Jane5711
Networker
Hi, I'm looking for some advice on coding the below referenced report. So far I have come up with
75630, 26, XU, 36245, LT, 37252, LT, 37253, LT
I feel as though I'm missing a code for the additional imaging of the left common femoral artery. Not sure if I can code 75774, 26
TIA
INDICATION FOR PROCEDURE: This is a 68-year-old gentleman with history of severe peripheral vascular disease, and severe activity restricting claudication, also with history of paroxysmal atrial fibrillation, coronary artery disease, status post PCI, dyslipidemia, left bundle branch block, and previous history of smoking. Patient had angiogram July 2023, at which time he had attempted angioplasty of the left iliac artery, although vessel could not be crossed luminally, in the meantime patient underwent PCI of OM, and is on Plavix, he comes for second attempt angioplasty of the chronically occluded iliac artery with intravascular ultrasound support. With these findings redo angiogram and intervention was planned. Pros and cons of procedure were discussed, consent was obtained.
TECHNIQUE: Arterial access was obtained to the right common femoral artery under direct ultrasound visualization with micropuncture kit and modified Seldinger technique, and 5 French sheath was introduced. Then 5 Omni Flush catheter was placed to the distal aorta above the bifurcation, and used for angiogram. Second arterial access was obtained with the micropuncture kit, and modified Seldinger technique under ultrasound visualization to the distal left common femoral artery which is known to be patent. And 6 French glide sheath was introduced and used for the angiogram and intervention. We used 5 French Omni Flush catheter position from right femoral approach to the distal aorta for distal aortic and iliac angiogram and procedure. Additional imaging of the left common femoral artery was obtained through the 6 French sheath positioned to the left common femoral artery. Local anesthesia was provided with 2% lidocaine 10 cc injected to the right and left groin. Patient was anticoagulated with IV heparin for PTT more than 200. Sedation was provided by department of anesthesia, please see separate report. Intravascular ultrasound was performed with 0.014 IVUS Philips catheter. Blood loss was negligible. Blood samples were also taken for ACT. Contrast used–80 cc Fluoroscopy time 22.6 minutes. Manual management of access site was provided. There were no immediate complications HEMODYNAMICS: Arterial pressure was 120/65mmHg.
PERIPHERAL ANGIOGRAM WAS OBTAINED AND PERSONALLY DICTATED ON JULY 19, 2023, ONLY DISTAL AORTIC AND ILIAC ARTERY ANGIOGRAM WAS OBTAINED TODAY, WHICH WAS UNCHANGED FROM JULY 2023 FOLLOWING FINDINGS: Normal size calcified distal abdominal aorta with evidence of the plaque but no obstructive or protruding plaque, no aneurysm, no dissection. Right: Common iliac artery is a large vessel with 70% proximal stenosis. External iliac artery is a large vessel with 40-50% stenosis Hypogastric is a relatively small vessel with 99% ostial stenosis and slow flow. Common femoral artery is a medium sized vessel with diffuse 30-40% stenosis. Known occlusion 100% of the distal superficial femoral artery, and three-vessel below the knee runoff. Left: Common and external iliac artery 100% occluded. Common femoral artery is moderately calcified vessel with 50-60% diffuse stenosis. No obstructive disease in the superficial femoral artery, popliteal artery, and three-vessel below the knee runoff.
UNSUCCESSFUL ANGIOPLASTY ATTEMPT OF THE LEFT ILIAC ARTERY: Once angiogram was completed, which showed occlusion of the left common iliac artery, but this time showed very small stump of the common iliac artery on the left, we proceeded with intervention. First I attempted to cross the lesion under fluoroscopy mask from the left femoral access in retrograde fashion with 4 French angled 90 cm Nava cross catheter and 260 cm angled 0.035 advantage wire, however the system was found to be subintimal at the level of the transition from common iliac artery to distal aorta. We then advanced 300 cm Sparta core wire to the proximal left common iliac artery and used 0.014 Phillips IVUS catheter which was advanced to the left common iliac artery, and then pullback was performed with following findings. INTRAVASCULAR ULTRASOUND FINDINGS: Luminal cross in the left external iliac artery with negatively remodeled and 100% occluded vessel measuring 5 x 6 mm in diameter. Subintimal crossing the left common iliac artery, which is heavily calcified, and 100% occluded. Once this findings by intravascular ultrasound were confirmed I first attempted to recross the lesion antegradely, and we did use 5 French Omni Flush catheter to engage the stump of the left common iliac artery, and then I attempted to use advantage wire, which would not cross the vessel, we then used 300 cm connect wire, which I was able to slightly navigate in the proximal portion of the left common iliac artery, but not to the midportion of the vessel despite multiple attempts. I then traced under intravascular ultrasound control to the point of transition from luminal to subintimal space in the left iliac artery, positioned the Nava cross catheter immediately distal to the identified point, and then I try to use connect wire to the navigated parallel to the Sparta core wire through the lumen of the occluded left common iliac artery, however, I was not able to navigate the wire through the true lumen, and procedure was stopped. Final angiogram was obtained with injection through the Omni Flush catheter positioned to the distal aorta, which showed unchanged occluded left common iliac artery, no evidence of extravasation, staining, and unchanged 70% stenosis of the right common iliac artery.
CONCLUSIONS: 1. Severe symptomatic peripheral vascular disease with 100% chronic occlusion of the left common and external iliac artery, and 100% occlusion of the distal right superficial femoral artery.
2. Unsuccessful peripheral revascularization attempt of the left iliac artery, unable to cross the lesion luminally, due to severe calcification, and chronicity of the occlusion.
3. We will discuss case with vascular surgery, and will plan referral for right to left femorofemoral bypass, including endarterectomy of the left common femoral artery, should patient except the option, then we will plan angioplasty and stent of the right common iliac artery and reevaluation of the external iliac artery for possible stent. Alternatively, additional endovascular intervention can be considered, which would include access from left radial or left brachial with an attempt to cross the iliac artery antegradely with additional support from arm access, compared to right femoral access. I have discussed this options with the patient's family, in my opinion definitive treatment, such as femorofemoral bypass is most reasonable at this time
75630, 26, XU, 36245, LT, 37252, LT, 37253, LT
I feel as though I'm missing a code for the additional imaging of the left common femoral artery. Not sure if I can code 75774, 26
TIA
INDICATION FOR PROCEDURE: This is a 68-year-old gentleman with history of severe peripheral vascular disease, and severe activity restricting claudication, also with history of paroxysmal atrial fibrillation, coronary artery disease, status post PCI, dyslipidemia, left bundle branch block, and previous history of smoking. Patient had angiogram July 2023, at which time he had attempted angioplasty of the left iliac artery, although vessel could not be crossed luminally, in the meantime patient underwent PCI of OM, and is on Plavix, he comes for second attempt angioplasty of the chronically occluded iliac artery with intravascular ultrasound support. With these findings redo angiogram and intervention was planned. Pros and cons of procedure were discussed, consent was obtained.
TECHNIQUE: Arterial access was obtained to the right common femoral artery under direct ultrasound visualization with micropuncture kit and modified Seldinger technique, and 5 French sheath was introduced. Then 5 Omni Flush catheter was placed to the distal aorta above the bifurcation, and used for angiogram. Second arterial access was obtained with the micropuncture kit, and modified Seldinger technique under ultrasound visualization to the distal left common femoral artery which is known to be patent. And 6 French glide sheath was introduced and used for the angiogram and intervention. We used 5 French Omni Flush catheter position from right femoral approach to the distal aorta for distal aortic and iliac angiogram and procedure. Additional imaging of the left common femoral artery was obtained through the 6 French sheath positioned to the left common femoral artery. Local anesthesia was provided with 2% lidocaine 10 cc injected to the right and left groin. Patient was anticoagulated with IV heparin for PTT more than 200. Sedation was provided by department of anesthesia, please see separate report. Intravascular ultrasound was performed with 0.014 IVUS Philips catheter. Blood loss was negligible. Blood samples were also taken for ACT. Contrast used–80 cc Fluoroscopy time 22.6 minutes. Manual management of access site was provided. There were no immediate complications HEMODYNAMICS: Arterial pressure was 120/65mmHg.
PERIPHERAL ANGIOGRAM WAS OBTAINED AND PERSONALLY DICTATED ON JULY 19, 2023, ONLY DISTAL AORTIC AND ILIAC ARTERY ANGIOGRAM WAS OBTAINED TODAY, WHICH WAS UNCHANGED FROM JULY 2023 FOLLOWING FINDINGS: Normal size calcified distal abdominal aorta with evidence of the plaque but no obstructive or protruding plaque, no aneurysm, no dissection. Right: Common iliac artery is a large vessel with 70% proximal stenosis. External iliac artery is a large vessel with 40-50% stenosis Hypogastric is a relatively small vessel with 99% ostial stenosis and slow flow. Common femoral artery is a medium sized vessel with diffuse 30-40% stenosis. Known occlusion 100% of the distal superficial femoral artery, and three-vessel below the knee runoff. Left: Common and external iliac artery 100% occluded. Common femoral artery is moderately calcified vessel with 50-60% diffuse stenosis. No obstructive disease in the superficial femoral artery, popliteal artery, and three-vessel below the knee runoff.
UNSUCCESSFUL ANGIOPLASTY ATTEMPT OF THE LEFT ILIAC ARTERY: Once angiogram was completed, which showed occlusion of the left common iliac artery, but this time showed very small stump of the common iliac artery on the left, we proceeded with intervention. First I attempted to cross the lesion under fluoroscopy mask from the left femoral access in retrograde fashion with 4 French angled 90 cm Nava cross catheter and 260 cm angled 0.035 advantage wire, however the system was found to be subintimal at the level of the transition from common iliac artery to distal aorta. We then advanced 300 cm Sparta core wire to the proximal left common iliac artery and used 0.014 Phillips IVUS catheter which was advanced to the left common iliac artery, and then pullback was performed with following findings. INTRAVASCULAR ULTRASOUND FINDINGS: Luminal cross in the left external iliac artery with negatively remodeled and 100% occluded vessel measuring 5 x 6 mm in diameter. Subintimal crossing the left common iliac artery, which is heavily calcified, and 100% occluded. Once this findings by intravascular ultrasound were confirmed I first attempted to recross the lesion antegradely, and we did use 5 French Omni Flush catheter to engage the stump of the left common iliac artery, and then I attempted to use advantage wire, which would not cross the vessel, we then used 300 cm connect wire, which I was able to slightly navigate in the proximal portion of the left common iliac artery, but not to the midportion of the vessel despite multiple attempts. I then traced under intravascular ultrasound control to the point of transition from luminal to subintimal space in the left iliac artery, positioned the Nava cross catheter immediately distal to the identified point, and then I try to use connect wire to the navigated parallel to the Sparta core wire through the lumen of the occluded left common iliac artery, however, I was not able to navigate the wire through the true lumen, and procedure was stopped. Final angiogram was obtained with injection through the Omni Flush catheter positioned to the distal aorta, which showed unchanged occluded left common iliac artery, no evidence of extravasation, staining, and unchanged 70% stenosis of the right common iliac artery.
CONCLUSIONS: 1. Severe symptomatic peripheral vascular disease with 100% chronic occlusion of the left common and external iliac artery, and 100% occlusion of the distal right superficial femoral artery.
2. Unsuccessful peripheral revascularization attempt of the left iliac artery, unable to cross the lesion luminally, due to severe calcification, and chronicity of the occlusion.
3. We will discuss case with vascular surgery, and will plan referral for right to left femorofemoral bypass, including endarterectomy of the left common femoral artery, should patient except the option, then we will plan angioplasty and stent of the right common iliac artery and reevaluation of the external iliac artery for possible stent. Alternatively, additional endovascular intervention can be considered, which would include access from left radial or left brachial with an attempt to cross the iliac artery antegradely with additional support from arm access, compared to right femoral access. I have discussed this options with the patient's family, in my opinion definitive treatment, such as femorofemoral bypass is most reasonable at this time
) I may be stretching a little with the codes, and I can't guarantee that they will get paid. But I would try these codes. 36245-LT for the right-side access into the left common iliac artery. 36140-LT,59 for the left common femoral access. 75710-LT for the left lower extremity (doctor is working on the left side so the right side is incidental). I agree with 37252 and would code 37253, however 37253 may not get paid.