Q & A with Dr. David Zielske


Is arch aortogram (36221) separately codeable with stent placement of subclavian artery?
I am a little confused when a non-selective cath placement of the aortic arch can be reported with a selective intervention of an upper extremity artery. It would seem in the report below that the physician had plans to perform the therapeutic procedure based on the history. In these cases, is the determining factor as to whether the non selective cath placement (36221) can be reported based on if it is related or not to the subclavian stent placement? How would a coder make that distinction? 

PROCEDURE: Left groin cannulation with left subclavian artery cannulation, balloon angioplasty and stent placement.
ANESTHESIA: 1% lidocaine for local with intravenous fentanyl and Versed for a nurse-monitored anesthesia time of 1.5 hours.
PROSTHETIC IMPLANT: Genesis balloon expandable stent, 8 x 39 mm placed within the origin of the left subclavian artery.
REASON FOR PROCEDURE: This is a 61-year-old gentleman with coronary artery disease status post coronary artery bypass grafting including a left internal mammary artery graft to the left anterior descending artery. The patient presented to ABC Medical Center with an acute myocardial infarction. Cardiac catheterization was performed demonstrating two patent coronary artery bypass grafts with a high-grade left subclavian artery stenosis. Patient was transferred to XYZ Hospital for definitive treatment including stenting of his left subclavian artery stenosis. I evaluated the patient and recommended left groin cannulation given his recent cannulation within his right groin with selective catheterization of the left subclavian artery and stenting as appropriate. The indication is to treat the subclavian lesion restoring perfusion to his left anterior descending artery bypass graft. The risks include bleeding, arterial injury, failure to revascularize his left subclavian artery as well as atheroembolization. In addition, potential recurrent stenosis. The patient requested we proceed.
PROCEDURE AS FOLLOWS: On 02/26/2013, after obtaining informed consent, the patient was taken to the angiography suite and placed on the angiography table in the supine position. After prepping and draping his left groin in the usual fashion with ChloraPrep, patient identification and operative checklist was performed. Utilizing ultrasound guidance, the left common femoral artery was cannulated overlying the femoral head in a retrograde fashion with a Micropuncture needle. A Microwire was advanced under fluoroscopic guidance to the aortic bifurcation. This was exchanged through a coaxial dilator for a 5-French sheath and eventually a 6-French Raabe sheath, 55 cm. The guidewire was placed in the ascending aorta. Patient was heparinized with 4000 units of IV heparin. A pigtail catheter was placed in the ascending aorta. Arch aortography was performed with a steep left anterior oblique view demonstrating the left subclavian artery origin with subtotal occlusion with retrograde filling of the left upper extremity through the vertebral artery. The left internal mammary artery is identified distally and found to be patent. The left common carotid artery is patent as is the innominate. A 6-French Raabe sheath was then placed over the guidewire to the origin of the left subclavian artery. The left subclavian origin was selected with a vertebral artery catheter and a 0.014 inch Thruway guidewire. The guidewire was placed in the proximal brachial artery. Balloon angioplasty of the stenosis was performed with a 4 mm balloon angioplasty catheter followed by placement of an 8 mm balloon expandable Genesis stent. The stent was dilated within its mid segment and proximally and very gently distally. Selective angiography demonstrates a patent result without evidence of a residual stenosis. Guidewire and catheters were removed. Angiography of the left groin demonstrates extensive calcification just distal to the cannulation site, therefore, the catheter was removed and hemostasis was obtained with manual compression. The patient tolerated the procedure and was transferred to his room in stable condition.
IMPRESSION: Successful balloon angioplasty with stent placement, left subclavian artery origin stenosis.


In this case, the physician has available a recent prior diagnostic study demonstrating the abnormality, and the patient is admitted with the intent of performing a subclavian stent to treat the stenosis.  Since this is a known lesion, with no change in symptoms and no indication for a repeat diagnostic angiography, I would only code the catheter placement and the stent (also, no intent to be successful with the small 4mm balloon, so no suboptimal angioplasty) with codes
36215, 37205 and 75960
. Had the initial study been limited, suboptimal or a change in patient symptoms, then a diagnostic study should be considered.