Wiki attempted cath placement

Greater Portland (Maine)
Best answers
How would this be coded? 75625, 75710, 37221 and 37224-74??

PREOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.

POSTOPERATIVE DIAGNOSIS: Atherosclerosis with tissue loss, right foot.

1. Angiogram of the abdominal aorta and right lower extremity.
2. Stent placement, right external iliac artery.
3. Unsuccessful attempt at crossing the right superficial femoral artery, unsuccessful attempt at accessing the right superficial femoral artery.

SURGEON: Xxxx X. Xxxxx, MD

ANESTHESIA: Local with moderate sedation.

EBL: Minimal.


ACCESS: 6-French sheath, left common femoral artery, retrograde.

1. The abdominal aorta was patent with solitary renal arteries bilaterally. On the left side, there was approximately 50% calcific stenosis near the origin of the common iliac artery. On the right side, a 40% right common iliac artery stenosis near the origin was noted with severe calcification.

2. Several marble-like radiolucencies were noted within the distal-most left common iliac artery and left external iliac artery which were not hemodynamically significant. On the right side, a similar calcified lesion was noted in the external iliac artery proximally and in the internal iliac artery proximally. Right and left hypogastric arteries were patent.

3. The right external iliac artery had several areas of significant calcifications to which were significantly occlusive. The left common femoral artery was patent.

4. A right hip prosthesis made imaging of the right common femoral artery more difficult than usual.

The right proximal common femoral artery was crossed successfully, but I could not cross into the proximal right superficial femoral artery which was chronically totally occluded near its origin. The right profunda femoris artery was also chronically totally occluded near its origin. Numerous collaterals radiated from the external iliac artery and common femoral artery proximally and entered the more distal profunda femoris artery and the more distal superficial femoral artery. These reconstituted the superficial femoral artery. The superficial femoral artery was then patent for 10 cm in the proximal thigh and then became chronically totally occluded. The distal superficial femoral artery then reconstituted and the popliteal artery was noted to be patent. Just above the knee, the popliteal artery had a 60-70% lesion. A right knee prosthesis also diminished imaging of the right popliteal artery behind the knee. After failing to successfully cross the right proximal-most SFA lesion from above, I then attempted to access the right superficial femoral artery and the right popliteal artery and these were unsuccessful.

At this point, I decided to place a stent within the right external iliac artery and a 9 x 40 balloon was used to post-dilate a 10-mm x 60-mm LifeStent in the external iliac position. Completion angiogram showed significant improvement in flow in the right external iliac artery.

I accepted this result.

CLINICAL HISTORY: This pleasant 65-year-old woman has atherosclerosis with ischemic rest pain and tissue loss of the right foot. She comes for arteriography with the intention to treat. ABIs were noted to be very diminished bilaterally.

PROCEDURE REPORT: The patient was taken to the Cardiac Catheterization Laboratory where she was placed on the table in the dorsal recumbent position. After excellent induction with moderate sedation, the skin of the groin area was prepared and draped in a standard sterile fashion. I then called a time-out for correct patient and procedural identification per Xxxxx Hospital protocol. Under local anesthesia and using Seldinger technique and using color flow Duplex ultrasound for guidance, I accessed the left common femoral artery in the retrograde direction. A 5-French sheath was inserted and aspirated and flushed easily. Through the sheath, I advanced an Omniflush catheter into the abdominal aorta. The Omniflush catheter was advanced into the L1-L2 vertebral body position and the guide wire was removed and bubbles were removed from the catheter; 3000 units of unfractionated heparin then administered IV. I then performed an angiogram of the abdominal aorta through the Omniflush catheter. The catheter was then pulled down to the aortic bifurcation where oblique images of the iliofemoral and pelvic runoff were obtained.

Next, I selectively catheterized the right common femoral artery from the left side. This did prove to be quite difficult due to the patient's right hip prosthesis. Additional images of the right lower extremity were obtained. I could not obtain meaningful images below the knee, although it appeared that the patient had 1-vessel run-off via the anterior tibial artery at the level of the distal ankle. Severe calcification was noted in the right lower extremity.

Next, I exchanged the 5-French sheath over a stiff guide wire for a 6-French Ansel-II sheath. The Ansel-II sheath was advanced into the distal external iliac artery. Using a combination of catheters and wires, I was unable to cross the right superficial femoral artery lesion. A 0.018-inch treasure 12 wire, a 0.018-inch Astato wire, a standard stiff and straight glide wire measuring 0.035 were all used in combination with supporting catheters. I then attempted to access the right superficial femoral artery distally and work backwards through the lesion and this was also unsuccessful as severe calcifications precluded accessing the right superficial femoral artery.

At this point, I decided to treat the right external iliac artery only and determined that the patient would likely need an open surgical approach to her right common femoral artery lesion and might need either bypass, angioplasty or stent placement in the right superficial femoral artery.

I then selected a LifeStent measuring 10 mm x 60 mm and this was deployed across the right external iliac artery lesions. These were then post-dilated with a 9-mm x 60 balloon. A completion arteriogram was performed. This demonstrated significant improvement in the right external iliac artery caliber and flow. I tried, once again, to cross the right superficial femoral artery after this and this was also, again, unsuccessful. I terminated the procedure. The sheath was removed. No closure device was used due to left common femoral artery disease. Direct pressure was applied until meticulous hemostasis was achieved.

I agree with your codeset. I would bill the 37224-74 as most consultants and hospital coders out there agree that the below portion of Medicare Transmittal 442 (Hospital Outpatient Prospective Payment System (OPPS): Use of Modifiers -52, -73 and -74 for Reduced or Discontinued Services) allows hospitals to bill for procedures that were attempted but discontinued (like yours) in order to cover the costs associated with the attempted procedure (the overhead costs of the room, the the time of the staff, the countless wires that do not cross, sheaths, the unused stent, additional contrast used etc). Additionally, your provider did a nice job of documenting the time and resources spent trying to cross the lesion and his plan for open intervention to treat the disease later.

Here is an excerpt from that transmittal under modifier 74:
This modifier [modifier 74] code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.

But the one part I always get hung up on though on this transmital is here:
C - Termination Where Multiple Procedures Planned
When one or more of the procedures planned is completed, the completed procedures are
reported as usual. When one or more of the procedures planned is completed, the completed procedures are reported as usual. The other(s) that were planned, and not started, are not reported.

I guess what we have to decide here is whether or not the 37224 actually started. Some would argue that it had, because you spent a great deal of time and resources trying to wire that lesion, which really won't be represented by any procedural charge unless you bill 37224-74. If you agree that it had, then bill 37224-74. My guess is that they probably had that stent ready, already opened, and out of the package. And if those supplies were made ready, but not used, the only charge that can cover that overhead of the opened but unused supply is to bill 37224-74.

Make sure to put a 59 on that 75710 so it doesnt edit with your 37221.

By the way, this is a nice report. Give this doctor a gold star for me, refreshing!

Thanks, Jayna. I appreciate your looking at it from different perspectives. I'm always re-reading that Medicare transmittal 442 to ensure that I'm applying it according to its intent. But, as you mentioned, sometimes it's not clear-cut. I've had discussions with this particular doctor about discontinued procedures and what I'd need to see in his documentation and he appears to have listened well. This was the first case I'd come across myself in which a procedure was completed in one territory, but not in another, so I was a little bit unsure. Thanks again for your opinion and guidance.