Renal

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PROCEDURE: Access left common femoral artery with catheter placement to second order vessel to the distal popliteal artery, balloon angioplasty of the chronic totally occluded left SFA with drug-coated balloon and subsequent self-expanding stent in light of dissection.
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HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old with history of coronary artery disease, previous PCI and extensive peripheral artery disease with carotid disease, iliac disease and SFA disease. He underwent previous endarterectomy as well as bilateral iliac stenting. He has persistent left lower extremity claudication symptoms and noninvasive imaging indicated depressed ABI to the left lower extremity after recent revascularization of his iliac arteries. As such, he is referred for percutaneous intervention.
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DETAILS OF PROCEDURE: Informed consent was obtained. The patient understood the risks, benefits and alternatives of the procedure and agreed to proceed with the procedure. The patient was taken to the cardiac catheterization lab, prepped in sterile fashion. The left groin was prepped and left femoral artery was accessed in an antegrade fashion. A 6-French Terumo Glidesheath was placed. Angiography revealed chronic total occlusion of the left SFA. Next, a Glidewire was navigated through the chronic total occlusion to the distal popliteal, which a 4-French Glidesheath was then passed distally and this catheter was then placed in the popliteal to allow passage of an Amplatz stiff wire. Over this wire, a 4.0 x 40- mm balloon was used to predilate the lesion and sequential inflations were achieved at 6 atmospheres. A 6.0 x 80-mm drug-coated balloon was then deployed for 3 minutes inflation at 6 minutes and more proximally a 6.0 x 60 drug-coated balloon was then deployed in an overlapping fashion across the diseased segment. There was evidence of proximal dissection. With subsequent balloon inflation this improved; however, there was residual dissection. It was then elected based on the residual dissection and insufficient expansion of the chronic total occlusion to then stent the segment. Based on this decision during the procedure, an Absolute 6.0 x 60 self-expanding stent was then deployed and postdilated with a 6.0 x 80 balloon to 6 atmospheres. There was effective, TIMI-III flow and effective expansion of the stent. There was residual proximal dissection that was not flow-limiting, and it was elected to remain.
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SUMMARY: Successful percutaneous intervention of the chronic totally occluded left SFA with balloon angioplasty and subsequent stenting.
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CLINICAL PATHWAY: We hope this will afford symptomatic benefit. We will be monitoring him and focusing on secondary prevention regimen. He will require dual antiplatelet therapy.

36140-XE
36246-59
I am lost with the rest of the codes, I do not understand these nor do I bill them. I need help to understand them any help is appreciated Thanks Nancy
 

cpc2007

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I agree with code 37226 for the superficial femoral artery stent (all angioplasty in the femoral/popliteal vessels in the same leg is inclusive). This code also includes the work of accessing the vessel undergoing intervention; CPT 36246 is bundled and 36140 is also bundled because the work of accessing the femoral artery for angiography is in the leg undergoing intervention and occurring through the same percutaneous access used for the intervention (the left common femoral artery). Finally, if the patient has had no prior catheter based angiograms or CTA preoperatively and the angiogram was needed to decide how/where to intervene in this case, I would allow for 75710.26.59; if the patient had these studies preoperatively though and came in for a planned SFA angioplasty/stent, the angiogram would be considered confirmatory shots/road mapping and would also bundle (might be something to discuss with the physician as the documentation regarding the diagnostic value of the angiogram is not abundantly clear in the note).

In conclusion, I would definitely code 37226; if the angiogram is truly diagnostic as explained above, add 75710.26.59.
 
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