As per the CPT book, mechanical thrombectomy can be coded separately when other percutaneous interventions are performed. I am looking for feedback on this scenario, please.

The question is mechanical thrombectomy. Upon diagnostic testing the patient is found to have CTO; there is known emboli when a patient has CTO so the plan is to go in and perform primary mechanical thrombectomy in the vessels; once in the case the physician is able to cross the lesion and perform additional percutaneous interventions and does so in conjunction with the thrombectomy. The primary planned thrombectomy is for emboli known to exist prior to the case ? not for emboli/thrombus created from performing PTA/atherectomy.

Preoperative Diagnosis: Non-healing ulcer right foot, CTO

Postoperative Diagnosis: Non-healing ulcer right foot, CTO

Procedure:
1. Aortogram with right extremity runoff
2. TurboHawk SSCL arthrectomy, Priority One thrombectomy x 4, SFA, CFA, popliteal, additional vessel and peroneal and PTA with Admiral Extreme 4x80. Star Close device was deployed.

Surgeon:

Fluoroscopy Time: 13 minutes, 17 seconds

Contrast: Optiray-320. 57 seconds

Clinical Data: Mr. ______ has a non-healing right great toe ulcer and known chronic total occlusion. He has had a previous stroke affecting the left side of his body. The right side is very important for his ability to stand and bear weight, etc. and to assist with his ADLs so he presents for arteriogram. He understands the risks and agrees to proceed.

Findings: The patient had normal aorta and iliac vessels bilaterally, normal right SFA. He had single vessel runoff via the peroneal and it was a diseased vessel below the knee. He had partial pedal arch. I was able to get a .014 wire across this and did the atherectomy and then the suction thrombectomy and then the PTA which much improvement in flow. Hopefully this will be enough to heal his ulcer. He will follow-up in the office to see me as scheduled.

Procedure: The patient was taken to the angio suite and placed in a supine position and given IV sedation. Both groins were clipped, prepped and draped sterilely. 1% lidocaine was used to anesthetize the area of the left common femoral. A left common femoral approach was used. Micropuncture needle was used to enter the4 vessel. A 5-French sheath was placed and Omniflush catheter was positioned in the distal aorta and aortogram was performed showing no evidence of aortic or iliac disease.

The up and over technique was used to cannulate the external iliac on the right and with the aid of the Bentsen wire the run was performed showing no proximal disease, but peroneal disease. Therefore at this point I placed a Rosen wire, placed an up and over 7-French sheath and was able to use a Glidewire and get into the peroneal artery and then we placed a catheter and then the .014 wire and then used the atherectomy with the TurboHawk SSCL and was able to atherectomize the entirety of the peroneal where the disease was with the aid of the glow and tell tape to mark it. This was then removed and we placed the Priority One suction thrombectomy as a planned primary thrombectomy in the four vessels as mentioned with an excellent result and removal of debris.

I was also able to PTA this with the Admiral Extreme 4x80 after I had to do a wire exchange and place the Glidewire.

Once this had been completed we performed a final run showing much improvement in flow.

The sheath was then pulled back into the external iliac on the left. The Bentsen was replaced and the Star Close device was deployed with no sign of hematoma. At this point direct pressure was held. He will be monitored for two hours prior to discharge and follow-up in the office to see me in a week.

Codes: 37225
37229
37184
37185
37185
75625-59
75710-59

Should modifiers be applied to the thrombectomy code(s)? Any feedback would be greatly appreciated. Thank you!!