37220-74 ???

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Greater Portland (Maine)
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Is it appropriate to add modifier 74 (facility coding) to 37220 in this case where doc attempted several times with different wire/catheter combinations to cross occlusion to treat CIA?

PREOPERATIVE DIAGNOSIS: Atherosclerosis with intermittent claudication, left greater than right.

POSTOPERATIVE DIAGNOSIS: Atherosclerosis with intermittent claudication, left greater than right.

NAME OF PROCEDURE:
1. Angiogram of the abdominal aorta with bilateral lower extremities.
2. Selective catheterization of the left common iliac artery.

SURGEON: Xxxx X Xxxxx, M.D.

ANESTHESIA: Local with moderate sedation x1 hour.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

ACCESS: Six French sheath, right common femoral artery, retrograde.

CLOSURE DEVICE: Angio-Seal 6 French.

CLINICAL HISTORY: This 77-year-old man has severe intermittent claudication left greater than right lower extremity and he has severely diminished ABIs bilaterally, left worse than right. He comes for arteriography of the aorta with intention to treat. He has a reasonable right groin pulse but no pulse on the left and is obese. He has chronic renal insufficiency with a creatinine of 1.7 and preoperative sodium bicarbonate protocol was initiated.

RADIOLOGIC FINDINGS:
1. The abdominal aorta was patent with solitary renal arteries bilaterally. The left renal artery had an area of stenosis of 60% to 70% approximately 2.5 cm from its origin. This was an eccentric plaque. The nephrogram on the left was better than that on the right. The superior mesenteric artery was patent and came off at the level of the right renal artery. It appeared to have a 90 degree angulation off the abdominal aorta.

2. There is atherosclerotic disease of the distal abdominal aorta, but this is not flow limiting.

3. On the right side, the common iliac artery was patent as was the hypogastric and external iliac arteries. The right hypogastric artery fed the left hypogastric artery, and the left lower extremity was thereby fed from the collaterals from the left hypogastric artery. The right common femoral artery was patent as was the superficial femoral artery. The superficial femoral artery was somewhat small, measuring approximately 2 mm near its origin, 3 to 4 mm proximally, and then 4 to 5 mm in the mid segment. In the mid thigh, a very calcific appearing lesion was present for a length of 10 cm. The superficial femoral artery was totally occluded across this area. A large collateral came off at the level of the occlusion and fed the more distal superficial femoral artery. The popliteal artery above the knee was patent. Behind the knee and below the knee were patent. There was single vessel runoff via the right peroneal artery. Distally, this gave a collateral to the posterior tibial artery at the level of the ankle. The anterior tibial artery was occluded throughout its length as was the posterior tibial artery.

4. On the left side, the common iliac artery was patent for approximately 1 cm and then became chronically totally occluded. The external iliac artery was totally occluded as was the origin of the hypogastric artery. As mentioned previously, collaterals from the hypogastric artery on the left fed the distal most common femoral artery. The more proximal common femoral artery appeared to be chronically totally occluded. Collaterals appeared to enter the proximal profunda femoris artery and retrograde filled the common femoral and superficial femoral arteries.

Due to the patient's renal insufficiency, I decided no further imaging of the left lower extremity was indicated at the present time.

5. I then selectively catheterized the left common femoral artery and attempted to cross the total occlusion. A 6 French Morph catheter was used in conjunction with numerous wires, and I was only able to enter a subintimal plane of the common iliac artery on the left, and decided that this was not going to be adequate. I desisted in my attempts to cross at this point.

A small plug of thrombus was removed through the Morph catheter.

An Angio-Seal device was used to close the puncture site.

OPERATIVE REPORT: The patient was taken to the Cardiac Catheterization Lab where he was placed on the table in the dorsal recumbent position. After excellent moderate sedation the skin of the groin areas were prepared and draped in the standard sterile fashion and I called a time out for correct patient and procedural identification per Xxxx Hospital protocol. Under local anesthesia and under ultrasound guidance, I accessed the right common femoral artery. The artery accessed easily, and I was unable to initially pass the guidewire, and this required a second puncture in the artery. This time, I was able to get the guidewire with difficulty up the right external and common iliac arteries and into the abdominal aorta. A 5 French sheath was inserted. Three-thousand units of unfractionated was administered IV. Next, I advanced an Omni flush catheter over a guidewire into the abdominal aorta. The catheter was fashioned to the abdominal aorta at the L1-L2 vertebral body position. Bubbles were removed and an AP angiogram of the abdominal aorta was obtained. I then pulled the catheter down to the aortic bifurcation and oblique images of the ileofemoral and pelvic runoff were obtained. Next, I removed the Omni flush catheter over a guidewire, and serialography of the entire right lower extremity from the femoral head to the ankle was performed. Distally, additional contrast was needed due to the total occlusion of the superficial femoral artery on the right.

Next, I inserted a 6 French Morph catheter on the right side. Through the Morph catheter, the Omni flush catheter was replaced and fashioned. The Omni flush catheter was used with the tip in the left common iliac artery proximally, and with the Omni flush catheter in place, the Morph catheter was fashioned over the Omni flush catheter with the tip in the left common iliac artery proximally. I then used the Morph catheter in conjunction with the Omni flush catheter, several different crossing catheters including a 0.018 inch CXI catheter and a 0.035 inch mini catheter in conjunction with numerous wires including a Treasure 12 wire, and an Astato wire, and a glidewire both stiff and normal, and curved and angled. Nonetheless, none of these wire/catheter combinations were successful in crossing any significant amount of the total occlusion on the left. Eventually I desisted. The Morph catheter was refashioned and removed. I noted significant difficulty aspirating the catheter, and so the valve on the Morph catheter was removed, this expressed a small plug of thrombus. An angiogram of the right ileofemoral position showed a reasonably normal appearing artery, and so the right groin area was re-prepared and redraped and Angio-Seal device was deployed. A dry sterile dressing was then placed. There were no complications and Mr. Xxxxx tolerated the procedure well. He received a total of 6000 units of unfractionated heparin IV and a total of approximately 65 mL of Isovue 300 contrast. Fluoro time is noted in the nursing notes.

I've got 75625, 75716, 37220-74. Don't know if I'm way off base here.
 

kimcpccircc

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Location
St Pete Beach, FL
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I believe you can only code what was performed. I believe you have a 1st order selective 36245, the first access 36140-59, and your angiograms.

Hope this helps! Kim
 
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