left SFA

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would appreciate some assistance on this report....36200, 75630, 75710, 37250,37205 appropriate codes?

thank you!

PROCEDURES PERFORMED DATE:
1. Conscious sedation.
2. Aortogram.
3. Lower extremity run off.
4. Left lower extremity angiography.
5. IVUS of the left superficial femoral artery.
6. Angioplasty of the left superficial femoral artery.
7. Stent of the left superficial femoral artery.
8. Perclose of the right common femoral artery.

CLINICAL HISTORY:
The patient is a 69-year-old male with a history of peripheral
arterial disease and prior peripheral vascular intervention, who
has developed severe left lower extremity claudication and
markedly abnormal arterial ultrasound suggesting high grade
stenosis of the left superficial femoral artery.

PROCEDURE:
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery. Conscious sedation was
administered; from 13:56 at the time of initiation of conscious
sedation to 15:45, the patient was monitored continuously with
intra-arterial blood pressure monitoring, heart rate monitoring,
pulse oximetry. A total of 2 mg of Versed and 150 mcg of Fentanyl
were used and administered in intermittent aliquots. After
obtaining percutaneous access with a #5 French sheath, a VCF
catheter was advanced over a Wholey wire into the abdominal aorta
and an aortogram was performed in a shallow LAO oblique
angulation. Following abdominal aortography, the catheter was
withdrawn to the aortic bifurcation and a lower extremity run off
was performed. Imaging of the iliac arteries and through the left
lower extremities was performed. I then advanced the VCF catheter
over a Wholey wire into the left superficial femoral artery and
performed additional imaging of the left superficial femoral
artery at its area of greatest stenosis. A decision was made at
this time to proceed with intervention.

Over the 0.035 wire, we exchanged the #5 French sheath in the
right groin for a #6 French Destination sheath. This was advanced
over the Wholey wire into the left superficial femoral artery.
5000 units of heparin were administered through the procedure.
Repeat boluses of heparin were administered to maintain an ACT
greater than 250. I then used a 6 x 40 mm SDS balloon to dilate
the lesion in the left SFA. Following balloon dilation, we had
adequate angiographic results with less than 50% stenosis of the
vessel. However, the vessel was extremely calcified and a
decision was made to perform IVUS on the lesion. I advanced a
Volcano IVUS catheter over an Iron Man wire into the left
superficial femoral artery. I performed imaging on the area that
we had angioplastied and we found severe residual eccentric
stenosis and a decision was made to stent that area. I therefore
deployed a Sentinel 8 mm x 40 mm self-expanding stent in the left
SFA. Following stent deployment, I returned with the SDS balloon
and performed angioplasty to fully dilate the stent. We had
excellent angiographic results. Again we returned with an
intravascular ultrasound and found the mid area of the stent to be
incompletely expanded with a very eccentric calcified plaque
protruding into the vessel. I returned therefore with a 7 x 20 mm
SDS balloon and performed angioplasty. We repeated the IVUS and
had excellent angiographic results. We did withdraw the IVUS
catheter through the left SFA to two areas of interest immediately
after the origin of the profundofemoris. Here the SFA had two
highly eccentric calcified plaques that resulted in approximately
60-70% stenosis of the lumen. We continued pullback of the IVUS
across the left external and common iliac arteries. I continued
with the pullback through the right common iliac artery and
through the stent of the right external iliac artery. We found
residual calcified plaque in the right common iliac artery
resulting in a 60% stenosis and then the stent in the right
external iliac artery was widely patent. After removal of the
wires, we performed final angiography at the right common femoral
artery demonstrating an arteriotomy
above the bifurcation that was felt to be suitable for a closure
device. I deployed a #6 French Perclose with adequate achievement
of hemostasis.

FINDINGS:


AORTOGRAM:
The aortogram demonstrates diffuse atherosclerotic plaquing
throughout the descending aorta. The celiac and mesenteric
arteries are patent but their origins are not visualized. The
right kidney appears normal in size and has a patent right renal
artery. The left renal artery appears severely diseased
throughout its proximal and mid segments with heavily calcified
plaque, probable 90% stenosis. The mid and inferior pole of the
left kidney are adequately visualized. The superior pole of the
left kidney is not visualized angiographically and may represent
an occlusion of separate or branch renal artery. At the aortic
bifurcation, there is calcified plaque that extends into the right
common iliac artery and results in a 60% stenosis.

There is moderate atherosclerotic plaquing in the distal right
common iliac artery prior to the origin of the right hypogastric
artery which is patent. There is a stent in the right external
iliac artery that is widely patent with minimal in-stent
restenosis. The right common femoral artery has mild
atherosclerotic plaquing. There is mild ectasia to the left
common iliac artery and then at the left hypogastric artery, that
artery is patent. The left external artery appears smooth with
minimal irregularities. There is mild to moderate calcification
of the left common femoral artery.

The right profundofemoris is widely patent. The right superficial
femoral artery has mild atherosclerotic plaquing at Hunter's Canal
resulting in 20% stenosis. There is a stent in the right
popliteal artery with mild in-stent restenosis and then
immediately distal to the stent in the mid right popliteal artery,
there is moderate to heavily calcified plaque resulting in 60-70%
stenosis. Distal to that area, the right popliteal artery appears
smooth and there is three vessel run off to the foot with mild
atherosclerotic plaquing in the inferopopliteal vessels.

On the left, the common femoral artery has moderate
atherosclerotic plaquing involving the origin of the left
profundofemoris and then through the proximal left SFA, there are
two heavily calcified and moderate to severe stenoses of 60-70%.
Through the mid left SFA, there is mild atherosclerotic plaquing
and then at Hunter's Canal is high grade heavily calcified plaque
resulting in probable 90% stenosis. Distal to Hunter's Canal, the
left SFA and popliteal artery and inferopopliteal vessels have
mild atherosclerotic plaquing but no high grade stenosis
identified. There is three-vessel run off to the foot.
 

donnajrichmond

True Blue
Messages
518
Location
Alexandria, LA
Best answers
0
would appreciate some assistance on this report....36200, 75630, 75710, 37250,37205 appropriate codes?

thank you!

PROCEDURES PERFORMED DATE:
1. Conscious sedation.
2. Aortogram.
3. Lower extremity run off.
4. Left lower extremity angiography.
5. IVUS of the left superficial femoral artery.
6. Angioplasty of the left superficial femoral artery.
7. Stent of the left superficial femoral artery.
8. Perclose of the right common femoral artery.

CLINICAL HISTORY:
The patient is a 69-year-old male with a history of peripheral
arterial disease and prior peripheral vascular intervention, who
has developed severe left lower extremity claudication and
markedly abnormal arterial ultrasound suggesting high grade
stenosis of the left superficial femoral artery.

PROCEDURE:
After obtaining informed consent, the patient was transported in
the nonsedated condition to the cardiac catheterization suite. The
patient was prepped and draped in a sterile fashion. Lidocaine 2%
was used to infiltrate the skin and subcutaneous tissue overlying
the right common femoral artery. Conscious sedation was
administered; from 13:56 at the time of initiation of conscious
sedation to 15:45, the patient was monitored continuously with
intra-arterial blood pressure monitoring, heart rate monitoring,
pulse oximetry. A total of 2 mg of Versed and 150 mcg of Fentanyl
were used and administered in intermittent aliquots. After
obtaining percutaneous access with a #5 French sheath, a VCF
catheter was advanced over a Wholey wire into the abdominal aorta
and an aortogram was performed in a shallow LAO oblique
angulation. Following abdominal aortography, the catheter was
withdrawn to the aortic bifurcation and a lower extremity run off
was performed. Imaging of the iliac arteries and through the left
lower extremities was performed. I then advanced the VCF catheter
over a Wholey wire into the left superficial femoral artery and
performed additional imaging of the left superficial femoral
artery at its area of greatest stenosis. A decision was made at
this time to proceed with intervention.

Over the 0.035 wire, we exchanged the #5 French sheath in the
right groin for a #6 French Destination sheath. This was advanced
over the Wholey wire into the left superficial femoral artery.
5000 units of heparin were administered through the procedure.
Repeat boluses of heparin were administered to maintain an ACT
greater than 250. I then used a 6 x 40 mm SDS balloon to dilate
the lesion in the left SFA. Following balloon dilation, we had
adequate angiographic results with less than 50% stenosis of the
vessel. However, the vessel was extremely calcified and a
decision was made to perform IVUS on the lesion. I advanced a
Volcano IVUS catheter over an Iron Man wire into the left
superficial femoral artery. I performed imaging on the area that
we had angioplastied and we found severe residual eccentric
stenosis and a decision was made to stent that area. I therefore
deployed a Sentinel 8 mm x 40 mm self-expanding stent in the left
SFA. Following stent deployment, I returned with the SDS balloon
and performed angioplasty to fully dilate the stent. We had
excellent angiographic results. Again we returned with an
intravascular ultrasound and found the mid area of the stent to be
incompletely expanded with a very eccentric calcified plaque
protruding into the vessel. I returned therefore with a 7 x 20 mm
SDS balloon and performed angioplasty. We repeated the IVUS and
had excellent angiographic results. We did withdraw the IVUS
catheter through the left SFA to two areas of interest immediately
after the origin of the profundofemoris. Here the SFA had two
highly eccentric calcified plaques that resulted in approximately
60-70% stenosis of the lumen. We continued pullback of the IVUS
across the left external and common iliac arteries. I continued
with the pullback through the right common iliac artery and
through the stent of the right external iliac artery. We found
residual calcified plaque in the right common iliac artery
resulting in a 60% stenosis and then the stent in the right
external iliac artery was widely patent. After removal of the
wires, we performed final angiography at the right common femoral
artery demonstrating an arteriotomy
above the bifurcation that was felt to be suitable for a closure
device. I deployed a #6 French Perclose with adequate achievement
of hemostasis.

FINDINGS:


AORTOGRAM:
The aortogram demonstrates diffuse atherosclerotic plaquing
throughout the descending aorta. The celiac and mesenteric
arteries are patent but their origins are not visualized. The
right kidney appears normal in size and has a patent right renal
artery. The left renal artery appears severely diseased
throughout its proximal and mid segments with heavily calcified
plaque, probable 90% stenosis. The mid and inferior pole of the
left kidney are adequately visualized. The superior pole of the
left kidney is not visualized angiographically and may represent
an occlusion of separate or branch renal artery. At the aortic
bifurcation, there is calcified plaque that extends into the right
common iliac artery and results in a 60% stenosis.

There is moderate atherosclerotic plaquing in the distal right
common iliac artery prior to the origin of the right hypogastric
artery which is patent. There is a stent in the right external
iliac artery that is widely patent with minimal in-stent
restenosis. The right common femoral artery has mild
atherosclerotic plaquing. There is mild ectasia to the left
common iliac artery and then at the left hypogastric artery, that
artery is patent. The left external artery appears smooth with
minimal irregularities. There is mild to moderate calcification
of the left common femoral artery.

The right profundofemoris is widely patent. The right superficial
femoral artery has mild atherosclerotic plaquing at Hunter's Canal
resulting in 20% stenosis. There is a stent in the right
popliteal artery with mild in-stent restenosis and then
immediately distal to the stent in the mid right popliteal artery,
there is moderate to heavily calcified plaque resulting in 60-70%
stenosis. Distal to that area, the right popliteal artery appears
smooth and there is three vessel run off to the foot with mild
atherosclerotic plaquing in the inferopopliteal vessels.

On the left, the common femoral artery has moderate
atherosclerotic plaquing involving the origin of the left
profundofemoris and then through the proximal left SFA, there are
two heavily calcified and moderate to severe stenoses of 60-70%.
Through the mid left SFA, there is mild atherosclerotic plaquing
and then at Hunter's Canal is high grade heavily calcified plaque
resulting in probable 90% stenosis. Distal to Hunter's Canal, the
left SFA and popliteal artery and inferopopliteal vessels have
mild atherosclerotic plaquing but no high grade stenosis
identified. There is three-vessel run off to the foot.
36200 would not be appropriate even if no intervention was performed because the doctor catheterized to the contralateral SFA for imaging - "I then advanced the VCF catheter
over a Wholey wire into the left superficial femoral artery and
performed additional imaging of the left superficial femoral
artery at its area of greatest stenosis." Had there been no intervention, the catheterization code would have been 36247.
But there was intervention, and those codes include the catheterization so 36247 cannot be coded. Angioplasty, stenting, and/or atherectomy in the legs are now coded with codes 37220-37235. Code 37205 specifically excludes lower extremity arteries (see the code description - "except coronary, carotid, vertebral, iliac, and lower extremity arteries".

For this case, the codes would be
37226 - stenting (and angioplasty) in the femoral - popliteal territory
75630-59 - diagnostic aortogram with bilateral runoff
75774-59 - additional diagnostic imaging in the left extremity from the SFA prior to the decision to intervene.
37250
37251 x 4
75945
75946 x 4

37250, 37251, 75945, and 75946 may or may not be allowed. The instructions for lower extremity revascularization say that codes 37220-37235 include "imaging performed to document completion of the intervention", however, none of the notes prohibit IVUS codes. There are no CCI edits for the IVUS codes with the revascularization codes. But, parentheticals under the IVUS codes list the codes they may be used with and 37220-37235 are not among those codes.
 

Jim Pawloski

True Blue
Messages
1,289
Location
Ann Arbor
Best answers
0
36200 would not be appropriate even if no intervention was performed because the doctor catheterized to the contralateral SFA for imaging - "I then advanced the VCF catheter
over a Wholey wire into the left superficial femoral artery and
performed additional imaging of the left superficial femoral
artery at its area of greatest stenosis." Had there been no intervention, the catheterization code would have been 36247.
But there was intervention, and those codes include the catheterization so 36247 cannot be coded. Angioplasty, stenting, and/or atherectomy in the legs are now coded with codes 37220-37235. Code 37205 specifically excludes lower extremity arteries (see the code description - "except coronary, carotid, vertebral, iliac, and lower extremity arteries".

For this case, the codes would be
37226 - stenting (and angioplasty) in the femoral - popliteal territory
75630-59 - diagnostic aortogram with bilateral runoff
75774-59 - additional diagnostic imaging in the left extremity from the SFA prior to the decision to intervene.
37250
37251 x 4
75945
75946 x 4

37250, 37251, 75945, and 75946 may or may not be allowed. The instructions for lower extremity revascularization say that codes 37220-37235 include "imaging performed to document completion of the intervention", however, none of the notes prohibit IVUS codes. There are no CCI edits for the IVUS codes with the revascularization codes. But, parentheticals under the IVUS codes list the codes they may be used with and 37220-37235 are not among those codes.
Hi Donna,
Great explaination of the intervention on this case. However, I disagree with you on the diagnostic codes. The catheter was placed in the abdominal aorta and imaging occured. But then the catheter was pulled down to the bifurcation and bilateral lower extremity angio was performed. I would have billed 75625-59 for the abdominal aorta, and 76716-59 for the lower extremity angiogram If the catheter was not pulled down, then I would bill the 76530-59.

Thanks,
Jim Pawloski, CIRCC
 

donnajrichmond

True Blue
Messages
518
Location
Alexandria, LA
Best answers
0
Hi Donna,
Great explaination of the intervention on this case. However, I disagree with you on the diagnostic codes. The catheter was placed in the abdominal aorta and imaging occured. But then the catheter was pulled down to the bifurcation and bilateral lower extremity angio was performed. I would have billed 75625-59 for the abdominal aorta, and 76716-59 for the lower extremity angiogram If the catheter was not pulled down, then I would bill the 76530-59.

Thanks,
Jim Pawloski, CIRCC
Jim, you are right. I had copied down the original codes to use as a reference in my discussion and I forgot to change that one.
 
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