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Intent not matching documentation

  1. #1
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    Greater Portland (Maine)
    Posts
    129
    Default Intent not matching documentation
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    The intent was 75625/75716 for the angiography done before the revascularization, but physician doesn't give description of findings on left side beyond the iliacs, despite the fact that it's clear he obtained add'l images of the LLE. Should the codes for this total procedure be 75630, 75710, 75774, 37220, 37224?

    PREOPERATIVE DIAGNOSES:
    1. Atherosclerosis with ischemic rest pain right lower extremity.
    2. Failing bypass, right lower extremity.

    POSTOPERATIVE DIAGNOSES:
    1. Atherosclerosis with ischemic rest pain right lower extremity.
    2. Failing bypass, right lower extremity.


    PROCEDURE PERFORMED:

    1. Angiogram of the abdominal aorta with bilateral lower extremity runoff.

    2. Cutting balloon angioplasty of right lower extremity bypass graft x2.

    3. Cutting balloon angioplasty of right external iliac artery (angio sculpt 6 mm x 4 cm).

    4. Additional images bilateral lower extremities.

    SURGEON: Xxxx X Xxxxx, MD.

    ANESTHESIA: Local with moderate sedation.

    ESTIMATED BLOOD LOSS: Minimal.

    COMPLICATIONS: None.

    ACCESS: A 6 French sheath, left common femoral artery with ultrasound guidance.

    CLOSURE DEVICE: Mynx.

    CLINICAL HISTORY: This pleasant 82-year-old woman is status post right femoral to popliteal artery bypass graft and right common femoral artery endarterectomy. The bypass was 6 mm PTFE. Serial surveillance with duplex ultrasound shows increasing velocities within the bypass graft in several areas with areas of greater than 50% stenosis which are getting worse. She is also developing ischemic rest pain in the right foot and complains of a burning pain in the right forefoot and toes.

    Plan is for arteriography with intention to treat.

    Additionally, she is complaining of left lower extremity pain, so left lower extremity images are planned. She has chronic renal insufficiency with a creatinine clearance of 45. Dye will be conserved in contrast and distant nephropathy protocol was initiated.

    RADIOLOGIC FINDINGS:

    1. The abdominal aorta was patent with solitary renal arteries bilaterally which were widely patent. The patient had evidence of prior kyphoplasty, and so cement within the vertebral bodies of the lumbar spine limited imaging, but there did not appear to be any focal stenosis within the abdominal aorta. Diffuse atherosclerosis with severe calcium was noted throughout the arterial tree.

    2. Both common iliac arteries were patent. Both internal iliac arteries were patent.

    3. On the right side, in the distal right external iliac artery, just proximal to the endarterectomized common femoral artery, a septated lesion was noted of greater than 50% stenosis.

    4. The right common femoral artery had evidence of prior endarterectomy and is widely patent.

    5. The right superficial femoral artery appeared to be chronically totally occluded. The right profundus femoralis artery was patent. The right lower extremity bypass graft was noted to be widely patent, but there was an area at the anastomosis to the bovine patch where there appeared that there might be another area of septation. In the distal bypass graft, very focally septated area approximately 1 cm from the distal anastomosis was noted on several views. This responded well to balloon angioplasty.

    6. There was retrograde flow into the superficial femoral artery proximally.

    7. There was antegrade flow down the widely patent right popliteal artery.

    8. There was evidence of 3 vessel runoff. Of these 3, the posterior tibial and anterior tibial artery appeared to be the dominant runoff. Flow was noted to be quite slow through the tibial system.

    9. After cutting balloon angioplasty with a 6 mm x 4 cm balloon, the distal anastomotic area, the proximal anastomotic area, and the external iliac artery on the right appeared to be significantly improved.

    PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the groin area was prepared and draped in the standard sterile fashion and I then called a time-out for correct patient and procedure identification per Mercy Hospital protocol. I accessed the left common femoral artery using local anesthesia, Seldinger technique, and ultrasound guidance. A 5 French sheath was inserted using a micro access system. The sheath was aspirated and flushed and the patient was given 3000 units of unfractionated heparin IV. Through the sheath, I advanced an Omni flush catheter over a guidewire. The Omni flush was fashioned in the descending thoracic aorta and bubbles were removed. The Omni flush catheter was pulled into the L1-L2 vertebral body position and an AP angiogram of the abdominal aorta was obtained. I then pulled the catheter down to the distal abdominal aortic, and additional iliofemoral and pelvic runoff images were obtained. Due to conservation of dye issues, I did not do a blank imaging of the pelvis, merely an AP projection. Next, I selectively catheterized the right common femoral artery from the left and performed additional images of the right lower extremity using serialography. Upon completion of the operation, I pulled the patient's sheath back into the left common femoral artery and obtained additional images of the left lower extremity, again using serialography.

    I then selectively catheterized the patient's right lower extremity bypass graft. This was noted to be quite tricky due to a significant angulation of the proximal anastomosis of the bypass graft. Nonetheless, glidewire and Omni flush catheter were used for this, and additional images of the right lower extremity were obtained below near the distal anastomosis of the bypass graft and below the knee.

    I then heparinized the patient with a total of 70 mg/kg of unfractionated heparin IV. I inserted an Ansel 2 sheath into the right lower extremity bypass graft from the left side. I then selectively catheterized the right popliteal artery. An angio score balloon measuring 6 mm x 4 cm was used to perform balloon angioplasty on the distal bypass graft very near the distal anastomosis. Several inflations were used, and full effacement of the balloon was noted. Upon completion of the balloon angioplasty, there was significantly improved appearance of the bypass with no significant septation noted.

    I then pulled the angio sculpt balloon into the proximal anastomosis, and inflated the balloon there. Full effacement of the balloon was noted. The balloon was next deflated and pulled into the distal external iliac artery, where balloon angioplasty of the more proximal lesion was performed. In all sites, balloon angioplasty occurred for 1 minute at 8 atmospheres.

    Completion arteriogram showed significantly improved patency of the external iliac artery and bypass graft. I accepted this result. I pulled the balloon and wire out, removed the sheath back into the left common femoral artery to obtain images of the left lower extremity. After this, I re-prepared and re-draped the left groin area. The Ansel sheath was replaced for short 6 sheath. I then used a Mynx closure device to close the puncture site in the left groin area without complication. Upon completion there was a 2+ femoral pulse bilaterally. Dry sterile dressings were applied.


    Any help would be appreciated.
    RCBartholomew, CPC-H, CEDC

  2. #2
    Default
    Quote Originally Posted by Rita Bartholomew View Post
    The intent was 75625/75716 for the angiography done before the revascularization, but physician doesn't give description of findings on left side beyond the iliacs, despite the fact that it's clear he obtained add'l images of the LLE. Should the codes for this total procedure be 75630, 75710, 75774, 37220, 37224?

    PREOPERATIVE DIAGNOSES:
    1. Atherosclerosis with ischemic rest pain right lower extremity.
    2. Failing bypass, right lower extremity.

    POSTOPERATIVE DIAGNOSES:
    1. Atherosclerosis with ischemic rest pain right lower extremity.
    2. Failing bypass, right lower extremity.


    PROCEDURE PERFORMED:

    1. Angiogram of the abdominal aorta with bilateral lower extremity runoff.

    2. Cutting balloon angioplasty of right lower extremity bypass graft x2.

    3. Cutting balloon angioplasty of right external iliac artery (angio sculpt 6 mm x 4 cm).

    4. Additional images bilateral lower extremities.

    SURGEON: Xxxx X Xxxxx, MD.

    ANESTHESIA: Local with moderate sedation.

    ESTIMATED BLOOD LOSS: Minimal.

    COMPLICATIONS: None.

    ACCESS: A 6 French sheath, left common femoral artery with ultrasound guidance.

    CLOSURE DEVICE: Mynx.

    CLINICAL HISTORY: This pleasant 82-year-old woman is status post right femoral to popliteal artery bypass graft and right common femoral artery endarterectomy. The bypass was 6 mm PTFE. Serial surveillance with duplex ultrasound shows increasing velocities within the bypass graft in several areas with areas of greater than 50% stenosis which are getting worse. She is also developing ischemic rest pain in the right foot and complains of a burning pain in the right forefoot and toes.

    Plan is for arteriography with intention to treat.

    Additionally, she is complaining of left lower extremity pain, so left lower extremity images are planned. She has chronic renal insufficiency with a creatinine clearance of 45. Dye will be conserved in contrast and distant nephropathy protocol was initiated.

    RADIOLOGIC FINDINGS:

    1. The abdominal aorta was patent with solitary renal arteries bilaterally which were widely patent. The patient had evidence of prior kyphoplasty, and so cement within the vertebral bodies of the lumbar spine limited imaging, but there did not appear to be any focal stenosis within the abdominal aorta. Diffuse atherosclerosis with severe calcium was noted throughout the arterial tree.

    2. Both common iliac arteries were patent. Both internal iliac arteries were patent.

    3. On the right side, in the distal right external iliac artery, just proximal to the endarterectomized common femoral artery, a septated lesion was noted of greater than 50% stenosis.

    4. The right common femoral artery had evidence of prior endarterectomy and is widely patent.

    5. The right superficial femoral artery appeared to be chronically totally occluded. The right profundus femoralis artery was patent. The right lower extremity bypass graft was noted to be widely patent, but there was an area at the anastomosis to the bovine patch where there appeared that there might be another area of septation. In the distal bypass graft, very focally septated area approximately 1 cm from the distal anastomosis was noted on several views. This responded well to balloon angioplasty.

    6. There was retrograde flow into the superficial femoral artery proximally.

    7. There was antegrade flow down the widely patent right popliteal artery.

    8. There was evidence of 3 vessel runoff. Of these 3, the posterior tibial and anterior tibial artery appeared to be the dominant runoff. Flow was noted to be quite slow through the tibial system.

    9. After cutting balloon angioplasty with a 6 mm x 4 cm balloon, the distal anastomotic area, the proximal anastomotic area, and the external iliac artery on the right appeared to be significantly improved.

    PROCEDURE REPORT: The patient was taken to the cardiac catheterization laboratory where she was placed on the table in the dorsal recumbent position. After excellent moderate sedation, the skin of the groin area was prepared and draped in the standard sterile fashion and I then called a time-out for correct patient and procedure identification per Mercy Hospital protocol. I accessed the left common femoral artery using local anesthesia, Seldinger technique, and ultrasound guidance. A 5 French sheath was inserted using a micro access system. The sheath was aspirated and flushed and the patient was given 3000 units of unfractionated heparin IV. Through the sheath, I advanced an Omni flush catheter over a guidewire. The Omni flush was fashioned in the descending thoracic aorta and bubbles were removed. The Omni flush catheter was pulled into the L1-L2 vertebral body position and an AP angiogram of the abdominal aorta was obtained. I then pulled the catheter down to the distal abdominal aortic, and additional iliofemoral and pelvic runoff images were obtained. Due to conservation of dye issues, I did not do a blank imaging of the pelvis, merely an AP projection. Next, I selectively catheterized the right common femoral artery from the left and performed additional images of the right lower extremity using serialography. Upon completion of the operation, I pulled the patient's sheath back into the left common femoral artery and obtained additional images of the left lower extremity, again using serialography.

    I then selectively catheterized the patient's right lower extremity bypass graft. This was noted to be quite tricky due to a significant angulation of the proximal anastomosis of the bypass graft. Nonetheless, glidewire and Omni flush catheter were used for this, and additional images of the right lower extremity were obtained below near the distal anastomosis of the bypass graft and below the knee.

    I then heparinized the patient with a total of 70 mg/kg of unfractionated heparin IV. I inserted an Ansel 2 sheath into the right lower extremity bypass graft from the left side. I then selectively catheterized the right popliteal artery. An angio score balloon measuring 6 mm x 4 cm was used to perform balloon angioplasty on the distal bypass graft very near the distal anastomosis. Several inflations were used, and full effacement of the balloon was noted. Upon completion of the balloon angioplasty, there was significantly improved appearance of the bypass with no significant septation noted.

    I then pulled the angio sculpt balloon into the proximal anastomosis, and inflated the balloon there. Full effacement of the balloon was noted. The balloon was next deflated and pulled into the distal external iliac artery, where balloon angioplasty of the more proximal lesion was performed. In all sites, balloon angioplasty occurred for 1 minute at 8 atmospheres.

    Completion arteriogram showed significantly improved patency of the external iliac artery and bypass graft. I accepted this result. I pulled the balloon and wire out, removed the sheath back into the left common femoral artery to obtain images of the left lower extremity. After this, I re-prepared and re-draped the left groin area. The Ansel sheath was replaced for short 6 sheath. I then used a Mynx closure device to close the puncture site in the left groin area without complication. Upon completion there was a 2+ femoral pulse bilaterally. Dry sterile dressings were applied.


    Any help would be appreciated.
    I would bill 75625, 75710, 37220 and 37224. Since he talks about the renals, I would give him the abdominal aortogram. With catheter movement, I would bill just for the right extremity angio. No 75774, since those images were for localizing the lesions. Since there is no findings of the left leg, no billing for that leg. Then bill for the intervention.
    HTH,
    Jim Pawloski, CIRCC

  3. #3
    Location
    Greater Portland (Maine)
    Posts
    129
    Default
    Makes sense. Many thanks!!
    RCBartholomew, CPC-H, CEDC

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