Ask Dr. Z

We are still confused about the new coding for arch angiograms. How would you code the following surgery? We came up with codes 36221, 36217, 36218, 75710, and 75774. Please help with explanation!

PREOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. POSTOPERATIVE DIAGNOSIS: Clinical steal syndrome, right upper extremity. OPERATION PERFORMED: 1. Arch angiogram. 2. Unilateral right upper extremity arteriogram. ANESTHESIA: Local with moderate sedation. INDICATIONS FOR OPERATION: The patient is a 31-year-old male with a history of end-stage renal disease. He has clinical steal syndrome, right upper extremity. Presents now for arteriogram. FINDINGS: 1. The patient had no branch stenosis of the supraaortic trunk; specifically, subclavian, right and left common, and right subclavian arteries were widely patent. 2. On the right upper extremity axillary and brachial artery were widely patent. The fistula anastomosis was visualized, and distal to the anastomosis clinical steal was occurring, as blood was flowing retrograde up the fistula from the more distal aspect of the brachial artery. Intrinsic arteries of the forearm, namely brachial, interosseous, and ulnar artery were otherwise widely patent. Palmar arch was predominant and from the ulnar artery distribution and with an intact palmar arch. DESCRIPTION OF OPERATION: After satisfactory monitoring lines were placed, the patient underwent moderate sedation. Single puncture access right common femoral artery with up size to a 5 French sheath over a Bentson wire. Pigtail catheter advanced into the ascending aorta where an arch angiogram was obtained. Selective catheterization then undertaken into the innominate artery and down the right subclavian artery. Sequential films were taken down the right upper extremity with advancement of a Mariner catheter. This included all the way down to the magnified view of the right hand. Catheter was then removed, and the sheath removed. A StarClose device was deployed uneventfully with satisfactory hemostasis achieved. The patient tolerated the procedure well with minimal blood loss. PLAN: Based upon the above angiographic findings, the patient will need to undergo a right upper extremity distal revascularization with interval ligation to improve flow to the right hand.