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Cerebral angiography with attempted cerebral thrombectomy

Date: Aug 22, 2022

Question:

We have a stroke patient who had a left internal carotid injection for diagnostic angiogram. Following that the physician placed a Sofia catheter to try to aspirate clot from MCA, but had to abort the procedure. 

Documentation states: "Multiple attempts were made to cross occluded M1 segment of proximal left middle cerebral artery using microwire and microcatheter without any success due to very calcified lesion likely subacute or chronic occlusion. Unfortunately, I was not able to advance intermediate catheter to M1 segment of left middle cerebral artery for direct suction due to very tortuous vascular anatomy, and the procedure was aborted."

Would you only code the diagnostic angiogram, or would you also add the attempted thrombectomy with a -74 modifier to account for the extra work?

Question ID : 17673
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