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Thread: Again Peripheral Angiography

  1. #1

    Default Again Peripheral Angiography

    AAPC: CPC Promo
    Indication: Intermittent claudication

    Procedure: Diagnostic peropheral angiography of the right lower extremity w/percutaneous intervention of the external iliac w/placement of a bare-metal stent.

    HPI: pt has history of CAD. He underwent a recent angiography, that demonstrated medically managed disease, however, in the course of his angiogram, there was external iliac dissection. He was managed conservatively; however, developed symtoms of intermittent claudication and underwent ultrasonography that demonstrated high-grade stenosis in the external iliac w/abnormal ABI's, and w/classic symptoms of claudication, he is referred for diagnostic peripheral angiography.

    Procedure: Left common femoral artery was accessed using micropuncture technique of which a 6 French 11 cm sheath was placed w/o complication. A Contra catheter was placed into the ascending aorta and with the assistance of a Terumo Glidewire, it wa then introduced across the aortic bifurcation and placed into the internal iliac distribution. Selective angiography was then performed, demonstrating that there was no significant disease in the common iliac or internal iliac; however, in the external iliac in the mid to distal portion, there was an eccentric 90% stenosis. The runoff angiography was then performed, which demonstrated no comprimise of the bifurcation of the SFA or deep profunda w/appropriate runoff down to the popliteal. A terumo wire was then used to navigate the lesion, was then placed in the distal SFA and the Contra wire was then passed to use in an exchange fashion for an 0.035 J-wire. At this point a 6 French 90 cm guide sheath was then exchanged and placed across the bifurcation into the common iliac artery. A 6.0x40 Fox Plus peripheral balloon was used to predilate the lesion. There was a residual 90% stenosis, which was deemed unsatisfactory. At that point, it was then decided to proceed w/stent placement due to the evidence of elastic recoil and suboptimal balloon angioplasty. At this point, a Gensis 8.0x39 biliary stent was then placed across the lesion and deployed to 8 atmospheres. There was an excellent angiographic result w/0% residual stenosis. There was no evidence of distal edge dissection. Further runoff was then performed demonstrating patency of the bifurcation of the SFA and deep profunda, as well as the lower extremity in the SFA down to the popliteal. The patient had improvement of his pulse in the lower extremity post-procedure to 2+. We then elected to Angio-Seal the arteriotomy in the left groin w/o complication.

    Summary:
    1. Diagnostic angiography of the external iliac demonstrated 90% stenosis.
    2. Unsuccessful balloon angioplasy of the external iliac artery.
    3. Successful stent placement in the external iliac artery w/0% residual stenosis.

    So these are what we think we should code
    443.9
    440.22

    36140-59 440.22
    75710-26-59 440.22
    36246-59 440.22 443.9
    37221 443.9 440.22
    Are we close?

  2. #2
    Join Date
    Apr 2007
    Location
    Ann Arbor
    Posts
    1,007

    Default

    Quote Originally Posted by n.anselmo@yahoo.com View Post
    Indication: Intermittent claudication

    Procedure: Diagnostic peropheral angiography of the right lower extremity w/percutaneous intervention of the external iliac w/placement of a bare-metal stent.

    HPI: pt has history of CAD. He underwent a recent angiography, that demonstrated medically managed disease, however, in the course of his angiogram, there was external iliac dissection. He was managed conservatively; however, developed symtoms of intermittent claudication and underwent ultrasonography that demonstrated high-grade stenosis in the external iliac w/abnormal ABI's, and w/classic symptoms of claudication, he is referred for diagnostic peripheral angiography.

    Procedure: Left common femoral artery was accessed using micropuncture technique of which a 6 French 11 cm sheath was placed w/o complication. A Contra catheter was placed into the ascending aorta and with the assistance of a Terumo Glidewire, it wa then introduced across the aortic bifurcation and placed into the internal iliac distribution. Selective angiography was then performed, demonstrating that there was no significant disease in the common iliac or internal iliac; however, in the external iliac in the mid to distal portion, there was an eccentric 90% stenosis. The runoff angiography was then performed, which demonstrated no comprimise of the bifurcation of the SFA or deep profunda w/appropriate runoff down to the popliteal. A terumo wire was then used to navigate the lesion, was then placed in the distal SFA and the Contra wire was then passed to use in an exchange fashion for an 0.035 J-wire. At this point a 6 French 90 cm guide sheath was then exchanged and placed across the bifurcation into the common iliac artery. A 6.0x40 Fox Plus peripheral balloon was used to predilate the lesion. There was a residual 90% stenosis, which was deemed unsatisfactory. At that point, it was then decided to proceed w/stent placement due to the evidence of elastic recoil and suboptimal balloon angioplasty. At this point, a Gensis 8.0x39 biliary stent was then placed across the lesion and deployed to 8 atmospheres. There was an excellent angiographic result w/0% residual stenosis. There was no evidence of distal edge dissection. Further runoff was then performed demonstrating patency of the bifurcation of the SFA and deep profunda, as well as the lower extremity in the SFA down to the popliteal. The patient had improvement of his pulse in the lower extremity post-procedure to 2+. We then elected to Angio-Seal the arteriotomy in the left groin w/o complication.

    Summary:
    1. Diagnostic angiography of the external iliac demonstrated 90% stenosis.
    2. Unsuccessful balloon angioplasy of the external iliac artery.
    3. Successful stent placement in the external iliac artery w/0% residual stenosis.

    So these are what we think we should code
    443.9
    440.22

    36140-59 440.22
    75710-26-59 440.22
    36246-59 440.22 443.9
    37221 443.9 440.22
    Are we close?
    Close, but too many codes. 36140 is if you just stuck the artery, placed a sheath and looked at that side. It goes away when you go into the aorta or selective. Since this is an intervention of lower extremity, all selective codes go away. So you have 75710-59 for the angiogram, and 37221 for the sent placement which includes angioplasty.
    HTH,
    Jim Pawloski, CIRCC

  3. #3

    Default

    Thanks

  4. #4

    Default

    Quote Originally Posted by Jim Pawloski View Post
    Close, but too many codes. 36140 is if you just stuck the artery, placed a sheath and looked at that side. It goes away when you go into the aorta or selective. Since this is an intervention of lower extremity, all selective codes go away. So you have 75710-59 for the angiogram, and 37221 for the sent placement which includes angioplasty.
    HTH,
    Jim Pawloski, CIRCC
    I agree with Jim and as far as the dx codes you should be using 440.21 only.
    Theresa CCS-P CPMA CCC ICDCT-CM

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