Very Complex Patient

megg1100

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Very Complex Intervention

Case #1

PROCEDURE: The patient was referred for redo bypass surgery because of the
small caliber of his vessels and the concern that he would not have complete
revascularization. He was turned down for bypass surgery and referred back for
staged revascularization of his arteries. The right femoral region was prepared
in the usual sterile and drape manner, anesthetized with 1% lidocaine solution.
Hemodynamic access was gained without difficulty. Blood pressure at the
beginning of the case was 169/58. The patient received Angiomax for
anticoagulation and a JR4 guiding catheter was advanced into the saphenous vein
graft to the right coronary artery. Angiography demonstrates a patent graft
with diffuse disease in a very small caliber right-sided PDA. Balloon
angioplasty was performed to the proximal stenosis with a 2.0 mm balloon and a
2.25 x 18 Resolute drug-eluting stent was deployed to nominal inflation
pressures. The guidewire was removed demonstrating an excellent angiographic
result. Attention was then turned to the left main. An XB 3.5 guiding catheter
was advanced into the left main and a Viper wire was used to negotiate the
heavily calcified left main stenosis and orbital atherectomy was performed at
low speed and then again at high speed yielding a channel through the calcified
left main. A 3.0 x 16 Promus stent was deployed and subsequently post-dilated
with a 3.5 mm balloon resulting in an excellent angiographic result. The
circumflex and first diagonal vessels were all extremely small caliber vessel.
There was a subtotal occlusion in the AV groove circumflex. This was crossed
with a 2.0 balloon and a 2.25 stent was placed for suboptimal angiographic
result. This was felt to be slightly oversized, although there was no evidence
of edged dissection and in comparison to the remainder of his vessels, all of
the rest of the vessels appeared to be approximately 2.0 and no further
intervention was performed. Attention was then turned towards the renal
arteries. He has significant bilateral renal artery stenosis and RDC catheter
was advanced to the ostium of the left kidney and this was crossed with a 0.14
wire. A 5 x 14 Medtronic stent was deployed in the ostium and then subsequently
dilated with a 6 x 2 balloon resulting in a 0% residual and excellent
angiographic result and good coverage of the ostium. The left renal artery was
then selectively engaged confirming the left renal artery stenosis.
Intervention was not performed to the right renal artery.

IMPRESSION:
1. Successful drug-eluting stent implantation to the native right-sided
posterior descending artery.
2. Atherectomy with stent implantation to the left main.
3. Percutaneous transluminal angioplasty with a drug-eluting stent implantation
in the AV groove circumflex.
4. Percutaneous transluminal angioplasty with stent implantation to the left
renal.
5. Renal angiography confirming a high-grade ostial right renal artery
stenosis.

RECOMMENDATIONS: Staged revascularization of his right renal and peripheral
arterial disease at a later date.





Case #2

PROCEDURE: Right renal angiography, right renal stent implantation, bilateral
iliac angiography, abdominal aortography, stent graft implantation in the right
common iliac for iliac artery aneurysm, left common iliac stent implantation
with PTA.

INDICATION FOR PROCEDURE: The right femoral region was prepared in the usual
sterile and drape manner, anesthetized with 1% lidocaine solution. Hemodynamic
access was gained without difficulty and a 25 cm 7-French sheath was placed and
advanced with moderate difficulty. Ultimately, the J wire was removed and an
Advantage Glidewire was used to advance the sheath into the terminal abdominal
aorta. The left femoral region was also accessed using the same technique. An
RDC catheter was advanced after the patient was fully anticoagulated. The left
renal stent was widely patent. The ostium of the right renal artery has an
80-90% stenosis, so this was crossed with 0.014 guidewire and the primary stent
implantation was performed with a 6 x 14 stent. This was postdilated to
slightly larger than 6.0 in the ostium. Angiography demonstrated an excellent
angiographic result, good stent apposition, good coverage of the ostium and
attention was then turned towards the right common iliac stenosis.

There was a big disparity between the ostial stenosis of the main portion of the
external and distal common iliac and a 12 mm aneurysmally dilated segments. The
decision was made to cover this and dilate this with a Viabahn stent graft
because of the inability to place a short stent and get good stent apposition in
the main portion of this aneurysm. An 8 x 5 Viabahn stent was then deployed and
apposition was ensured with careful balloon dilatation with a 7 x 4.
Angiography demonstrates excellent apposition, resolution of the aneurysm and
complete resolution of the gradient in the right common iliac artery. A Wholey
wire was previously placed in the left-sided common iliac artery. PTA was
performed to the left and a 9 x 8 self-expanding Medtronic stent was deployed in
the ostium. This was then postdilated with a 7 x 4 balloon in several
locations. A UF catheter was then advanced over the left guidewire and
abdominal aortography was performed. This demonstrated excellent stent graft
apposition and complete resolution of the gradients on both the right and left
side with exclusion of the right iliac aneurysm. Both the right and left renal
arteries were widely patent. Because of the calcified nature of disease in both
the right and left common femoral, manual compression was used for hemostasis
and the patient was transferred to the recovery area.

IMPRESSION:
1. Complex percutaneous endovascular revascularization.
2. Successful renal artery stent implantation in the right renal artery.
3. Viabahn stent graft implantation for iliac stenosis and iliac aneurysm on
the right side.
4. Self-expanding stent implantation in the left common and external iliac
artery.

I have come up with:

Case #1

37236-59
36245
92933-LM
92928-RC,59
92928-LC,59

Case #2
37225
37236-59
36245-59 x2
34900

Do any of my fellow Interventional Coders have an opinion?

Thanks

CPC,CIRCC
 
Last edited:

Jim Pawloski

True Blue
Messages
1,494
Location
Ann Arbor
Best answers
2
Case #1

PROCEDURE: The patient was referred for redo bypass surgery because of the
small caliber of his vessels and the concern that he would not have complete
revascularization. He was turned down for bypass surgery and referred back for
staged revascularization of his arteries. The right femoral region was prepared
in the usual sterile and drape manner, anesthetized with 1% lidocaine solution.
Hemodynamic access was gained without difficulty. Blood pressure at the
beginning of the case was 169/58. The patient received Angiomax for
anticoagulation and a JR4 guiding catheter was advanced into the saphenous vein
graft to the right coronary artery. Angiography demonstrates a patent graft
with diffuse disease in a very small caliber right-sided PDA. Balloon
angioplasty was performed to the proximal stenosis with a 2.0 mm balloon and a
2.25 x 18 Resolute drug-eluting stent was deployed to nominal inflation
pressures. The guidewire was removed demonstrating an excellent angiographic
result. Attention was then turned to the left main. An XB 3.5 guiding catheter
was advanced into the left main and a Viper wire was used to negotiate the
heavily calcified left main stenosis and orbital atherectomy was performed at
low speed and then again at high speed yielding a channel through the calcified
left main. A 3.0 x 16 Promus stent was deployed and subsequently post-dilated
with a 3.5 mm balloon resulting in an excellent angiographic result. The
circumflex and first diagonal vessels were all extremely small caliber vessel.
There was a subtotal occlusion in the AV groove circumflex. This was crossed
with a 2.0 balloon and a 2.25 stent was placed for suboptimal angiographic
result. This was felt to be slightly oversized, although there was no evidence
of edged dissection and in comparison to the remainder of his vessels, all of
the rest of the vessels appeared to be approximately 2.0 and no further
intervention was performed. Attention was then turned towards the renal
arteries. He has significant bilateral renal artery stenosis and RDC catheter
was advanced to the ostium of the left kidney and this was crossed with a 0.14
wire. A 5 x 14 Medtronic stent was deployed in the ostium and then subsequently
dilated with a 6 x 2 balloon resulting in a 0% residual and excellent
angiographic result and good coverage of the ostium. The left renal artery was
then selectively engaged confirming the left renal artery stenosis.
Intervention was not performed to the right renal artery.

IMPRESSION:
1. Successful drug-eluting stent implantation to the native right-sided
posterior descending artery.
2. Atherectomy with stent implantation to the left main.
3. Percutaneous transluminal angioplasty with a drug-eluting stent implantation
in the AV groove circumflex.
4. Percutaneous transluminal angioplasty with stent implantation to the left
renal.
5. Renal angiography confirming a high-grade ostial right renal artery
stenosis.

RECOMMENDATIONS: Staged revascularization of his right renal and peripheral
arterial disease at a later date.





Case #2

PROCEDURE: Right renal angiography, right renal stent implantation, bilateral
iliac angiography, abdominal aortography, stent graft implantation in the right
common iliac for iliac artery aneurysm, left common iliac stent implantation
with PTA.

INDICATION FOR PROCEDURE: The right femoral region was prepared in the usual
sterile and drape manner, anesthetized with 1% lidocaine solution. Hemodynamic
access was gained without difficulty and a 25 cm 7-French sheath was placed and
advanced with moderate difficulty. Ultimately, the J wire was removed and an
Advantage Glidewire was used to advance the sheath into the terminal abdominal
aorta. The left femoral region was also accessed using the same technique. An
RDC catheter was advanced after the patient was fully anticoagulated. The left
renal stent was widely patent. The ostium of the right renal artery has an
80-90% stenosis, so this was crossed with 0.014 guidewire and the primary stent
implantation was performed with a 6 x 14 stent. This was postdilated to
slightly larger than 6.0 in the ostium. Angiography demonstrated an excellent
angiographic result, good stent apposition, good coverage of the ostium and
attention was then turned towards the right common iliac stenosis.

There was a big disparity between the ostial stenosis of the main portion of the
external and distal common iliac and a 12 mm aneurysmally dilated segments. The
decision was made to cover this and dilate this with a Viabahn stent graft
because of the inability to place a short stent and get good stent apposition in
the main portion of this aneurysm. An 8 x 5 Viabahn stent was then deployed and
apposition was ensured with careful balloon dilatation with a 7 x 4.
Angiography demonstrates excellent apposition, resolution of the aneurysm and
complete resolution of the gradient in the right common iliac artery. A Wholey
wire was previously placed in the left-sided common iliac artery. PTA was
performed to the left and a 9 x 8 self-expanding Medtronic stent was deployed in
the ostium. This was then postdilated with a 7 x 4 balloon in several
locations. A UF catheter was then advanced over the left guidewire and
abdominal aortography was performed. This demonstrated excellent stent graft
apposition and complete resolution of the gradients on both the right and left
side with exclusion of the right iliac aneurysm. Both the right and left renal
arteries were widely patent. Because of the calcified nature of disease in both
the right and left common femoral, manual compression was used for hemostasis
and the patient was transferred to the recovery area.

IMPRESSION:
1. Complex percutaneous endovascular revascularization.
2. Successful renal artery stent implantation in the right renal artery.
3. Viabahn stent graft implantation for iliac stenosis and iliac aneurysm on
the right side.
4. Self-expanding stent implantation in the left common and external iliac
artery.

I have come up with:

Case #1

37236-59
36245
92933-LM
92928-RC,59
92928-LC,59

Case #2
37225
37236-59
36245-59 x2
34900

Do any of my fellow Interventional Coders have an opinion?

Thanks

CPC,CIRCC

Case #1, I would agree with your codes except for the right coronary. It looks like the doctor went thru the bypass graft to the RC, so I would code that part 92937-RC.
Case #2, Looks like the patient has had some previous imaging. I would code 37236-rt for the renal stent, 34900-59 and 75954 for the right iliac covered stent, and 37221 for the left iliac stent. A 36245 could be coded for the renal stent procedure, but not for the lower extremity interventions as they are bundled into stent placement and also non-selective since both access were in the common femoral arteries.

HTH,
Jim Pawloski, CIRCC, R.T. (CV)
 
Messages
626
Location
Gatlinburg, TN
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Case #1, I would agree with your codes except for the right coronary. It looks like the doctor went thru the bypass graft to the RC, so I would code that part 92937-RC.
Case #2, Looks like the patient has had some previous imaging. I would code 37236-rt for the renal stent, 34900-59 and 75954 for the right iliac covered stent, and 37221 for the left iliac stent. A 36245 could be coded for the renal stent procedure, but not for the lower extremity interventions as they are bundled into stent placement and also non-selective since both access were in the common femoral arteries.

HTH,
Jim Pawloski, CIRCC, R.T. (CV)

I agree with JIM.
 

megg1100

Networker
Messages
31
Location
New Bern, NC
Best answers
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Case #1, I would agree with your codes except for the right coronary. It looks like the doctor went thru the bypass graft to the RC, so I would code that part 92937-RC.
Case #2, Looks like the patient has had some previous imaging. I would code 37236-rt for the renal stent, 34900-59 and 75954 for the right iliac covered stent, and 37221 for the left iliac stent. A 36245 could be coded for the renal stent procedure, but not for the lower extremity interventions as they are bundled into stent placement and also non-selective since both access were in the common femoral arteries.

HTH,
Jim Pawloski, CIRCC, R.T. (CV)


Thanks for your help!

Case 2: I actually do have 37221; 37225 was a typo. OOPS! I wasn't sure about billing 75954 since the patient did have prior imaging of that area. Thanks, I will add that. I have a question about the stent graft though. I interpreted the CPT guidelines to say, introduction of guide wires and catheters were additionally reported with 34900. Maybe 36245 isn't the right code since it doesn't say that he went up and over. Would I use 36200 since the wires were advanced into the Aorta from the right side (the same side as the stent graft)? Am I not reading the manual right? HELP!
 
Last edited:

Jim Pawloski

True Blue
Messages
1,494
Location
Ann Arbor
Best answers
2
Thanks for your help!

Case 2: I actually do have 37221; 37225 was a typo. OOPS! I wasn't sure about billing 75954 since the patient did have prior imaging of that area. Thanks, I will add that. I have a question about the stent graft though. I interpreted the CPT guidelines to say, introduction of guide wires and catheters were additionally reported with 34900. Maybe 36245 isn't the right code since it doesn't say that he went up and over. Would I use 36200 since the wires were advanced into the Aorta from the right side (the same side as the stent graft)? Am I not reading the manual right? HELP!

You don't code for wires, you code for the catheter position. And the renal angio. and iliac stent for aneurysm CPT includes catheter position.

HTH,
JIm Pawloski, CIRCC
 
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