# (help!!)   pta/stent of common feroral artery & pta/stent right femoral to popliteal



## Carmen7414 (Mar 24, 2016)

*(help!!)   pta/stent of common feroral artery & pta/stent right femoral to popliteal*

*_*_*
PROCEDURE PERFORMED:
1.  Insertion of sheath in the left femoral artery.
2.  Advancement of catheter across the aortic bifurcation into the right distal external iliac artery.
3.  Right leg angiogram with distal runoff.
4.  PTA and stent of the proximal part of the right femoral to popliteal vein graft.
5.  PTA and stent of the right common femoral artery.

INDICATIONS:
A 72-year-old male who had lifestyle limiting claudication and had stents done in the right superficial femoral artery in the past and recent angiogram showed 100% occlusion of the right SFA at the ostium with a long occlusion, so patient was referred to Dr. Keyhani and had a right fem-pop bypass in 02/2016.  He came for graft scanning and was found to have severe stenosis of the proximal right femoral to popliteal graft as well as in the common femoral artery with monophasic waveform in the entire leg.

DESCRIPTION OF PROCEDURE:
Informed consent was obtained.  Patient was brought to the cath lab.  Left groin was prepped and draped in usual fashion.  Using a micropuncture needle, cannulization of the left femoral artery was obtained using modified Seldinger technique and then the micropuncture sheath was introduced and then an 0.035 wire was introduced and a 5-French sheath was introduced. The internal mammary artery catheter was then advanced across the aortic bifurcation into the right distal external iliac artery and right leg angiogram was done using hand injection. It demonstrated that the patient had severe stenosis of the right common femoral artery and the right femoral to popliteal bypass had severe stenosis in its proximal part, involving a long segment where it just looks like a string and very slow flow into the graft.

Interventional procedure was started.  The existing 5-French sheath was exchanged with a crossover 8-French sheath.  Initially, a Storq wire was used but did not cross the lesion, was exchanged with a V18 control 0.018 wire, which was then advanced across the common femoral artery lesion, which was then dilated using a 6 x 4 mm balloon.  After we paid attention to the fem-pop graft and the V-18 wire did not enter the graft so the 0.014 BMW wire was used and advanced into the graft and the proximal narrowing was dilated with a 3.0 x 80 balloon. That whole segment was then stented using a 5 mm x 10 cm Viabahn stent which was then postdilated with a 5 x 6 balloon.  Now we paid attention to the CFA lesion which was then stented using an 8 mm x 5 cm Viabahn stent and that was postdilated to 7 x 4 balloon.  Angiography was done and showed that the distal part of the stent and the fem-pop graft was not fully expanded so I went back with the 5 balloon to dilate that. The intervention procedure was completed.  Final angiography revealed excellent results with no residual stenosis in the common femoral artery or in the graft.  The proximal fem-pop graft also had no residual stenosis and now there was brisk flow into the graft.

The patient did receive 6000 units of heparin at the beginning of the intervention.

After completing the intervention, the crossover sheath was pulled into the left external iliac artery and left leg angiogram with runoff was done.  The procedure was completed, the long sheath was exchanged with a short 8-French sheath and patient was sent to recovery area in stable condition for sheath to be removed and hemostasis to be obtained once ACT is below 160.

FINDINGS:
There is evidence of stent in the right external iliac artery, as well as a long stent of the right superficial femoral artery.  On contrast angiography, the right common femoral artery has an ulcerated eccentric lesion which is causing at least 80% narrowing.  Most of the  blood is flowing through the profunda. The fem-pop graft is extremely narrow in its long segment in the proximal portion.  It is really looking like it is red and has slow flow. The profunda actually has a brisker flow.  Following PTA and stent, there was no residual stenosis in the common femoral artery or the femoral popliteal graft and it showed that the graft was actually connected to the popliteal artery below the knee.  The distal anastomosis was normal.

For details of the distal runoff please look at the previous angiogram report.

On the left side, the external iliac artery is unremarkable.  The common femoral artery has minimal plaques.  The superficial femoral artery has presence of stent and there is no significant stenosis in any of the vessels.  The popliteal artery is unremarkable and the anterior tibial artery is 100% occluded.  The posterior tibial artery is occluded in a single-vessel runoff and then both the anterior and posterior tibial artery reconstitutes via collaterals from the peroneal artery.

FINAL DIAGNOSES:
Severe peripheral vascular disease as described above. The patient has recent fem-pop bone graft, which was not really successful with 90% stenosis of the proximal part of the graft and also there was an 80% lesion in the common femoral artery, both of which were treated successfully with PTA and stent using a Viabahn covered stent.

** I COME UP WITH 75716-59
AND 37226-RT-22
MY DOCTORS STATES I SHOULD BILL 37226 X 2 SINCE PTA/STENT DONE TWICE.. 
ISNT THE FEMORAL AND POPLITEAL VESSEL ARE IN THE SAME VASCULAR TERRITORY SO I CAN ONLY BILL A SINGLE CODE?   IS THAT RIGHT OR IS THE DOCTOR RIGHT?


----------



## heart123 (Mar 24, 2016)

Femoral/Popliteal Vascular Territory-The entire femoral/popliteal territory in 1 lower extremity is considered a single vessel for CPT reporting specifically for the endovascular lower extremity revascularization codes 37224-37227. 
hope this helps


----------



## csorensen21@yahoo.com (Apr 1, 2016)

I would show the CPT code book to the doctors in regards to the Fem/pop territory coding guidelines. I had this similar situation about a year ago happen and my physician's insisted I bill up to 3 times when they were in that territory for one case. I educated the doctors on correct coding guidelines for revascularization codes and its made them more aware. But yes you are correct you only report the most complex service for more then one lesion in the territory.


----------

