Instent Laser Atherectomy

Alfaro33

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Physician would like to bill 37799 unlisted procedure, vascular surgery for the laser atherectomy of Instent along with 37221, 36200, 37252, 36140, 75625, 76937. Any suggestions?


Indication for Surgery
Patient is a 89 Years F who has a complex vascular surgical history with a left iliol femoral artery bypass and crossover femoral-femoral artery bypass done in the past. Patient presents to the office with severe lifestyle limiting claudication and a CT angiogram was performed which showed evidence of InStent stenosis and severe stenosis of anastomosis of iliol femoral bypass. Explained to the patient the patient's family that she has a threatened ileal femoral bypass which supplied circulation to both lower extremities therefore both upper limbs are were threatened because of the InStent stenosis and the severe stenosis at the anastomosis. Therefore I recommended the patient to undergo a stent placement across the area of high-grade stenosis. I explained to the patient and the patient's family the risks of the procedures which include but not limited to bleeding, retroperitoneal hematoma, anastomosis disruption. Patient and patient's family is a where the risks and wished to proceed.

Preoperative Diagnosis

Threatened left ileal femoral bypass
Severe lifestyle limiting bilateral lower extremity claudication

Postoperative Diagnosis

Above

Operation

1. Ultrasound-guided access of the left ileal femoral artery bypass
2. Diagnostic aortogram with catheter placement in the abdominal aorta
3. Intravascular ultrasound of the left common iliac and ileal femoral artery bypass
4. Laser atherectomy of InStent stenosis of the left common iliac artery
5. Placement of a balloon mounted 6 x 39 mm Omnilink iliac stent placement


Findings

Severe InStent stenosis of left common iliac stent with a lumen measuring 3 mm with intravascular ultrasound
Severe stenosis along the iliofemoral anastomosis

Specimen(s)

Complications

Technique
Patient was brought into the operative room and intubated in the supine position. Patient was given proper preoperative antibiotics the patient was prepped and draped in usual sterile fashion. With the ultrasound probe over the distal ilio femoral artery bypass I performed a successful arterial puncture with a micro needle. I then advanced the micro wire in place and upsized this to a 5 French sheath. With the help of a Glidewire and NaviCross catheter I was able to manipulate through the InStent stenosis and was able to place a catheter into the abdominal aorta. I Performed a contrast injection which confirmed the catheter was intraluminal. I then exchanged for an Omni Flush catheter and perform diagnostic aortogram which showed that there was an area of high-grade stenosis along the course of the distal common iliac artery. There was also an area of stenosis along the area of the anastomosis of the previously placed ilio femoral artery bypass. Patient was systemically heparinized and a 6 x 23 cm sheath was then placed. I then placed a 018 Spartacore wire and placed intravascular ultrasound within aorta. A run was performed with intravascular ultrasound which showed areas of severe stenosis along the distal stent and anastomosis measuring approximately 3 mm of lumen. Considering that this was supplying both lower extremities I elected to treat the areas of high-grade stenosis.

I introduced a laser arthrectomy device and I performed an atherectomy of the distal InStent stenosis at 45 fluence and 45 rate. . I then increased the frequency the laser to 50 fluence and 50 rate. After laser atherectomy and a run which showed improvement of the areas of InStent stenosis. Therefore elected to treat this with a Omniflush 6 x 39 mm stent. I introduced a stent and I deployed stent across the area of stenosis. The stent was balloon dilated with an 8 x 40 mm balloon. Final run showed excellent resolution of the areas of stenosis. Perform a repeat run with the intravascular ultrasound which showed ultrasound resolution of the areas of stenosis with improvement of the true lumen to 8 mm. There was an excellent pulse along the femoral arteries bilaterally. I then removed the wires and catheters and placed a short 6 French sheath. I then closed the arteriotomy site with a is Mynx closure device. Patient tolerated procedure well was sent to the PACU in good condition.
 

Jim Pawloski

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This is how I would code this procedure. First, delete codes 36200 and 36014 as the intervention supersedes the catheterization codes. I agree with the 37221 code and for the atherectomy of the iliac artery, I would code 0238T. I also agree with the 37252 for the IVUS of the Iliac artery. I would not code 76937 as there is no documentation of an image saved to PACS or the chart. Last one is that I would not code 75625 as there is a contrast CTA was performed. So you wind up coding 37221, 37252, 0238T.
HTH,
Jim Pawloski, CIRCC
 

Alfaro33

Contributor
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This is how I would code this procedure. First, delete codes 36200 and 36014 as the intervention supersedes the catheterization codes. I agree with the 37221 code and for the atherectomy of the iliac artery, I would code 0238T. I also agree with the 37252 for the IVUS of the Iliac artery. I would not code 76937 as there is no documentation of an image saved to PACS or the chart. Last one is that I would not code 75625 as there is a contrast CTA was performed. So you wind up coding 37221, 37252, 0238T.
HTH,
Jim Pawloski, CIRCC
Thank you!!
 
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