Question Vascular coding help needed

whejen66

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INDICATIONS: This 97-year-old male with multiple risk factors
for coronary artery disease and moderate aortic stenosis is
admitted to ____ Medical Center in the setting of severe
right lower extremity heel pain and significantly abnormal ABIs
less than or equal to 0.5 on the right. He is referred for
distal aortography and possible intervention.
PROCEDURES PERFORMED: Distal aortography with runoff, right
superficial femoral artery catheterization and angiography with
runoff, left popliteal artery catheterization angiography with
runoff. IVUS, right femoral artery. IVUS, right popliteal
artery. IVUS, right anterior tibial artery. Balloon
angioplasty, right superficial femoral artery using drug-eluting
balloon angioplasty. Atherectomy, right popliteal artery balloon
angioplasty, right popliteal artery atherectomy, right anterior
tibial artery balloon angioplasty, right anterior tibial artery,
ultrasound-guided left common femoral artery access.
ANESTHESIA: Moderate Conscious sedation; start time 11:34, stop
time 13:08. 150 mcg of fentanyl used, 2 mg of Versed.
DIAGNOSES: Peripheral arterial disease with symptoms, right
lower extremity ischemia.
DESCRIPTION OF PROCEDURE: After informed consent was obtained,
the patient was brought to cardiac catheterization suite in
fasting state. Patient prepped and draped in usual sterile
fashion. Using ultrasound guidance, a 6-French sheath was placed
in the left femoral artery. Distal aortography with runoff was
performed with 4-French pigtail catheter. We gained access to
the contralateral limb using a rim catheter and advanced angled
Glidewire and catheter to the proximal superficial femoral artery
and performed angiography with runoff. We then advanced a
Glidewire and catheter to the proximal popliteal artery and
performed angiography with runoff. The patient tolerated
angiography well without complication.
FINDINGS:
1. Sixty percent in the right renal artery. A calcified and
tortuous distal aorta with aneurysmal dilatation of the distal
aorta distal to the kidneys.
2. Tortuous right common iliac and external iliac arteries,
which were heavily calcified, but patent. Heavily calcified,
patent right superficial femoral artery with focal 70% to 80%
stenosis proximally. Patent stent in right superficial femoral
artery. Eighty to 90% stenosis in the distal popliteal artery.
Seventy to 80% focal stenosis in the right anterior tibial
artery. Total occlusion distally of the anterior tibial artery
with a large collateral filling the dorsalis pedis with
collaterals to the posterior tibial.
INTERVENTIONAL PROCEDURE: Based on these findings, we elected to
treat the superficial femoral artery distal popliteal artery and
anterior tibial artery. We turned attentions first to treating
below the knee disease. We exchanged the 6-French sheath for a
65 cm Destination sheath brought to the contralateral right
superficial femoral artery. We successfully crossed the lesion
using a Viper wire, advancing into the distal anterior tibial
artery. The patient was administered a total of 9000 units of
heparin. Procedure ACT was 307. We elected to perform IVUS of
the distal popliteal artery using 125 CSI micro orbital
atherectomy device. Atherectomy was performed at low and medium
speeds, resulting in a good, but suboptimal result. We then
elected to perform atherectomy of the proximal anterior tibial
artery using the 125 CSI micro orbital atherectomy device at low
and medium speed obtaining a good but suboptimal result. We then
elected to IVUS the popliteal and anterior tibial arteries. IVUS
was performed using the 0.018 Volcano IVUS system. IVUS revealed
concentric calcification in the distal popliteal artery with
concentric focal narrowing in the distal popliteal artery of
greater than 50% and concentric calcification in the anterior
tibial artery with residual narrowing greater than 50%.
Therefore, elected to treat the distal popliteal artery. The
diameter of the popliteal artery measured 3.2 mm and the anterior
tibial artery 2.6 mm. Therefore, we treated the anterior tibial
artery initially with a 2.5/40 mm VascuTrak balloon with slow
inflations up to nominal pressures, resulting in a good result
with less than 20% residual narrowing. We elected to accept this
result. Balloon inflations in the distal popliteal artery using
a 3.0 x 40 mm VascuTrak balloon and eventually with a 3.5 x 40 mm
VascuTrak balloon, resulting in good result, less than 20% to
30%. We elected to accept this result as there was no dissection
and excellent outflow distally after the administration of
intra-arterial verapamil and nitroglycerin. We then turned our
attentions to the proximal superficial femoral artery where we
performed IVUS using the 0.018 Volcano IVUS system. IVUS
revealed a greater than 70% concentric focal stenosis in the
proximal vessel with heavy concentric calcification and a vessel
diameter of 6.2 mm. We therefore, elected to treat the heavily
calcified area using a 6.0 x 60 mm lithoplasty shock wave
balloon. Treatment at this area with the lithoplasty shock wave
balloon resulted in an excellent result less than 30% residual
narrowing with excellent outflow distally. We then performed
balloon inflations at the site using a 6.0 x 80 mm Lutonix
balloon, thus delivering paclitaxel. Followup angiography
revealed excellent result with no flow limiting dissection with
less than 20% to 30% residual narrowing. We elected to accept
this result as was great outflow distally. A total of 110 mL of
Visipaque contrast was used during the study. At the conclusion
of the study, the left femoral sheath was removed. Hemostasis
was obtained using the Perclose ProGlide device. Patient
tolerated the procedure well without complication.
IMPRESSION:
1. Seventy to 80% heavily calcified stenosis in proximal right
superficial femoral artery, treated with a shock wave lithoplasty
balloon and Lutonix balloon ranging in less than 20% to 30%
residual narrowing.
2. Patent stent, in the mid right superficial femoral artery.
3. Eighty to 90% focal stenosis in the distal right popliteal
artery, status post atherectomy and balloon angioplasty resulting
in less than 20% residual narrowing. Seventy to 80% stenosis in
the right anterior tibial artery, status post atherectomy and
balloon angioplasty resulting in less than 10% to 20% residual
narrowing.
4. Total occlusion of the very distal anterior tibial artery
with a large collateral filling the dorsalis pedis with minimal
to moderate collateralization to the posterior tibial artery
distally and total occlusion of the right peroneal and posterior
tibial arteries.
 

ernist8489

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We would code this case as follows.
37229- RT Anterior Tibial atherectomy /Angioplasty.
37225- RT SFA/Popliteal Atherectomy & Angioplasty.
(Catheter placements all bundled with al interventions performed from the same access whether ipsilateral or contra lateral, faccess site which was the left femoral )
37252- IVUS (1st Vessel) Anterior Tibial.
37253X 2- IVUS (2 additional IVUS one in SFA one in popliteal)
75716- 26-XU- Bilateral lower ext diagnostic Angiogram.
75625- 26- Aortogram.
76937-26 (U/S guidance for left femoral access).
99152- moderate sedation 1st 15 minutes.
99153x 5 units (each additional 15 minutes = 1 unit ).
Let me know if you have any further questions on interventional radiology/ cardiovascular coding.

Erik Brown, CIRCC, CPC
 

ernist8489

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We would code this case as follows.
37229- RT Anterior Tibial atherectomy /Angioplasty.
37225- RT SFA/Popliteal Atherectomy & Angioplasty.
(Catheter placements all bundled with al interventions performed from the same access whether ipsilateral or contra lateral, faccess site which was the left femoral )
37252- IVUS (1st Vessel) Anterior Tibial.
37253X 2- IVUS (2 additional IVUS one in SFA one in popliteal)
75716- 26-XU- Bilateral lower ext diagnostic Angiogram.
75625- 26- Aortogram.
 

whejen66

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Campbell, TX
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We would code this case as follows.
37229- RT Anterior Tibial atherectomy /Angioplasty.
37225- RT SFA/Popliteal Atherectomy & Angioplasty.
(Catheter placements all bundled with al interventions performed from the same access whether ipsilateral or contra lateral, faccess site which was the left femoral )
37252- IVUS (1st Vessel) Anterior Tibial.
37253X 2- IVUS (2 additional IVUS one in SFA one in popliteal)
75716- 26-XU- Bilateral lower ext diagnostic Angiogram.
75625- 26- Aortogram.
76937-26 (U/S guidance for left femoral access).
99152- moderate sedation 1st 15 minutes.
99153x 5 units (each additional 15 minutes = 1 unit ).
Let me know if you have any further questions on interventional radiology/ cardiovascular coding.

Erik Brown, CIRCC, CPC
Thank you so much!!! I am learning this coding and it has been challenging with vascular. Can I get your contact information?
 
Last edited:

Jim Pawloski

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Ann Arbor
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We would code this case as follows.
37229- RT Anterior Tibial atherectomy /Angioplasty.
37225- RT SFA/Popliteal Atherectomy & Angioplasty.
(Catheter placements all bundled with al interventions performed from the same access whether ipsilateral or contra lateral, faccess site which was the left femoral )
37252- IVUS (1st Vessel) Anterior Tibial.
37253X 2- IVUS (2 additional IVUS one in SFA one in popliteal)
75716- 26-XU- Bilateral lower ext diagnostic Angiogram.
75625- 26- Aortogram.
76937-26 (U/S guidance for left femoral access).
99152- moderate sedation 1st 15 minutes.
99153x 5 units (each additional 15 minutes = 1 unit ).
Let me know if you have any further questions on interventional radiology/ cardiovascular coding.

Erik Brown, CIRCC, CPC
Wouldn't be just one charge of IVUS for the femoral/popliteal region?
 

ernist8489

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Wouldn't be just one charge of IVUS for the femoral/poplitea
NOPE :) IVUS and Primary Percutaneous Transluminal Arterial Mechanical thrombectomy are both per vessel treated, Femoral popliteals are seperate vessels for coding purposes for IVUS and Thrombectomy. For IVUS Unless they are bridging lesions then we may report separately.
That is distinct for lower extremity fem pop revascularizations which we can only report the one procedure for highest intervention performed- (I.E Stenting of popliteal, atherectomy of the Profunda - (37227) Where as if IVUS is performed on the SFA and there are findings documented for that IVUS of 70 pct stenosis, they then run the IVUS into the popliteal and diagnosis a seperate stenosis or thrombus etc then we may report 37252, and 37253. I found something from Dr. Z \
 
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