Stenting of right external iliac artery with self-expanding bare-metal stent PTA of right common femoral artery and right superficial femoral artery w

AgnieszkaMarek

Networker
Messages
66
Location
Saratoga Springs, NY
Best answers
0
I think 37221,37224,75716 my question is if we code cath placement for angiography in this case. I know it's bundled with few exceptions, it was Lt femoral access with bilateral angio and intervention at contralateral side. That's why i am questioning if 36246 should be added.
Thank you in advance for all your answers.

PREOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
POSTOPERATIVE DIAGNOSIS:
Severe bilateral lifestyle limiting intermittent claudication
Severe right external iliac stenosis
Severe in-stent restenosis of bilateral SFA
PROCEDURE:
Pelvic angiography
Bilateral selective lower extremity angiography
Stenting of right external iliac artery with self-expanding bare-metal stent
PTA of right common femoral artery and right superficial femoral artery with drug-coated balloons

FINDINGS:
Pelvic angiography:
Small abdominal aortic aneurysm right above the aortic bifurcation.
Right common iliac artery is patent with moderate 30 to 40% stenosis, right external iliac artery with severe 70% stenosis at proximal segment, right internal iliac arteries patent.
Left common iliac artery is patent with mild diffuse disease, left external iliac artery with moderate diffuse disease, left internal iliac artery is patent.

Right lower extremity angiography:
Right common femoral artery with moderate 50 to 60% stenosis at distal segment, right SFA with long stented segment from the ostium to distal segment with severe 80% in-stent restenosis at its proximal half, right profunda is large and patent, right above-knee popliteal artery is heavily calcified moderate 50 to 60% stenosis, right below-knee popliteal artery is widely patent, the trifurcation is widely patent with three-vessel runoff to the foot.

Left lower extremity angiography: Left common femoral artery with moderate 50 to 60% stenosis at proximal portion, left SFA has a stent at its mid and distal portions. There is critical subtotal occlusion at the proximal SFA, moderate diffuse in-stent restenosis, the left profunda is large and patent, above-knee popliteal artery with moderate diffuse 50% stenosis, below-knee vessels are faintly opacified but seems to be patent with three-vessel runoff to the foot.

Intervention: Significant 30 to 40 mmHg pressure gradient was measured across the right external iliac artery. Stenting of the right external iliac artery with an ever flex 8.0/60 mm self-expanding stent, postdilated with a 7.0/60 mm balloon. Excellent final angiographic result with no residual pressure gradient.
Balloon angioplasty of the right common femoral artery and proximal right SFA in-stent with a Lutonix 6.0/150 mm drug-coated balloon. Residual stenosis at the ostium of the SFA was further dilated with Dorado 6.0/40 mm NC balloon high-pressure. Balloon angioplasty of the above-knee popliteal artery with a Lutonix 5.0/150 mm drug-coated balloon. Satisfactory final angiographic result across the right SFA and above-knee popliteal arteries.

Conclusions:
1. Severe bilateral lifestyle limiting lower extremity claudication. Recent ABI/PVR shows recurrent severe PAD with ABI around 0.5 at both legs. Patient had bilateral prior endovascular interventions with his stenting of both SFAs.
2. Severe right inflow disease of the right external iliac artery and severe right SFA in-stent restenosis.
3. At least moderate left inflow disease of the left external iliac artery and severe left SFA restenosis.
4. Successful stenting of right external iliac artery with self-expanding stent.
5. Successful reintervention of right common femoral artery and right SFA with drug-coated balloon. PTA of right above-knee popliteal artery with a drug-coated balloon.

Recommendations:
1. Optimal risk factor modification including tight glycemic control and improved lipid lowering.
2. Return for intervention on left external iliac artery and left SFA in 4 weeks.
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 left groin area (initial plan was to intervene on the left leg, but we had difficulty in gaining the right femoral access).

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 advanced to the distal abdominal aorta and pelvic angiography performed. Then, the catheter was advanced across the aortic bifurcation, up and over, over an angled Glidewire, with the tip of the catheter positioned in the right external iliac artery. Segmental selective right lower extremity angiography was performed

We then proceeded with right SFA intervention. The short sheath was exchanged for a 65 cm Terumo Destination sheath over a stiff Amplatz wire. Bolus heparin was given and repeated to achive an ACT around 250.

We then advanced a 0.035 angled Glidewire supported by angled 4F Glidecatheter across the SFA into the below the knee popliteal artery. The Glidewire was exchanged for a Super stiff long Amplatz wire. The proximal SFA and right common femoral artery were dilated with the loop tonics 6.0/150 mm balloon. The above-knee popliteal artery was dilated with a loop tonics 5.0/150 mm balloon. Additional angioplasty of the ostium of the right SFA was performed with an Dorado 6.0/40 mm noncompliant balloon to high pressure. The origin of the right profunda was then dilated with the 4.0/60 mm Coyote balloon to preserve patency of the profunda. We then withdrew the sheath to the proximal right common iliac artery. A 5F glide catheter was advanced to the right SFA. We recorded simultaneous pressures while the glide catheter was slowly pulled back from the SFA into the right common iliac artery. We noticed most of the pressure gradient was across the lesion in the right external iliac artery. This lesion was treated with a Ever Flex 8.0/60 mm self-expanding stent. The stent was postdilated with a 7.0/60 mm Mustang balloon.
Completion angiography showed very good angiographic result, with no residual significant stenosis or dissection, and preserved runoff to the foot.

The long sheath in the left groin was exchanged for a short 6F sheath, which was sutured in place, to be later manually removed.

Patient tolerated the procedure well, no complications were noted. He was transferred to the holding area in stable condition.
I noticed a robust +2 DP pulse in the right foot after the procedure
 

Jim Pawloski

True Blue
Messages
1,390
Location
Ann Arbor
Best answers
1
Hi Agnus,
First, in any intervention of the lower extremity, the catheterization code is bundled. So in this case, there is no 35247. What you do have I agree with. In addition, if the doctor reported how long was the sedation and how much was given by who, 99152 and 99153 x? could be coded also.
HTH,
Jim
 

AgnieszkaMarek

Networker
Messages
66
Location
Saratoga Springs, NY
Best answers
0
Hi Agnus,
First, in any intervention of the lower extremity, the catheterization code is bundled. So in this case, there is no 35247. What you do have I agree with. In addition, if the doctor reported how long was the sedation and how much was given by who, 99152 and 99153 x? could be coded also.
HTH,
Jim
Jim,
Thank you for your reply and reassuring me in my way of thinking. I am attaching reference guidelines from our coding software. take a look on these 3 exceptions when you actually report catheterization. I was a little bit confused if the Exception 2 may be applied.
I red this Op report carefully once again and I see it can be because the catheter wasn't placed and pulled back.
once again- Thank You so much !
Agnieszka

Lower Extremity Revascularization (37220-37235): Additional Catheterization Reporting (36200, 36245, 36246)

The July 2011 edition of CPT Assistant featured an article discussing the intent and use of the lower extremity revascularization procedure codes. Also included in the article were several commonly asked questions related to specific therapeutic lower extremity revascularization interventions involving additional arterial catheterization.

To offer further clarification, several examples are provided here to illustrate the reporting of those instances in which catheterization of specific arterviies) (eg, external iliac, common iliac) mayor may not allow for additional reporting. In particular, code 36200, Introduction of catheter, aorta, code 36245, Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family, and code 36246, Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family, are discussed as well as the use of modifier 59, Distinct Procedural Service.

Each lower extremity revascularization code (37220-37235) includes the associated catheterization of the treated vessel. Exceptions to this reporting instruction are illustrated in the following three interventions.

Exception 1: A diagnostic study is performed from a separate puncture site than what was used for the interventional procedure. The appropriate catheterization code for the diagnostic study would be reported with modifier 59 to indicate that this catheterization is separate from that used for the intervention.

Example: A diagnostic aortogram with bilateral lower extremity arteriogram is performed from a right femoral puncture with the catheter advanced into the abdominal aorta for imaging. A proximal left common iliac stenosis is identified and treated via a second puncture of the left common femoral artery. In this case, the right groin approach via the aortic catheterization would be reported with code 36200 with modifier 59 appended. The left femoral puncture with catheter placement for the iliac intervention is included in the therapeutic code and is not separately reported.

Exception 2: A diagnostic study is performed via the same access site but requires a higher level of selectivity than is required for the intervention. In this case, the higher-level catheterization is reported in addition to the intervention with modifier 59 appended to signify that the higher degree of selectivity was not part of the work of the intervention.

Example: A diagnostic aortogram with bilateral lower extremity arteriogram is performed via a left femoral puncture with the catheter advanced into the abdominal aorta for imaging of the aorta and iliac arteries. The catheter is then selectively positioned into the right common femoral artery to perform a right lower extremity arteriogram. The catheter is then pulled back into the left iliac artery and a left lower extremity angiogram is performed. A proximal left common iliac stenosis is identified and treated via the left femoral puncture. In this case, the catheterization required to perform the left iliac intervention is described by code 36200, but additional work was required to select the right common femoral artery for the diagnostic study. This additional work would be reported with code 36246 with modifier 59 appended, in addition to the lower extremity revascularization code.

Exception 3: An intervention is performed in a non-lower extremity artery at the same setting as a lower extremity endovascular intervention. Currently, many interventions other than those in the lower extremity continue to follow component coding guidelines, so the catheterization for the additional intervention(s) would be coded in addition to the lower extremity intervention code and reported with modifier 59 appended to signify that this catheterization was not part of the lower extremity revascularization intervention.

Example: A right common iliac stenosis is treated with stenting via a right femoral approach. At the same time, the right renal artery origin is also treated with stent placement. In this case, the right iliac treatment is reported with code 37221, Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed, which includes the work of placing a catheter into the aorta. However, additional selective work is required to treat the renal artery, and this is reported with code 36245 with modifier 59 appended (when a first order selection is used for the renal stenting).
 

Jim Pawloski

True Blue
Messages
1,390
Location
Ann Arbor
Best answers
1
My comment to Exception 2 is when the right rt common femoral is selected from the left femoral puncture, you will code 36246-59,RT. 36200 is a non-selective catheterization code, and goes away when the catheter goes selective. The left side is coded with the intervention code, so if it's only angioplasty, code 37220-LT. If a stent is placed, code 37221-LT. So for the example, I would code 3722x-LT, 36246-59,RT, and 75716-59.
HTH,
Jim
 

AgnieszkaMarek

Networker
Messages
66
Location
Saratoga Springs, NY
Best answers
0
My comment to Exception 2 is when the right rt common femoral is selected from the left femoral puncture, you will code 36246-59,RT. 36200 is a non-selective catheterization code, and goes away when the catheter goes selective. The left side is coded with the intervention code, so if it's only angioplasty, code 37220-LT. If a stent is placed, code 37221-LT. So for the example, I would code 3722x-LT, 36246-59,RT, and 75716-59.
HTH,
Jim
Jim,
Thank you once again for clarification and explanation.
 
Top