Bundled Codes

hammonds77

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I am not too familiar with Vascular coding. Provider reported 37228,36246-59, 76937-26 and 75716-26,59. Both 36246 and 75716 was denied as bundled. Is there anyway to appeal this, I have attached the OP note below

Date: 04/03/19



Attending: Carl Gonzales, MD



Pre Op Dx:


1. Atherosclerosis of extremity artery with ulceration

2. Peripheral Arterial Disease



Post Op Dx:


same



Procedures:


1. Ultrasound guided percutaneous access of right common femoral artery

2. CO2 angiography of Aortoiliac system and left lower extremity

3. Angioplasty of left anterior tibial artery

4. Angioplasty of left peroneal artery



Findings: Aortoiliac and femoropopliteal arteries are widely patent.  Severe tibial disease with occlusion of all three tibial vessels, the DP reconstitutes at the ankle.



EBL: 10 mL



Complications: none



Fluoroscopy Time: 21.7 mins



Radiation Dose: 398 mGy



Contrast used: 10 mL



Indications:


Mr. Burkett is a 57-year-old African-American male who presented to the office 1 week prior to the angiogram for evaluation of a nonhealing left foot ulcer.  He underwent podiatric surgery with subsequent infection and nonhealing of the surgical wound.  He has been undergoing local wound care by the Rockdale wound care center.  Prior to the visit last week, he was seen August 2018 where a noninvasive study illustrated mild to moderate arterial disease in the bilateral lower extremities with an ABI of the left leg noted to be 0.69.  Due to the nonhealing ulcer and the nonpalpable pedal pulses in the left foot he was indicated for an angiogram with intention to treat.  Risks and benefits of procedure were discussed with the patient and he agreed to proceed with surgical intervention.





Procedure in Detail:


After informed consent was obtained from the patient, the patient was taken to the Cath Lab and placed in supine position on the Cath Lab table.  His bilateral groins were then prepped and draped in usual sterile fashion.  Moderate sedation was induced and ultrasound guidance was used along with Seldinger technique and a micropuncture kit to gain access into the right common femoral artery.  Eventual placement of a 5 French sheath was advanced into the right common femoral artery and a stiff Glidewire was advanced into the distal abdominal aorta.  A rim catheter was advanced over the Glidewire and positioned in the distal abdominal aorta.  The Glidewire was removed and due to his elevated creatinine and low GFR, CO2 angiography was used.  The CO2 angiography was obtained which illustrated a widely patent abdominal aorta, aortic bifurcation, bilateral common iliac arteries, and bilateral external iliac arteries with rapid clearance of CO2.  There were no significant stenosis noted.  Access was gained over the aortic bifurcation with the rim catheter and a stiff Glidewire, with eventual advancement of the rim catheter to the level of the left common femoral artery.  Serial angiograms using CO2 was then obtained of the left lower extremity which illustrated a widely patent common femoral artery, bifurcation, profunda femoris, superficial femoral artery, and popliteal artery.  The stiff Glidewire was then advanced into the left SFA and the rim catheter was removed.  An 035 quick cross catheter was then advanced over the Glidewire and was positioned in the popliteal artery.  The Glidewire was removed and lower leg angiograms were obtained with contrast to evaluate the tibial vessels.  This illustrated patent C of the origins of the tibial vessels however the anterior tibial artery occluded shortly after its origin and the tibioperoneal trunk also occluded and there was multiple collateral vessels noted in the calf with reconstitution of the dorsalis pedis artery at the level of the ankle.



Patient was systemically anticoagulated with 5000 units of IV heparin and after advancing a stiff Glidewire back into the left popliteal artery and removed and the quick cross catheter, the 5 French sheath was exchanged for a 5 French by 90 cm Ansell destination sheath which was positioned in the left popliteal artery.  A Navicross catheter was then advanced over the Glidewire to the level of the tibial plateau and the Glidewire was then removed.  An 014 command wire was then advanced to the Nava cross catheter and access was gained into the anterior tibial artery the Nava cross catheter was then removed and exchanged for an 018 quick cross catheter and access was gained into the anterior tibial artery to the level of the midcalf however the wire and the catheter would not advance any further.  The command wire was exchanged for a V 18 wire and the V 18 wire was be was able to be advanced to the level of the midcalf but the quick cross catheter would not advance any further therefore the quick cross catheter was then removed and a 3 mm x 60 mm Pacific plus Balloon was then advanced over the V 18 wire and balloon angioplasty was performed of the left anterior tibial artery.  There was a severe waist noted during balloon inflation with a 3 mm balloon therefore that balloon was deflated after 2 minutes of inflation, and a after exchanging the V 18 wire for a command wire, a 3 mm x 15 mm angiosculpt scoring balloon was then advanced over the command wire and this was inflated to burst pressures and it also was not able to open the severe stenosis in the proximal anterior tibial artery.  Several other balloons were then used including a noncompliant coronary Quantum Apex balloon that was 2.5 mm x 15 mm however that would continue to slip therefore a noncompliant Euphora RX 2.5 mm x 27 mm balloon was then advanced and this also was unable to open up the severe stenosis.  After spending over an hour of attempting to open up that stenosis this was abandoned access was gained into the peroneal artery and an attempt was made to revascularize the peroneal artery to the level of the ankle to supply better collateral flow to the dorsalis pedis, however this was unsuccessful.  The wire would not advance beyond the distal calf and it was angioplastied with a Pacific 2.5 mm x 120 mm balloon over a V 18 wire.  Repeat angiogram was obtained from the Ansell sheath which illustrated improved collateral flow from the anterior tibial and peroneal arteries however no direct in-line flow via any of the tibial vessels were noted.  At this time the procedure was then terminated.  The 5 French by 90 cm Ansell sheath was exchanged for a 5 French 10 cm sheath in the right common femoral artery over a stiff Glidewire.  The Glidewire and the dilator were then removed and a Mynx 5 French closure device was successfully deployed in the right common femoral artery.  Manual pressure was gently applied until hemostasis was achieved.  Patient tolerated the procedure well and was transferred to the CDU in stable condition.
 

cpc2007

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Hi, after reviewing the documentation, the catheter work is bundled, and I'm only seeing a complete angiogram on the left leg only without a clear decision to intervene which may be why the payer is denying the 75716.

To explain, the physician starts from the right common femoral artery, goes up into the aorta, and eventually over into the left leg down to the level of popliteal artery, taking angiogram pictures as he goes. That catheter placement from the right common femoral to the left popliteal is actually a third order or higher (36247) rather than a 36246. The reason it will bundle, though, is because the subsequent intervention (the angioplasty in the anterior tibial artery) is also performed from the right common femoral artery approach and also requires a third order or higher catheter placement in the same leg where the angiogram was performed. So the catheter work to perform the angiogram occurs "en route" to and from the same access point as the catheter work for the angioplasty procedure. Since the 37228 already includes the catheter work needed to perform the procedure (which in this case is that third order or higher catheterization from the right common femoral artery), the physician was already paid for the catheter work with the 37228 and the catheter code bundles. So I would delete the 36246.

For the radiology S&I code for the angiogram, while he starts off imaging from the lower abdominal aorta and comments on the iliac arteries (common and external) over on the right, I believe these arteries were incidentally imaged and therefore commented on and would code for the left leg angiogram only (75710 instead of 75716) if this was a truly diagnostic study. When dye or CO2 are introduced in the lower abdominal aorta, the physician will start by taking a couple of pictures across the entire pelvic area normally, and will therefore see the iliac arteries and sometimes even the very top of the common femoral arteries on both sides. If a physician sees an artery in an image, they will typically comment on whether it is normal or abnormal even if they weren't intending to image that artery. That's what I think is happening here. Reading the history, the only symptoms mentioned are on the left leg so I think in the course of performing the intended angiogram on the left starting from the common iliac down, he incidentally saw the right and commented on it, but there is no medical necessity for imaging the right leg that is noted in the report. So again would be looking at 75710 instead of 75716.

The final piece not clearly noted is his "decision to intervene based on the angiogram." Full angiographic images, the lack of a prior angiogram study, and the decision to intervene together would make this diagnostic. I do think your physician intended this as a diagnostic angiogram (he only mentions a non-invasive study happening before this surgery which is not an angiogram). But he says he is going to perform an angiogram with "intention to treat" (as if he's already decided to treat). I think he means he will treat if the angiogram confirms a specific abnormality requiring treatment as I don't ever see vascular surgeons decide to intervene based on noninvasive studies, but I would clarify this with him and encourage him to note his decision to intervene in these types of reports moving forward if the angiogram is diagnostic and necessary to make that decision (will help in getting these studies paid when they should be).

One final note - I noticed your physician's name and the patient's last name were included in the screen shot of the note. To protect patient confidentiality, I would take all reference to names (physician, patient, hospital) out of notes on posts on the forum just to be safe. I hope that helps. Sorry I know it's a long response, but since you mentioned you were newer to vascular, I wanted to break down the "why" for each part of the response to help with these cases moving forward :)

Kim
www.codingmastery.com
 

arclayton

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Hello Hammonds!
I would change your coding to the following:
37228-LT - Left anterior tibial artery
37232-LT - Left peroneal artery
75710-LT-XU - Left leg angiogram

The angioplasty of the left peroneal artery was unsuccessful but it was still performed and reported with 37232. In order to report a leg angiogram the legs must be imaged beyond the pelvis, usually at least to the knees or below. We don't see anything on the right side below the external iliac so 75716 would be inappropriate. I don't see any mention of the US guidance images being permanently stored so I would not report 76937.

For Unsuccessful Procedures, I like to refer to the advice on RadRX:
Unsuccessful Revascularization or Unacceptable Outcome.
If a revascularization is unsuccessful because the lesion cannot be crossed, then the appropriate access and/or selection and imaging only should be coded. On the other hand, if the lesion is crossed and the revascularization is performed but with an unacceptable outcome, then the revascularization is coded since all the work of the revascularization was done. If the revascularization has been initiated and it is discontinued, assign the revascularization codes with the appropriate modifiers (Physician: ‐53, Hospital: ‐73, ‐74).
 
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