pelvic and bilateral extremity angiogram.

AgnieszkaMarek

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PREOPERATIVE DIAGNOSIS:

PAD-severe right lower extremity intermittent claudication

POSTOPERATIVE DIAGNOSIS:

Severe diffuse right common iliac and right external iliac artery stenosis

Patent bilateral infrainguinal vessels with three-vessel runoff

PROCEDURE:

Pelvic angiography

Bilateral selective lower extremity angiography

Stenting of right common iliac artery with self-expanding stent

Stenting of right external iliac artery with self-expanding stent

Balloon angioplasty of distal right external iliac artery with drug-coated balloon

SURGEON:

FINDINGS:

Pelvic angiography:

Distal abdominal aorta is patent with mild disease.

Right common iliac artery with severe ulcerated 80 to 90% stenosis at proximal and midportion.

Right external iliac artery with severe ulcerated 80 to 90% stenosis at mid and distal portions.

Right internal iliac artery is patent.

Left common iliac artery is patent with mild diffuse disease and healed spontaneous dissection.

Left external iliac arteries patent with mild diffuse disease.

Left internal iliac arteries patent



Right lower extremity angiography:

Common femoral artery is patent.

Superficial femoral artery is patent with mild diffuse disease.

Deep femoral artery is patent.

Popliteal artery is patent with mild to moderate stenosis above the knee.

Tibioperoneal vessels are widely patent with three-vessel runoff



Left lower extremity angiography:

Common femoral artery is patent with mild to moderate disease

Superficial femoral arteries patent with mild diffuse disease.

Deep femoral arteries patent.

Popliteal arteries patent with mild diffuse disease.

Tibioperoneal vessels are widely patent with three-vessel runoff.



Intervention: Successful balloon angioplasty and stenting of right common iliac artery from the ostium with an ever flex 8.0/60 mm self-expanding stent (postdilated with a 7.0 mm Mustang balloon). End of right external iliac artery with an ever flex 7.0/60 mm self-expanding stent (postdilated with a 6.0 mm Mustang balloon). Distal portion of right external iliac artery into the proximal portion of the right common femoral artery was dilated with a Lutonix 6.0/60 mm drug-coated balloon. Very good final angiographic result with preserved three-vessel runoff to the foot.



Conclusions:

1. Indication-severe lifestyle limiting right lower extremity intermittent claudication.

2. Severe diffuse right iliac inflow disease. Left iliac vessels are patent. Patent bilateral infrainguinal vessels.

3. Successful stenting of right common iliac and right external iliac artery with self-expanding stents and balloon angioplasty of distal right external iliac artery with a drug-coated balloon.



Recommendations:

1. Dual antiplatelet therapy with aspirin and clopidogrel.

2. Optimal risk factor modification including smoking cessation.



Clinical history:

65-year-old white male, former heavy smoker (currently smokes pipe), history of worsening right lower extremity proximal intermittent claudication. ABI/PVR shows severe right inflow disease. Patient was referred for bilateral lower extremity angiography.

DESCRIPTION OF PROCEDURE:

After informed consent was obtained, the patient was brought to the cardiac catheterization lab, prepped and draped in usual sterile manner for femoral access procedure. The patient was sedated with Versed and fentanyl. 2% lidocaine applied to both groin areas.

First arterial access was gained in the left groin under fluroscopic guidance, using micropuncture technique, and 5F sheath was inserted in the LCFA. Selective segmental left lower extremity angiography was performed via the sheath. A 4F UF catheter was then dvanced to the distal abdominal aorta and pelvic angiography performed, demonstrating the severe disease in the right common and external iliac arteries. Using roadmapping from the pelvic angiography, access was gained in the right groin using micropuncture technique, and 23 cm BriteTip 6F sheath was inserted in the RCFA.

Bolus heparin was given and repeated to achive an ACT around 250. 600 mg Plavix loading was given.

We then advanced a Stiff 0.035 Glidewire across the right iliac artery.

At this point hemodynamic evaluation of the RCIA stenosis was performed using simultaneous pressure measurments, showing signficant gradient across the lesion. The lesions in the right common and external iliac arteries were predilated with a Mustang 5.0/80 mm balloon followed by stenting of the right common iliac artery from the ostium with an EverFlex 8.0/60 mm self-expanding stent and stenting of the right external iliac artery with an EverFlex 7.0/60 mm self-expanding stent. The stents were postdilated with the 7.0 and 6.0 mm balloons, accordingly. In addition, we performed balloon angioplasty of the distal right external iliac artery into the proximal right common femoral artery with a Lutonix 6.0/60 mm drug-coated balloon.

Completion angiography showed very good final angiographic result and preserved three-vessel runoff to the right foot.

The left common femoral artery 5F sheath with suture in place. The right common femoral artery sheath was removed and successful hemostasis was achieved using a Perclose closure device.

In my opinion definitely 37221 I am also thinking 36200?? I know angiography is included in 37221 but it was the next separate approach on the opposite side. how about codes with 70000 series. I struggle with these because I code only for facilities.
This one is a little different than usual.
 

suchang78

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Had the patient has a prior arteriogram done before the IR and the IR service is planned from previous arteriogram? If not,, u can code imaging( with finding) with mod " 59" or X- ( depends on your facility). I will look into your case later.
 

Jim Pawloski

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There is no evidence of a prior angio, so I agree with your thoughts Agnes. I would code 37221-RT, 36200-59, 75716-59. You can code for the angio., if there is no documentation of a angiogram prior to the intervention.
HTH,
Jim Pawloski, CIRCC
 

suchang78

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I have 37221-RT and 37223 ( stents for external iliac artery at mid and distal portions, I assign 37223 one time only because the stents were placed in the same artery, and the surgeon didn't indicate there was 2 different lesions in the same artery)
 

Jim Pawloski

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So then should you only charge for one stent placement since the lesion is either one long stenosis or a bridging lesion covered by one stent?
 

suchang78

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So then should you only charge for one stent placement since the lesion is either one long stenosis or a bridging lesion covered by one stent?



1. When there are multiple stents placed in the same vessel, only one stent placement is reported.
2. At times a " bridging lesion" may be encountered. This is a single lesion that spans two vessels. Only one stent code should be assigned in these instances.

For endovascular revascularization, iliac vascular territory is divided into 3 vessels: common iliac, internal iliac, and external iliac. A single primary code is used for the initial iliac artery treated in each leg ( 37220 or 37221). If other iliac vessels are also treated in that leg, these interventions are reported with the appropriate add-on code(s) (37222, 37223). Up to 2 add-on codes can be used in a unilateral iliac vascular territory since there are 3 vessels which could be treated. Add-on codes are used for different vessels, not distinct lesions within the same vessel. ( I copied it from AMA CPT)
 
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AgnieszkaMarek

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For endovascular revascularization, iliac vascular territory is divided into 3 vessels: common iliac, internal iliac, and external iliac. A single primary code is used for the initial iliac artery treated in each leg ( 37220 or 37221). If other iliac vessels are also treated in that leg, these interventions are reported with the appropriate add-on code(s) (37222, 37223). Up to 2 add-on codes can be used in a unilateral iliac vascular territory since there are 3 vessels which could be treated. Add-on codes are used for different vessels, not distinct lesions within the same vessel. ( I copied it from AMA CPT)
Thank you very much for your answers, sorry I do it so late.. Agnieszka
 

AgnieszkaMarek

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For endovascular revascularization, iliac vascular territory is divided into 3 vessels: common iliac, internal iliac, and external iliac. A single primary code is used for the initial iliac artery treated in each leg ( 37220 or 37221). If other iliac vessels are also treated in that leg, these interventions are reported with the appropriate add-on code(s) (37222, 37223). Up to 2 add-on codes can be used in a unilateral iliac vascular territory since there are 3 vessels which could be treated. Add-on codes are used for different vessels, not distinct lesions within the same vessel. ( I copied it from AMA CPT)
Thank you very very much for your answers ! Agnieszka
 
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