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stent placement & angioplasty

  1. Default stent placement & angioplasty
    Exam Training Packages
    Can we code angioplasty seperately for the below mentioned case or is it included in the stent placement???


    Following informed consent, the patient was placed in the supine
    position and continuous physiologic monitoring was performed
    throughout the examination. The patient was fully
    recovered in the interventional radiology holding area under
    direct, continuous monitoring.

    The right groin sheath and catheter were prepped and draped in a
    sterile fashion. Preprocedure antibiotics were given. A total of
    8,000 units of heparin was given. Intra-arterial paparverine was
    also given. Measurements of the ACT were also made during the
    procedure.

    The previously placed infusion catheter was removed over a guide
    wire. Via the 6 Fr vascular sheath, contrast was injected and
    selective left lower extremity angiography with imaging of the
    foot was performed.

    The length of the proximal graft to the level of the knee joint
    was dilated to 3 mm. The proximal anastomosis was dilated to 4
    mm. And injection of contrast demonstrated improvement in flow
    within the graft. Residual areas of moderate to severe narrowing
    of the proximal third of the graft was present. Residual filling
    defect at the proximal anastomosis is consistent with residual
    thrombus.

    This residual thrombus in the proximal graft was treated with
    pharmaco-mechanical thrombolysis using the Angiojet system and 10
    mg TPA. TPA was administered using a power pulse technique with
    10 mg given in 70 cc normal saline. The TPA was allowed to dwell
    for 45 minutes to facilitate declotting of the proximal portion of
    the graft. Subsequently the AngioJet device was operated in the
    usual mechanical thrombectomy mode.

    Subsequent angiography demonstrates improvement of flow in the
    graft. Residual narrowing within the graft is present down to the
    knee joint. This segment was dilated to 4 mm. The proximal
    anastomosis was dilated to 5 mm.

    Follow-up angiography demonstrates that good antegrade flow within
    the graft is preserved. However long segment areas of moderate to
    severe narrowing are present in the proximal portion of the graft.
    In addition, a focal area of extravasation is present in the graft
    just above the knee joint. Despite multiple attempts at
    prolonged, submaximal balloon inflation to reduce extravasation at
    this site, these attempts were not successful.

    It was decided that percutaneous stent placement would
    be performed to treat the contrast extravation from the graft.
    The patient's lateral leg demonstrates swelling secondary to the
    extravastion. The hematoma was not tense. A 6-mm by 40-mm
    self-expanding nitinol vascular stent was placed across the
    perforation. There was decreased contrast extravasation following
    stent deployment.

    Final contrast angiography with the tip of the catheter in the
    left common femoral artery demonstrates a patent proximal
    anastomosis. There is good flow within the graft. Multiple areas
    of long segment moderate is diffuse narrowing are present in the
    proximal graft. There is good flow across the stent in the mid
    graft. There is good flow in the distal graft. The distal
    anastomosis is widely patent. The left dorsalis pedis artery is
    patent. There is diffuse narrowing of the dorsalis pedis artery
    distally.

    The patient will continue to be carefully monitored in the SICU.

    FINDINGS:

    Up to this point, the patient has received 25-26 mg tPA tissue
    plasminogen activator (Alteplase)

    The left femoral artery to dorsalis pedis artery bypass graft
    composed of vein conduit was initially occluded. Antegrade flow
    in the graft was restored with dilatation of the proximal graft 3
    mm and then to 4 mm.

    Residual filling defects (consistent with thrombus) at the
    proximal anastomosis of the proximal aspect of the graft was
    treated with pharmaco-mechanical thrombolysis. Following frontal
    lysis there is resolution of the thrombus in the proximal graft.
    At this point there is good flow within the graft. There is no
    thrombus in the greater distal graft. The proximal graft was
    dilated again to 4 mm. At this point it was noted that focal
    areas of extraluminal contrast extravasation were noted in the
    proximal graft. These areas are secondary to diffuse intrinsic
    conduit disease in the proximal graft. In addition a focal area
    of extravasation in the graft at the level of the knee is related
    to previous balloon perforation. Extravasation at this site was
    treated with deployment of a 6-mm self-expanding vascular stent.
    There is improvement in extravasation following stent deployment.

    There is good flow within the graft at the conclusion of the
    study. The proximal and distal anastomoses are patent. There is
    decreased contrast extravasation at the site of prior perforation.
    Diffuse intrinsic proximal graft disease is present and graft
    revision is recommended. The ossicle artery, ultrasound is pedis
    artery, is patent at the conclusion of the procedure.

    IMPRESSION:
    Restoration of antegrade flow within the left femoral artery to
    dorsalis pedis artery bypass graft following balloon angioplasty
    of the length of the proximal half of the graft.

    Residual thrombus in the proximal aspect of the graft treated with
    pharmaco-mechanical thrombolysis using the Angiojet system.

    Restoration of good antegrade flow in the distal graft with a
    patent distal anastomosis. Patent left dorsalis pedis artery with
    distal disease.

    Severe narrowing of the conduit at the knee joint treated with
    balloon angioplasty to 4mm. Balloon rupture leading to small
    conduit perforation. Following discussion with the vascular
    surgeon, it was decided that deployment would be performed. 6 mm
    self-expanding nitinol vascular stent deployment resulting in
    reduced contrast extravasation.

    At the conclusion of the study, there is good flow within the
    graft. Multiple focal areas of moderate to severe narrowing
    present in the proximal graft.

    The distal and proximal anastomoses are widely patent. There is
    good flow into the left dorsalis pedis artery which demonstrates
    disease distally.
    Prabha CPC

  2. Default
    Yes you can bill both the angioplasty and the stent of the same vessel. If there was a post dilation of a stent placement then you can only bill the stent. In this case the stent will need a 59 modifier due to the Primary Mech. Thrombectomy performed.

    Michael D. Reyland, CPC, CIRCC
    Surgical Specialists of Georgia

  3. Default
    Thanks for your help
    Prabha CPC

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