Question Should I unbundle?

Alfaro33

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Codes: 37229, 36247, 36200, 36140, 75710, 75625, 76937

New to Cardiovascular coding and trying to determine if 36200 and 36140 are distinct from 36247 since it's bundled.





Preoperative Diagnosis

Limb threatening ischemia to the left lower extremity
Diabetic foot infection of the left great toe

Postoperative Diagnosis
Limb threatening ischemia to the left lower extremity
Diabetic foot infection of the left great toe

Operation

1. Ultrasound-guided access of the right common femoral artery
2. Diagnostic aortogram with catheter placement in the infrarenal aorta
3. Third order catheterization of the left lower extremity with final catheter placement in the left anterior tibial artery
4. Diagnostic left lower extremity arteriogram
5. Orbital atherectomy of the left anterior tibial artery with a 1.25 crown CSI device
6. Balloon angioplasty of the left anterior tibial artery with final balloon dilatation with a 3 x 150 cm coyote balloon




Patient was brought into the operative room and sedated in the supine position. Patient was given proper preoperative antibiotics the patient was prepped and draped in usual sterile fashion. An ultrasound probe was placed over the right common femoral artery and I gained access into the right common femoral artery with a micro needle. I advanced the micro wire under fluoroscopic visualization and upsized to a 5 French sheath. I then placed a Bentson wire into the aorta and advanced a Omniflush catheter in the infrarenal aorta. I performed a diagnostic aortogram of the infrarenal aorta which showed a patent infrarenal aorta, bilateral common iliac, bilateral hypogastric arteries, bilateral external iliac arteries. I then cannulated the contralateral external iliac artery with a Glidewire in place NaviCross catheter in the distal external iliac artery and performed selective diagnostic run of the left lower extremity. This showed the patient had a patent common femoral, profunda, SFA, popliteal vessels. The catheter was then placed in the infrapopliteal artery and showed that patient had severe areas of stenosis to occlusion along the course of the anterior tibial artery with distal reconstitution via peroneal communicating branches. The posterior tibial artery was patent down to the ankle supplying plantar branches. There was areas of moderate stenosis along the course of the posterior tibial artery but was not appear to be flow limiting.

Considering that the patient had a toe lesion I then elected to recannulate the anterior tibial artery. Patient was then systemically heparinized. I then placed a Rosen wire under direct visualization into the left popliteal artery and I placed a 6 French destination sheath to the mid SFA. With the combination of 0.018 and wire and NaviCross catheter I was able to cannulate the anterior tibial artery and cross the area of occlusion distally. The catheter was right above the ankle and a perform a diagnostic run which showed that I was in the lumen of the distal anterior tibial artery. The M wire was exchanged for a .014 Viper wire and I then performed an introduce an orbital atherectomy with a 1.25 crown CSI device in the anterior tibial artery. A perform an atherectomy through the course of the anterior tibial artery proximally to the distal anterior tibial artery right above the ankle. Once arthrectomy was complete I then serially dilated the anterior tibial artery starting with a 2.0 x 220 cm coyote balloon. I then followed this with a 2.5 by 200 balloon. Final balloon dilatation was completed with a 3 mm x 150 cm balloon. The balloon was inflated to nominal pressure for prolonged inflation of 2 minutes. I then injected nitroglycerin through the course of the anterior tibial artery.

Final angiographic run showed that the patient had excellent resolution of the areas of stenosis and complete occlusion of the course of the anterior tibial artery. There was a essentially 2 vessel runoff down to the foot with a complete pedal arch. Therefore I withdrew the wires and catheters and the sheath was exchanged for a short 6 French sheath. The arterial puncture site was closed with the is Mynx closure device. Postprocedure patient had an excellent triphasic signal along the dorsalis pedis and biphasic signal in the posterior tibial vessels. Patient is now revascularized in preparation for podiatry amputation.
 

mk2001

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Codes: 37229, 36247, 36200, 36140, 75710, 75625, 76937

New to Cardiovascular coding and trying to determine if 36200 and 36140 are distinct from 36247 since it's bundled.





Preoperative Diagnosis

Limb threatening ischemia to the left lower extremity
Diabetic foot infection of the left great toe

Postoperative Diagnosis
Limb threatening ischemia to the left lower extremity
Diabetic foot infection of the left great toe

Operation

1. Ultrasound-guided access of the right common femoral artery
2. Diagnostic aortogram with catheter placement in the infrarenal aorta
3. Third order catheterization of the left lower extremity with final catheter placement in the left anterior tibial artery
4. Diagnostic left lower extremity arteriogram
5. Orbital atherectomy of the left anterior tibial artery with a 1.25 crown CSI device
6. Balloon angioplasty of the left anterior tibial artery with final balloon dilatation with a 3 x 150 cm coyote balloon




Patient was brought into the operative room and sedated in the supine position. Patient was given proper preoperative antibiotics the patient was prepped and draped in usual sterile fashion. An ultrasound probe was placed over the right common femoral artery and I gained access into the right common femoral artery with a micro needle. I advanced the micro wire under fluoroscopic visualization and upsized to a 5 French sheath. I then placed a Bentson wire into the aorta and advanced a Omniflush catheter in the infrarenal aorta. I performed a diagnostic aortogram of the infrarenal aorta which showed a patent infrarenal aorta, bilateral common iliac, bilateral hypogastric arteries, bilateral external iliac arteries. I then cannulated the contralateral external iliac artery with a Glidewire in place NaviCross catheter in the distal external iliac artery and performed selective diagnostic run of the left lower extremity. This showed the patient had a patent common femoral, profunda, SFA, popliteal vessels. The catheter was then placed in the infrapopliteal artery and showed that patient had severe areas of stenosis to occlusion along the course of the anterior tibial artery with distal reconstitution via peroneal communicating branches. The posterior tibial artery was patent down to the ankle supplying plantar branches. There was areas of moderate stenosis along the course of the posterior tibial artery but was not appear to be flow limiting.

Considering that the patient had a toe lesion I then elected to recannulate the anterior tibial artery. Patient was then systemically heparinized. I then placed a Rosen wire under direct visualization into the left popliteal artery and I placed a 6 French destination sheath to the mid SFA. With the combination of 0.018 and wire and NaviCross catheter I was able to cannulate the anterior tibial artery and cross the area of occlusion distally. The catheter was right above the ankle and a perform a diagnostic run which showed that I was in the lumen of the distal anterior tibial artery. The M wire was exchanged for a .014 Viper wire and I then performed an introduce an orbital atherectomy with a 1.25 crown CSI device in the anterior tibial artery. A perform an atherectomy through the course of the anterior tibial artery proximally to the distal anterior tibial artery right above the ankle. Once arthrectomy was complete I then serially dilated the anterior tibial artery starting with a 2.0 x 220 cm coyote balloon. I then followed this with a 2.5 by 200 balloon. Final balloon dilatation was completed with a 3 mm x 150 cm balloon. The balloon was inflated to nominal pressure for prolonged inflation of 2 minutes. I then injected nitroglycerin through the course of the anterior tibial artery.

Final angiographic run showed that the patient had excellent resolution of the areas of stenosis and complete occlusion of the course of the anterior tibial artery. There was a essentially 2 vessel runoff down to the foot with a complete pedal arch. Therefore I withdrew the wires and catheters and the sheath was exchanged for a short 6 French sheath. The arterial puncture site was closed with the is Mynx closure device. Postprocedure patient had an excellent triphasic signal along the dorsalis pedis and biphasic signal in the posterior tibial vessels. Patient is now revascularized in preparation for podiatry amputation.
Catheterization is included in 37229 so would not be able to bill 36140, 36200 or 36247 since the catheter placement was from the same access as the intervention & the intervention was performed at the highest degree of selectivity.

I hope this helps!
 

Jim Pawloski

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I would not code 75625 as there is no description of the renal arteries. Infrarenal aorta is coded as part of the extremity arteriogram. I would also not code for U/S vascular access since there is no description of vessel patency or an imaged of the vascular access documented. So I would be coding 37229, 75710-LT,59.
HTH,
Jim Pawloski, CIRCC
 
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