Peripheral/pta scenario


Temple City, CA
Best answers


HISTORY OF THE PRESENT ILLNESS: This patient is well-known to me for history
of peripheral arterial disease. The patient has had progressive intermittent
claudication, right greater than left, which has limited activities of daily
living. The patient had noninvasive imaging showing significant in-stent
restenosis of stents that were placed approximately 4 years ago. The patient
was also noted to have severe left-sided disease. However, his right leg is
more limiting than his left. Thus, the patient has been explained the risks,
benefits, and alternatives of peripheral angiography plus/minus angioplasty and
stenting and agrees to proceed.

PROCEDURE: The patient was brought to the catheterization laboratory and
prepped and draped in a sterile fashion. Lidocaine was placed in the left
common femoral area, and a 6-French short sheath was placed using Seldinger
technique and fluoroscopic guidance into the left common femoral artery.
Angiography through the sheath was completed with runoff down to the ankle
level. Next a J wire was placed into the descending thoracic aorta, and the 6-French
short sheath was exchanged for a 6-French Ansel sheath and was placed to the
left common iliac. Next, up-and-over access was obtained with a 6-French LIMA
catheter and a long Glidewire to telescope the Ansel sheath to the right common
femoral artery. Angiography down the right leg was performed.
Next, the Glidewire was able to cross the SFA into the popliteal segment, and a
5.0 x 80 EverCross balloon was placed into the popliteal artery and balloon
angioplasty was performed to 14 atmospheres for severe diffuse in-stent
restenosis. Stenting was from popliteal to proximal SFA segment. This was
performed in overlapping fashion over the entire segment to 14 and then higher
up to 16 atmospheres. Balloon was removed. Wire was left in place. Repeat
angiography was performed.
At this point there was still approximately 30% residual stenosis in some
areas. Thus, it was felt prudent to use a 6 x 80 EverCross balloon to the
distal SFA all the way to the proximal SFA again in serial overlapping
segments, inflated to 10 atmospheres of pressure. Balloon was removed. Repeat
angiography showed less than 10% residual stenosis the entire stented segment,
brisk flow throughout the vessel, and significantly improved flow of the
peroneal and posterior tibial artery. Wire and balloon were removed. The
catheter was brought up and over to the left external iliac. ACT was 160.
Thus, manual pressure was held to the left common femoral artery with good
groin hemostasis and no evidence of oozing, bruising, or hematoma. I reviewed
the findings with the patient.

1. Bilateral iliac arteries are widely patent.

2. On the left side common femoral artery has moderate 50-70% disease,
somewhat calcified. In the proximal SFA segment there is long diffuse
severe 70-90% stenosis. In the mid SFA there is a short stent which is
widely patent with mild in-stent restenosis. In the distal SFA there is
again 70-85% stenosis. At the level of the popliteal segment there is no
evidence of significant greater than 70% stenosis. The infrapopliteal
segment at the anterior tibia was widely patent. However, the posterior
tibial and peroneal branch is completely occluded.

3. The right common femoral artery and right ostial SFA is widely patent.
There is long stenting of the proximal SFA into the popliteal segment with
multiple areas of severe diffuse greater than 80% in-stent restenosis.
Status post balloon angioplasty with a 5.0 followed by a 6.0 balloon now
reveals less than 10% residual stenosis, markedly improved flow. There is
now a widely patent peroneal branch. There is a posterior tibial which has
a focal 70% lesion. Otherwise it has brisk flow into the foot and the
anterior tibia was occluded.

POST PROCEDURE: The patient tolerated the procedure well and remains
hemodynamically stable. The patient has been on Plavix and blood pressure
therapy. He has had difficulty using Zocor cholesterol therapy. We have
educated him, and we will reeducate him on restarting. We will have him
increase his overall activities. If he remains symptomatic now from the left
leg we will repeat procedure with balloon angioplasty and possible stenting. I
have explained the findings to him.
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I would bill 37224, for angioplasty (ballooning) of the femoral/popliteal territory.

What do you think about also coding the angios of the legs with 75716-59?

The last I understood was that diagnostic angio is reportable if;

No prior catheter based angiographic study is available and guidelines allow contrast angio to be billed even if a CTA or MRA is performed prior to diagnostic study.:rolleyes:
Peripheral Angio?

I was up in the air on whether to code 75716. The way I read the guidelines in the CPT book is you can code a diagnostic angio separately if: There is no prior cath based angio study AND a full diagnostic study is performed AND the decision to intervene is based on the diagnostic study. That was the question for me...was the decision to intervene based on the angio's taken during this session?

The way the report reads to me I would say no, so I would not bill 75716. The patient is well-known to this doctor to have PAD and there was a noninvasive study done recently showing in-stent restenosis. Those things lead me to believe the doctor knew he would be intervening before the procedure started. But that's just my interpretation :)

What do you think about also coding the angios of the legs with 75716-59?

The last I understood was that diagnostic angio is reportable if;

No prior catheter based angiographic study is available and guidelines allow contrast angio to be billed even if a CTA or MRA is performed prior to diagnostic study.:rolleyes:
Those are good points! But I think i would go ahead and code the 75716-59 based on the patient is having progressive claudication and since his last intervention(stent) the only other test he has had is non invasive( no cath based diagnostic testing). I think the intervention was based on the cath and not based soley on the non invasive test. Also I was taking the sentence "peripheral angio plus/minus angioplasty and stenting" part as this wasnt a planned intervention until they got inside there to see for sure what was going on?

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