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Tibial atherectomy and PTA

  1. #1
    Default Tibial atherectomy and PTA
    Medical Coding Books
    Could someone please check this op-note out for me. The codes the physician has choosen are listed at the top, the codes I believe should be billed are listed at the bottem of the report. I'm not sure if I am leaving out alot of codes, or if he majorly over billing.
    Thanks

    Physician's CPT:
    36247
    36248 x3
    35495
    35495-59
    35470
    35470-59
    75630-26
    75774-26 x5
    75992-26
    75993-26
    75962-26 x2

    Procedure: percutaneous entry into the right femoarl artery was accomplished after local anesthesia. A guidewire and sheath were inserted. Retrograde angiogram was done showing a normal distal aorta and iliac arteries on both sides. The catheter was pased over the aortic bifurcation and down into the external iliac on the left side and an angiogram was done here showing the bifurcation. The catheter was then advanced into the superficial femoral artery. There was a normal superficial femoral artery down to the popliteal had a stent within it. An amplatz wire was placed in this position, and a 90 cm shealtg was advanced down into the proximal popliteal of the left leg. Once this was accomplished, angiography was done below the knee showing that the anterior tibia was completely occluded. The peroneal artery was widely patent down to the ankle but did not communicate into the foot. The posterior tibial artery had significant disease within it and was totally occluded at the level of the ankle. A v-18 wire was led into the posterior tibial artery and proceeded down the posterior tibial to about half to two-thirds of the way down the calf. At this point, there was complete obstruction, and the wire could not be passed any further. Exchange was made for a Grand Slam wire. A crosser catheter was passed over the wire and down the posterior tibial. Moving very slowly, the crosser was able to get through the totally occluded, and we were able to get all the way down into the foot into the lateral tarsal artery. With the wire in the lateral tarsal artery, the laser catheter was passed using a 1.7 laser on a couple settings. We could not get through the area that was totally occluded before crossing it with the crosser. At this point, the wire was again exchanged for a Viper wire, and the oribital atherectomy device was passed down into the past. This was spun at a couple different speeds. The follow-up angiogram showed much better and continued patency of the posterior tibial into the foot. However, the diameter was not adequate, and the contour of the vessel was quite irregular. At this point, the 2.5 mm Vascutrak ballon was passed down into the lateral tarsal artery and brought up through the posterior tibial all the way up to the tibioperoneal trunk. This was inflated a number of times, with low pressure not exceeding 5 atmospheres in only 1 area and mostly 2-3 atmospheres of pressure. The follow-up angiogram showed a totally patent posterior tibial artery down into the tarsal vessels. The procedure was felt to be complete. The apparatus was then removed. Hemostasis was secured using the Angio-Seal device. Sterile dressings were applied. The patient was taken to the recovery room in satisfactory condition.

    CPT:
    35470
    36247
    75962
    75630
    75774

  2. #2
    Location
    Birmingham, Alabama
    Posts
    890
    Default
    Quote Originally Posted by cmweyand View Post
    Could someone please check this op-note out for me. The codes the physician has choosen are listed at the top, the codes I believe should be billed are listed at the bottem of the report. I'm not sure if I am leaving out alot of codes, or if he majorly over billing.
    Thanks

    Physician's CPT:
    36247
    36248 x3
    35495
    35495-59
    35470
    35470-59
    75630-26
    75774-26 x5
    75992-26
    75993-26
    75962-26 x2

    Procedure: percutaneous entry into the right femoarl artery was accomplished after local anesthesia. A guidewire and sheath were inserted. Retrograde angiogram was done showing a normal distal aorta and iliac arteries on both sides. The catheter was pased over the aortic bifurcation and down into the external iliac on the left side and an angiogram was done here showing the bifurcation. The catheter was then advanced into the superficial femoral artery. There was a normal superficial femoral artery down to the popliteal had a stent within it. An amplatz wire was placed in this position, and a 90 cm shealtg was advanced down into the proximal popliteal of the left leg. Once this was accomplished, angiography was done below the knee showing that the anterior tibia was completely occluded. The peroneal artery was widely patent down to the ankle but did not communicate into the foot. The posterior tibial artery had significant disease within it and was totally occluded at the level of the ankle. A v-18 wire was led into the posterior tibial artery and proceeded down the posterior tibial to about half to two-thirds of the way down the calf. At this point, there was complete obstruction, and the wire could not be passed any further. Exchange was made for a Grand Slam wire. A crosser catheter was passed over the wire and down the posterior tibial. Moving very slowly, the crosser was able to get through the totally occluded, and we were able to get all the way down into the foot into the lateral tarsal artery. With the wire in the lateral tarsal artery, the laser catheter was passed using a 1.7 laser on a couple settings. We could not get through the area that was totally occluded before crossing it with the crosser. At this point, the wire was again exchanged for a Viper wire, and the oribital atherectomy device was passed down into the past. This was spun at a couple different speeds. The follow-up angiogram showed much better and continued patency of the posterior tibial into the foot. However, the diameter was not adequate, and the contour of the vessel was quite irregular. At this point, the 2.5 mm Vascutrak ballon was passed down into the lateral tarsal artery and brought up through the posterior tibial all the way up to the tibioperoneal trunk. This was inflated a number of times, with low pressure not exceeding 5 atmospheres in only 1 area and mostly 2-3 atmospheres of pressure. The follow-up angiogram showed a totally patent posterior tibial artery down into the tarsal vessels. The procedure was felt to be complete. The apparatus was then removed. Hemostasis was secured using the Angio-Seal device. Sterile dressings were applied. The patient was taken to the recovery room in satisfactory condition.

    CPT:
    35470
    36247
    75962
    75630
    75774

    Here is what I came up with and why:
    35495/75992 for the arterectomy (lazer) in the lateral tarsal artery
    35470/75962 for the angioplasty (balloon) in the lateral tarsal
    35470-59/75964 for the posterior tibial into the tibioperoneal trunk
    36247 for catheter end postition in the lateral tarsal (includes pathway arteries)
    75710 for angiography of the left extremity.
    75774 for additional injection at the proximal popliteal artery with additional interpretation.

    I did not feel like there was sufficient documentation/interpretation for an aortogram with bilateral iliofemoral runoff (75630).

    My thoughts are that the doctor selected his/her codes based on memory (what he or she actually did), but failed to adequately document the work performed. The report has a lot of holes.

    I hope this helps.
    Danny L. Peoples
    CIRCC,CPC

  3. #3
    Default
    After looking further into this reprot I don't believe it is appropriate to bill for both the Angioplasty and Atherectomy in the lateral tarsal artery. Per CMS National Correct Coding Policy Manual Chap. 5 Version 14.3.1 (updated April 2009) it states when an angioplasty and atherectomy are done to only bill for the most comprehensive atherectomy.

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