Question AAA Coding Conundrum

mcauffman86

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Saint Joseph, MI
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My physician attempted a AAA repair but it was aborted due to iliac artery tortuosity. The left external iliac artery was stented. What procedures can I bill for with this? Also this procedure was performed by co-surgeons. Which components/codes can each physician bill for? Below are both co-surgeons reports:

Co-Surgeon 1
Preoperative Dx: AAA

Postoperative Dx: Same

Procedure: Access into bilateral femoral artery with US guidance
Introduction of catheter into abdominal aorta
Aortography
Selective B retrograde iliac angiography
Left external iliac angioplasty
Left external iliac stent placement - 100 to 0%
Aborted EVAR


EBL: Min

Indication:

This is a 64 YO male with COPD presented with enlarging asymptomatic AAA. CTA showed 55 mm AAA with highly tortuous iliac arteries.

Description of procedure:

After full informed consent was obtained, the patient was taken to the angio suite and placed in supine position. Appropriate monitoring was established. Adequate anesthesia was administered.

Access into both femoral artery was obtained using a needle with direct US visualization and guidance followed by insertion of a wire and 7 Fr sheath under fluoroscopic visualization. A Glidewire was selected to advance into the aorta. The wire would not advance on either side beyond mid external iliac arteries. Retrograde selective iliac angio showed dissection of both external iliac arteries. A Glidewire was successfully advanced through the true lumen on the L side into the aorta. Extensive antegrade and retrograde attempts to establish access across the R iliac artery true lumen were unsuccessful. The iliac arteries were extremely tortuous and friable. At this point the decision was made to abort the planned EVAR.

The L external iliac artery was treated with a balloon angioplasty using a 6x80 mm balloon followed by deployment of overlapping 7x60 mm and 7x40 mm Absolute stents starting from the take-off of internal iliac to the take-off of inferior epigastric distally. Angio showed excellent flow with 0% residual stenosis.

No intervention to the R iliac was performed due to inability to cross with wire. Angio showed good flow through collaterals perfusing the R femoral. The pressure gradient across the totally occluded R iliac was 30 mmHg. The R leg was carefully examined and appeared well perfused.

The arterial sheaths were removed with good hemostasis after return of ACT to baseline with Protamine. Patient tolerated the procedure well and was transferred to the recovery room in stable condition.




Co-Surgeon 2

Pre-Operative Diagnosis: Abdominal aortic aneurysm

Post-Operative Diagnosis: Iliac artery dissection. Aborted EVAR

Estimated Blood Loss: Minimal

Procedure:
Peripheral angiogram and peripheral angioplasty and stent placement report

INDICATION FOR PROCEDURE:
64-year-old gentleman with history of tobacco abuse, COPD and chronic kidney disease as well as history of abdominal aortic aneurysm dating back to 2015
Patient was followed for over last several years and noted to have an enlarging aortic aneurysm from 5.6-5.9 over the last 6 months.
Review of the CT angiogram film demonstrated patient is an appropriate candidate for endovascular repair of abdominal aortic aneurysm using a Cook Zenith endograft.
Patient is scheduled for endovascular AAA repair.
At the time of the EVAR procedure, vascular access was achieved with US.
However, during the wire access, there are bilateral iliac artery dissection due to severe iliac artery tortuosity.
Emergent left iliac artery angioplasty and stent placement was performed.
EVAR procedure was aborted.

Nature of procedure, including benefits, alternative and risks, e.g. bleeding, CVA, MI, renal failure, infection, emergency CABG and even death explained.

NAME OF PROCEDURE:
1. Arterial access via the right and left groin groin.
2. Suprarenal Abdominal Aortogram.
3. Bilateral iliac artery angiogrm.
4. PTA and stent placement of the left external iliac artery with a flexible guidewire and 6.0 mm balloon and 7 x 80 mm and 7 x 40 mm Absolute stent Stent
5. Attempted to re-enter the true lumen of the right iliac artery with multiple flexible guidewire and was unsuccessful due to iliac artery tortuosity.

DESCRIPTION OF PROCEDURE:
After an informed consent, the patient was brought into the cath lab and prepped and draped in the usual fashion. General anesthesia was administered by anesthesiologist and the anesthesia record will be reported separately.

After the bilateral groins was anesthetized, vascular access was achieved without difficulty using US by Dr *********.
However, there is bilateral iliac artery dissection during wire insertion due to bilateral iliac artery tortuosity.
We are able to found there true lumen on the left iliac artery and a 5-French Tennis Racquet was advanced into abdominal aorta. Suprarenal abdominal aortogram was performed without complication. Peripheral angiography demonstrated left iliac artery dissection and occluded the vessel to 90%. Emergency left iliac artery angioplasty and stent placement is recommended.

We were able to cross the 90% left iliac artery dissection and stenosis with flexible guide wire and angioplasty was performed with a 6.0 mm balloon.
Subsequently, due to inadequate result, stent placement was recommended using a 7x80 mm and 7x40 mm Absolute Stent.

The right iliac artery dissection can not be re-cross to the true lumen due to severe tortuosity and further attempts are aborted. There is a gradient of 30 mm across the left iliac artery from 110 to 80 mm Hg. This will be treated medically at this time.

Patient tolerated the procedure well and was transferred to CVL recovery for post-procedure management.

The right and left groin sheaths was removed using Manuel pressure with good hemostasis and without complication.

FLUOROSCOPY:
Demonstrated bilateral Aorto iliac and SFA calcification.

CINE INTERPRETATION:
Aortoiliac angiogram demonstrated calcification with AAA.
The left iliac artery dissection 90% was reduced to 0% post Angioplasty and Stent placement
The right iliac artery has a iliac artery dissection and will be treated medically.

RECOMMENDATION:
The EVAR procedure is aborted.
Recommend Aspirin and Plavix therapy.
Noninvasive study as clinically needed to rule out restenosis.
Noninvasive study to follow AAA to guide further therapy.
 
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