Question Revascularization codes or selective catherization/angiogram codes??

uneeq3

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Hello, learning IR and I would appreciate input for the following case. I'm not sure if I'm using revascularization codes or selective catheter/angiogram codes. Thank you in advance and I appreciate your time.

If revascularization, I have 37213, 37227, 37322x2, and 75710-59, 99152, 99153 X3
If not, I have 37213, 36247, 36248 X2 75710, 75774 X3 99152, 99153 X3


PROCEDURE:
1. Post thrombolysis right lower extremity angiogram.
2. Selective angiogram of the anterior tibial artery/dorsal pedis artery.
3. Selective angiogram of the posterior tibial artery.
4. Selective angiogram of the peroneal artery.
5. Pulse spray thrombolysis within the posterior tibial artery.
6. Pulse spray thrombolysis within the peroneal artery.
7. Catheter reposition and continued intra-arterial thrombolysis within the anterior tibial and dorsal pedis arteries.

HISTORY: RLE ischemia, Covid pneumonia

SURGEON:

TECHNIQUE: The left groin was prepped and draped in usual sterile fashion. Utilizing the existing left-sided arterial sheath, a guidewire was placed through the infusion catheter and infusion catheter removed. A right lower extremity angiogram was performed through the existing vascular sheath. This demonstrates some improved arterial flow within the popliteal artery, however, there is minimal but significantly improved residual thrombus in the popliteal artery. The the anterior tibial artery demonstrate antegrade arterial to the ankle joint. A quick cross microcatheter over an 014 command guidewire was advanced into the dorsal pedis artery. An additional angiogram of the dorsal pedis artery was performed. This demonstrates no flow within the digital arteries. The guidewire could placed into multiple arteries, however, this appear to opacify the distal arteries but there is no outflow disease arteries identified. This is either due to distal emboli or end-stage ischemia of the toes. Multiple attempts to cross the plantar arch are performed without success. As result, the 018 quick cross was withdrawn and selectively placed into the posterior tibial artery. An additional angiogram of the posterior tibial artery was performed. This demonstrates that the plantar artery is patent small emboli are present within the distal posterior tibial artery. There is short segment occlusion of the posterior tibial artery as well. As result, 2 mg of intra-arterial TPA was pulse sprayed into the posterior tibial artery over 10 minutes. The quick cross catheter was then removed and selectively placed into the peroneal artery. This also demonstrates thrombus within multiple segments of the peroneal artery. As result, 1 mg of intra-arterial TPA was pulse sprayed in this vessel is well over 10 minutes. The quick cross catheter was then withdrawn and selectively placed into the anterior tibial artery. Using the Seldinger technique, it was exchanged for an infusion catheter. This was positioned within the anterior tibial artery. Through this an infusion wire was advanced coaxially through an infusion catheter down the anterior tibial artery and into the dorsal pedis artery under fluoroscopic visualization. Thrombolysis was reinstituted and well now extend from the dorsal pedis artery to the superficial femoral artery via the infusion catheter and distal infusion wire. The catheter and wires were secured in place.

SEDATION: The patient was sedated using a combination of intravenous propofol and Versed titrated to comfort level and vital parameters. The patient remained stable throughout the procedure. A nurse with critical care level certification was present to administer the medications and monitor the patient during the entire procedure. The physician ordering the sedation was in continuous attendance during the entire procedure. The total sedation time was 60 minutes.

Kerma area product: 28 GyCM2

CONTRAST: 72 cc of Visipaque


IMPRESSION:

1. NEAR COMPLETE THROMBUS RESOLUTION OF THE POPLITEAL ARTERY WITH MINIMAL RESIDUAL THROMBUS REMAINING IN THE POPLITEAL ARTERY.
2 NEAR COMPLETE RECANALIZATION OF THE ANTERIOR TIBIAL ARTERY WITH MINIMAL NONOCCLUSIVE RESIDUAL THROMBUS DISTALLY WITHIN THE ANTERIOR TIBIAL ARTERY.
3. RECANALIZATION OF THE PLANTAR ARTERY, HOWEVER, THE DIGITAL BRANCHES AND TARSAL BRANCHES OF THE DORSAL PEDIS ARTERY REMAIN OCCLUDED.
4 PARTIAL RECANALIZATION OF THE POSTERIOR TIBIAL ARTERY AND PERONEAL ARTERY WITH SUBSEQUENT REOCCLUSION. THE THROMBUS BURDEN WITHIN THESE ARTERIES IS SIGNIFICANTLY DIMINISHED. AS RESULT, PULSE SPRAY INTRA-ARTERIAL TPA WAS UTILIZED TO HELP INITIATE THROMBOLYSIS.
5. ADDITIONAL THROMBOLYSIS WILL BE CONTINUED FOLLOWING REPOSITIONING OF THE INFUSION WIRE AND CATHETER FROM THE DORSAL PEDIS ARTERY THROUGH THE ANTERIOR TIBIAL ARTERY AND INTO THE POPLITEAL/SUPERFICIAL FEMORAL ARTERY.
6. A FOLLOW-UP ARTERIOGRAM WILL PERFORMED AFTER ADDITIONAL THROMBOLYSIS.

Lisa, COC :)
 

Jim Pawloski

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I would only code 37213 for this procedure. Catheter exchange and imaging are bundled into 37213. I don't believe an actual thrombectomy was performed as TPA was injected thru the microcatheter to help in the treatment.
HTH,
Jim Pawloski, CIRCC
 

uneeq3

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Hi Jim, thank you. I was way off with the imaging codes; lessened learned. :) As always, I greatly appreciate your time.

Lisa, COC
 
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