bhargavi
Guru
should I code for atherectomy 0238T or just angio 37220?
I am thinking of coding 37225,36247,75630,0238T but does medicare pays for atherectomy? I bill for facility. please help
Procedures
Peripheral Angiography W/ Poss Intervention / pta / stent / iliac / tib artery / fem pop
Pre-procedure Diagnosis
Peripheral vascular disease, unspecified [I73.9]
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
PAD
Nonehaling leg ulcer
Indications
Peripheral vascular disease, unspecified [I73.9 (ICD-10-CM)]
Unspecified cardiovascular disease [I25.10 (ICD-10-CM)]
Calciphylaxis of lower extremity with nonhealing ulcer, limited to breakdown of skin, unspecified laterality [L97.901 (ICD-10-CM)]
Atherosclerosis, generalized [I70.91 (ICD-10-CM)]
Postsurgical aortocoronary bypass status [Z95.1 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the left groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 5 French arterial sheath was placed without difficulty into the left femoral artery. We then obtained a 5 French modified Hope catheter was positioned in the distal abdominal aorta. We then perform digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed mild to moderate calcification of the bilateral common iliac vessels without any significant disease. Both of the external and internal iliac vessels were patent. In the distal external iliac vessel leading into the common femoral, there was diffuse lengthy 80% stenosis that actually continued into the proximal superficial femoral artery. The profunda femoris artery was occluded proximally with collateralization and reconstitution. There was a large collateral vessel just above this that actually filled the above-knee popliteal. The distal SFA into the adductor canal had another area of 95% stenosis followed by a lengthy area of diffuse disease throughout the above-knee popliteal with multiple areas of 90-95% stenosis. The popliteal just above the knee joint was 100% occluded. Geniculate collaterals reconstituted part of the below-knee popliteal and allowed for filling of the peroneal vessel. The anterior tibial artery was 100% occluded and never reconstituted. The posterior tibial artery was occluded and reconstituted just above the ankle joint.
*
After identification of multiple areas of disease in the iliofemoral vessels, SFA, and popliteal, we elected to attempt percutaneous revascularization of the iliofemoral vessel and SFA in order to improve collateralization into the above and below knee popliteal. The existing 5 French catheter was exchanged over a 180 cm magic torque wire for a 7 French by 4570–destination sheath. 5500 units of intravenous heparin was administered in order to achieve an activated clotting time in excess of 200 seconds. Later in the procedure, an additional 1000 units of intravenous heparin was administered. We then obtained a 4 French by 60 cm glide catheter and withdrew the magic torque wire and exchanged it for a 0.014" x 300 cm length journey wire. We were able to advance the journey wire to the level of the severe distal SFA stenosis, but unfortunately were unable to advance this wire further. We obtained a 0.018 inch Rubicon catheter and advanced it to this level, exchanging the journey wire for a V 18 wire. The V18 wire across the area of subtotal occlusion successfully and was advanced to the level of the popliteal artery just above the point of occlusion. We advanced the Rubicon catheter and then withdrew the V18 wire in exchange for 0.014 inch 300 cm length Thruway wire. We then obtained a 2.1/3.0 jetstream catheter and performed multiple passes through the entire area of disease in the distal external iliac, common femoral, proximal superficial femoral, distal superficial femoral, and proximal popliteal vessels. Follow-up angiography did reveal an overall improvement in flows in the vessel. We decided to perform balloon angioplasty of the areas treated with the jetstream catheter utilizing a 5.0 x 100 mm mustang balloon. This was after the Thruway wire was exchanged for a 0.035 inch 260 cm stiff angled tip zip wire. We were able to advance this wire beyond the point of distal occlusion in the above-knee popliteal, and it appeared briefly that we were in the below the knee popliteal successfully. However, after follow-up angiography, we noted that the zip wire was in a subintimal plane, and therefore no additional attempts were made at crossing this area of disease. We then performed balloon dilatation utilizing the aforementioned mustang balloon throughout the areas that were treated with the jetstream device. Follow-up angiography revealed continued flow throughout the areas of disease with some mild improvement in collateralization distally. We then performed a drug-eluting balloon angioplasty of the distal most area of disease utilizing a 5.0 x 120 mm Lutonix balloon to 12 atm of pressure. We treated the proximal area of disease utilizing a 5.0 x 100 mm Lutonix balloon to 12 atm of pressure. Each of these inflations were for 2 minutes. Follow-up angiography revealed continued overall improvement in the angiographic caliber of the distal external iliac, common femoral, and proximal SFA as well as the distal SFA and above-knee popliteal. Flow dynamics were somewhat decreased compared to originally, but there did appear to be improvement of collateralization. Of note, there was now evidence of occlusion of the below knee popliteal with continued collateral filling of the peroneal vessel. Given that we felt that there was no additional role for further attempts at intervention, we elected to conclude this procedure. We were hopeful that with time flow dynamics would continue to improve and that collateralization would also continue to improve. We then removed the wire.
*
The destination sheath was then withdrawn to the level of the external iliac on the left, and runoff angiography was performed. This revealed a patent common femoral artery and patent vein graft from the proximal profunda femoris artery down to the level of the posterior tibial vessel on the left. The posterior tibial vessel was patent, though the anterior tibial and peroneal vessels were occluded.
*
After documentation of an activated clotting time of 192 seconds, the arterial sheath was removed with manual compression for hemostasis. The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Severe, multifocal disease on the right including distal external iliac, common femoral, proximal SFA, distal SFA, and popliteal with above-knee popliteal occlusion and collateralization of the below the knee vessel with single vessel runoff to the peroneal artery.
2. Status post jetstream atherectomy of the above lesions with unsuccessful crossing of the above-knee popliteal occlusion.
3. Status post balloon angioplasty with drug-eluting balloon treatment of external iliac, common femoral, proximal SFA, and distal SFA/proximal popliteal disease
4. Patent left femoral distal bypass graft
5. Manual compression utilized for hemostasis.
*
Plan:
*
1. Plavix indefinitely.
2. Resume Pradaxa tomorrow.
3. Aggressive risk factor modification.
4. Consider surgical referral for femoral distal bypass should the patient continue to have poor wound healing and continued symptoms.
I am thinking of coding 37225,36247,75630,0238T but does medicare pays for atherectomy? I bill for facility. please help
Procedures
Peripheral Angiography W/ Poss Intervention / pta / stent / iliac / tib artery / fem pop
Pre-procedure Diagnosis
Peripheral vascular disease, unspecified [I73.9]
Link to Procedure Log
Procedure Log
Post-procedure Diagnosis
PAD
Nonehaling leg ulcer
Indications
Peripheral vascular disease, unspecified [I73.9 (ICD-10-CM)]
Unspecified cardiovascular disease [I25.10 (ICD-10-CM)]
Calciphylaxis of lower extremity with nonhealing ulcer, limited to breakdown of skin, unspecified laterality [L97.901 (ICD-10-CM)]
Atherosclerosis, generalized [I70.91 (ICD-10-CM)]
Postsurgical aortocoronary bypass status [Z95.1 (ICD-10-CM)]
Conclusion
After obtaining informed consent, the patient was prepped and draped in the usual fashion. Approximately 10 mL 2% lidocaine anesthesia was administered to the left groin prior to placement of the arterial sheath. Under fluoroscopic guidance and using modified Seldinger technique, a 5 French arterial sheath was placed without difficulty into the left femoral artery. We then obtained a 5 French modified Hope catheter was positioned in the distal abdominal aorta. We then perform digital subtraction angiography of the distal abdominal aorta with bilateral iliofemoral runoff. This revealed mild to moderate calcification of the bilateral common iliac vessels without any significant disease. Both of the external and internal iliac vessels were patent. In the distal external iliac vessel leading into the common femoral, there was diffuse lengthy 80% stenosis that actually continued into the proximal superficial femoral artery. The profunda femoris artery was occluded proximally with collateralization and reconstitution. There was a large collateral vessel just above this that actually filled the above-knee popliteal. The distal SFA into the adductor canal had another area of 95% stenosis followed by a lengthy area of diffuse disease throughout the above-knee popliteal with multiple areas of 90-95% stenosis. The popliteal just above the knee joint was 100% occluded. Geniculate collaterals reconstituted part of the below-knee popliteal and allowed for filling of the peroneal vessel. The anterior tibial artery was 100% occluded and never reconstituted. The posterior tibial artery was occluded and reconstituted just above the ankle joint.
*
After identification of multiple areas of disease in the iliofemoral vessels, SFA, and popliteal, we elected to attempt percutaneous revascularization of the iliofemoral vessel and SFA in order to improve collateralization into the above and below knee popliteal. The existing 5 French catheter was exchanged over a 180 cm magic torque wire for a 7 French by 4570–destination sheath. 5500 units of intravenous heparin was administered in order to achieve an activated clotting time in excess of 200 seconds. Later in the procedure, an additional 1000 units of intravenous heparin was administered. We then obtained a 4 French by 60 cm glide catheter and withdrew the magic torque wire and exchanged it for a 0.014" x 300 cm length journey wire. We were able to advance the journey wire to the level of the severe distal SFA stenosis, but unfortunately were unable to advance this wire further. We obtained a 0.018 inch Rubicon catheter and advanced it to this level, exchanging the journey wire for a V 18 wire. The V18 wire across the area of subtotal occlusion successfully and was advanced to the level of the popliteal artery just above the point of occlusion. We advanced the Rubicon catheter and then withdrew the V18 wire in exchange for 0.014 inch 300 cm length Thruway wire. We then obtained a 2.1/3.0 jetstream catheter and performed multiple passes through the entire area of disease in the distal external iliac, common femoral, proximal superficial femoral, distal superficial femoral, and proximal popliteal vessels. Follow-up angiography did reveal an overall improvement in flows in the vessel. We decided to perform balloon angioplasty of the areas treated with the jetstream catheter utilizing a 5.0 x 100 mm mustang balloon. This was after the Thruway wire was exchanged for a 0.035 inch 260 cm stiff angled tip zip wire. We were able to advance this wire beyond the point of distal occlusion in the above-knee popliteal, and it appeared briefly that we were in the below the knee popliteal successfully. However, after follow-up angiography, we noted that the zip wire was in a subintimal plane, and therefore no additional attempts were made at crossing this area of disease. We then performed balloon dilatation utilizing the aforementioned mustang balloon throughout the areas that were treated with the jetstream device. Follow-up angiography revealed continued flow throughout the areas of disease with some mild improvement in collateralization distally. We then performed a drug-eluting balloon angioplasty of the distal most area of disease utilizing a 5.0 x 120 mm Lutonix balloon to 12 atm of pressure. We treated the proximal area of disease utilizing a 5.0 x 100 mm Lutonix balloon to 12 atm of pressure. Each of these inflations were for 2 minutes. Follow-up angiography revealed continued overall improvement in the angiographic caliber of the distal external iliac, common femoral, and proximal SFA as well as the distal SFA and above-knee popliteal. Flow dynamics were somewhat decreased compared to originally, but there did appear to be improvement of collateralization. Of note, there was now evidence of occlusion of the below knee popliteal with continued collateral filling of the peroneal vessel. Given that we felt that there was no additional role for further attempts at intervention, we elected to conclude this procedure. We were hopeful that with time flow dynamics would continue to improve and that collateralization would also continue to improve. We then removed the wire.
*
The destination sheath was then withdrawn to the level of the external iliac on the left, and runoff angiography was performed. This revealed a patent common femoral artery and patent vein graft from the proximal profunda femoris artery down to the level of the posterior tibial vessel on the left. The posterior tibial vessel was patent, though the anterior tibial and peroneal vessels were occluded.
*
After documentation of an activated clotting time of 192 seconds, the arterial sheath was removed with manual compression for hemostasis. The patient was then transferred to the recovery area in stable condition.
*
Impression:
*
1. Severe, multifocal disease on the right including distal external iliac, common femoral, proximal SFA, distal SFA, and popliteal with above-knee popliteal occlusion and collateralization of the below the knee vessel with single vessel runoff to the peroneal artery.
2. Status post jetstream atherectomy of the above lesions with unsuccessful crossing of the above-knee popliteal occlusion.
3. Status post balloon angioplasty with drug-eluting balloon treatment of external iliac, common femoral, proximal SFA, and distal SFA/proximal popliteal disease
4. Patent left femoral distal bypass graft
5. Manual compression utilized for hemostasis.
*
Plan:
*
1. Plavix indefinitely.
2. Resume Pradaxa tomorrow.
3. Aggressive risk factor modification.
4. Consider surgical referral for femoral distal bypass should the patient continue to have poor wound healing and continued symptoms.