2. Aortogram with birenal imaging.
3. Select bilateral renal arteries.
4. Bilateral renal artery angioplasty and stenting.
5. Vascade placement access site on right.

Description of Procedure: The patient was taken to the procedure room, placed in the supine position, underwent a timeout, given oral sedation, and had the right and left groins draped and prepped in a sterile fashion.

With a single front-wall stick, the right common femoral artery was accessed. A 6 Fr sheath was placed followed by a SOS Omni Flush at the perirenal aorta. Aortogram with birenal imaging was performed. Single renal arteries were seen. There were no cortical abnormalities. There were no findings of aneurysmal disease. Bilateral renal artery stenosis was seen, orificial on the right and orificial extending into the main portion of the renal artery on the left.

The patient was given 3,500 units of heparin, and we used a guide cath and a 0.018 wire to gain access and angioplastied the renal arteries separately. A 5 x 1.5 balloon expandable stent was used on the right, and a 6 x
1.8 balloon expandable stent was used on the left. This resulted in marked improvement of flow across both renal arteries. There were no touchdown site abnormalities, no significant persistent stenosis, no distal embolization, and no sluggish flow. Having optimized the vascular status as much as possible, the procedure was terminated, and a Vascade was placed on the access site on the right.

SuperCoder Answered Fri 05th of February, 2016 07:08:45 AM

Code 35471 bundles into 37236 but a modifier is allowed in order to differentiate between the service provider. Rest of the codes (36252 and 37237) are correct.

Michelle Posted Fri 05th of February, 2016 09:16:41 AM

Thanks so much for your help.

SuperCoder Answered Sun 07th of February, 2016 23:45:16 PM

Happy to Help!

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