Wiki How should an attempt to cross a lesion in left popliteal artery be coded?

mcauffman86

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Provider attempts to cross totally occluded popliteal artery in left lower extremity. How should this be coded? Would you code the interventional code 37224 with a 53 modifier? or just the cath placement code 36247? The codes I came up with are 36247-LT, 75716-26. I do professional billing for cardiology. These unsuccessful attempts at crossing a lesion have always been a gray area for me.

PROCEDURE: Aortobifemoral artery angiography with runoff, cross over from right to left side, attempted to cross the totally occluded left popliteal artery

DATE OF PROCEDURE: 3/12/2020

INDICATION: Peripheral vascular disease with worsening claudication rather for stage III

PROCEDURES PERFORMED:
1. Fluoroscopy of the lower abdomen and bilateral leg
2. Placement of the sheath in the right common femoral artery
3. Aortobifemoral artery angiography with runoff
4. Crossover from right to left side and selective left SFA and popliteal artery angiography for better visualization with placement of the catheter at the common femoral and SFA
5. Attempt to cross the totally occluded popliteal artery


EQUIPMENT USED:
1. 0.035 Navi cross catheter
2. 0.018 mini catheter
3. 0.035 Glidewire and 0.018 30 g estato wire

DESCRIPTION OF PROCEDURE:
Ultrasound guided vascular access was performed using the Lumify vascular system.
The right common femoral artery was identified by Ultrasound above the profunda femoral branch.
The vessel demonstrated good color flow and appears suitable for vascular access.
Real time live visualization of vascular needle entry and direct puncture into the right common femoral artery was performed to ensure safe access to the vessel without double puncture.
Vascular access was achieved with a single puncture without difficulty. A french arterial sheath was introduced safely with Ultrasound guidance. There are no complications.

Patient was brought into the Cath Lab, draped and prepped in conventional fashion and using Xylocaine anesthesia a 6 French sheath was placed in the right common femoral artery. With a Tennis Racquet catheter placed in the descending aorta at the bifurcation of the aorta and aortobifemoral artery angiography with runoff was performed.

CINE INTERPRETATION:
Fluoroscopy shows severely calcified SFA and popliteal artery



Right Leg:
Common Iliac Arteries: Calcification noted with some mild tortuosity no obstructive disease is noted
Internal Iliac Artery: Moderate size vessel with no obstructive disease
External Iliac Artery: Calcification is noted at the junction of external and common iliac artery there is 70-80% stenosis
Common Femoral Artery: Severely calcified very distal common femoral artery has severely calcified and eccentric 80-90% stenosis
Profundus Femoral Artery: Moderate-sized vessel with no obstructive disease
Superficial Femoral Artery: Severely calcified mid segment has got severe calcification and 80-90% stenosis distal segment also has got 90% stenosis and further down at the popliteal area which is diffusely diseased and calcified and multiple lesions were noted in the proximal segment in the midsegment is completely occluded with collaterals numerous channels were noted and gives rise to one vessel runoff few diffusedly diseased vessels in the upper segment of the collaterals were noted
Popliteal Artery: popliteal area which is diffusely diseased and calcified and multiple lesions were noted in the proximal segment in the midsegment is completely occluded
Below the Knee: collaterals numerous channels were noted and gives rise to one vessel runoff few diffusedly diseased vessels in the upper segment of the collaterals were noted

Left Leg:
Common Iliac Arteries: Severely calcified from ostial to proximal segment appears to be 50-60% stenosis is noted however the pressure gradient was measured and there was no significant gradient was seen. The mid to distal common iliac artery doesn't show any stenosis
Internal Iliac Artery: Moderate-sized vessels are not large and there is aneurysmatic segment is noted
External Iliac Artery: Significant calcification is noted.
Common Femoral Artery: Severely calcified with severe stenosis of 80-90% is noted just in the proximal segment and before the bifurcation
Profundus Femoral Artery: Moderate size branch with no stenosis
Superficial Femoral Artery: Distal segment has got eccentric 90% plus stenosis. Further down the multiple lesions of 80-90% is noted
Popliteal Artery: Has severe 80-90% stenosis of proximal segment and midsegment and the knee is completely occluded and with the multiple collateral channels there is one-vessel runoff was seen
Below the Knee: One-vessel runoff in multiple collateral channels.

MODERATE SEDATION:
Moderate sedation was administered using IV Versed and Fentanyl. Patient received continuous EKG, hemodynamic and oximetry monitoring with physician being present for the entire time. Total moderate sedation duration = 55 min.

CONTRAST:
Medication Name Total Dose
iodixanol (Visipaque) 320 mg/mL injection 130 mL


PTA AND STENTING:
Patient was given 5000 units of intravenous heparin. Selective SFA and popliteal artery Jennifer was performed after crossing from right to the left side. 0.035 wire with the use she was passed all the way down to the distal SFA and with the help of 0.035 Nellie cross the distal segment was passed and reached at the total occlusion of the popliteal artery. Because of very large collaterals coming from the mid to proximal popliteal artery wire was professionally going into that. Then the wire was passed somewhat down into the total occlusion with a U-shaped but the Navy cross would not go through and then the .035 wire was changed to 0.018 wire and Navy cross was changed to 0.018 mini cross. the picture of the wire was going below the collaterals was taken but it would not cross through and after trying for good time procedure was stopped. In all instruments were taken out. Patient will need the surgery with the endarterectomy of the common femoral artery with family to bypass, and probably will need surgery bilaterally.. We'll review the cine with vascular surgeon

CINE INTERPRETATION:
1. Pre-PTA totally occluded SFA with multiple SFA and common femoral artery lesion on the left leg unable to cross the total occlusion


FINAL DIAGNOSIS:
1. Right leg shows severe calcification and iliac common femoral artery stenosis with SFA shows multiple lesion totally occluded popliteal artery with one-vessel runoff
2. Left leg shows severe calcification with severe stenosis of the common femoral artery and multiple lesions in the SFA was totally occluded popliteal artery with one-vessel runoff
3. Attempt to cross the totally occluded popliteal artery wasn't successful

RECOMMENDATION:
Patient will be discharged home today. Will review the cine film with the vascular surgeon and patient will be electively seen by surgeon for surgical revascularization
 
Code the cath placement with imaging.

I like to refer to RadRX's advice on cancelled procedures:
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 (‐53, ‐73, ‐74).
 
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