# 75625 vs 75630



## Rita Bartholomew (Apr 5, 2012)

_At first, I assigned 36246,75625,75710, but seeing that the pt also had an AAA (despite the fact we were checking his lt fem-pop bypass graft), I thought that perhaps 36246,75630,75710 would be appropriate.  Any other thoughts?_

PREOPERATIVE DIAGNOSIS:  Failing bypass graft, left lower extremity with atherosclerosis and intermittent claudication.  

POSTOPERATIVE DIAGNOSIS:  Failing bypass graft, left lower extremity with atherosclerosis and intermittent claudication.  

NAME OF PROCEDURE:  
1.  Angiogram of the abdominal aorta. 
2.  Left lower extremity arteriogram.

SURGEON:  Xxxx X Xxxxxx, MD

ANESTHESIA:  Local with monitored sedation. 

ESTIMATED BLOOD LOSS:  Minimal. 

COMPLICATIONS:  None. 

CLINICAL HISTORY:  This 83-year-old man is status post left lower extremity bypass graft on 07/13/09.  He notes significant hip and buttock claudication bilaterally, as well as lower extremity claudication.  

Duplex demonstrates a significant stenosis at the inflow of the left lower extremity bypass graft where there is a greater than 50% stenosis and velocities of 386 cm per second, which is increased from 255 cm per second from 1 year ago.  ABI is noted to be 0.72 on the right at rest and 0.71 on the left at rest, where as 1 year ago it was 0.9 on the right at rest and 0.76 on the left at rest.  He also is known to have an abdominal aortic aneurysm.  He comes for imaging of the left lower extremity with intention to treat the bypass graft stenosis. 

Of note, his preoperative creatinine level was 2.13, which is significantly higher than previously noted, and he has been given preoperative hydration with plans to minimize contrast. 

RADIOLOGIC FINDINGS: 
1.  The abdominal aorta was patent with solitary renal arteries bilaterally.  Nephrograms were noted to be poor and the kidney on the right was noted to be quite small. 

2.  An abdominal aortic aneurysm was present and significant calcification and tortuosity was noted in the iliac arteries bilaterally.  No significant focal stenosis was noted throughout the aorta, common iliac, external iliac arteries bilaterally.  On the left side, there was no evidence of hemodynamically significant hypogastric artery stenosis, although the hypogastric artery was severely attenuated.  On the right side there was a very significant hypogastric artery stenosis at the origin of the hypogastric artery.  On the left side, the common femoral artery was patent.  The profunda femoris artery was patent.  The femoral to popliteal artery bypass graft was noted to be patent throughout its length with no significant stenosis noted at the origin of the bypass.  There was some element of septation at the origin of the bypass, this did not appear to be flow limiting.  There was a stump of chronically totally occluded superficial femoral artery proximally. 

3.  The bypass graft was patent to the distal artery, which appeared to be the above the knee popliteal artery.  This appeared to be fashioned in an end-to-side fashion, and there was no retrograde flow up the superficial femoral artery.  The popliteal artery  had calcification but was patent.  This gave rise to an anterior tibial artery which was occluded at approximately 1.5 cm from its origin and a common TP trunk which was noted to have a patent peroneal artery proximally, which became chronically totally occluded.  Distally, the peroneal artery reconstituted.  A branch radiated toward the left posterior tibial artery, however it was clear that the posterior tibial artery and anterior tibial artery were chronically totally occluded.  

IMPRESSION:  
1.  Anterior tibial, posterior tibial and peroneal artery chronic total occlusion below the knee. 
2.  No evidence of significant stenosis in the origin of the left femoral to popliteal artery bypass graft. 
3.  Small abdominal aortic aneurysm noted

DESCRIPTION OF PROCEDURE:  The patient was taken to the cardiac catheterization laboratory where he was placed on the table in a dorsal recumbent position.  After excellent moderate sedation, skin of the groin area was prepared and draped in the standard sterile fashion and I called a time-out for correct patient and procedure identification per Xxxxx Hospital protocol.  Next, under local anesthesia, I accessed the right common femoral artery I the retrograde direction using ultrasound guidance and standard Seldinger technique.  A micro-access sheath, 5 French, was inserted into the right common femoral artery using Seldinger technique.  The sheath was aspirated and flushed, and aspirated and flushed easily.  The patient was heparinized with 3000 units of unfractionated heparin IV.

Next, through the sheath, I advanced an Omni flush catheter into the abdominal aorta at the L1-L2 vertebral body level.  The guidewire was removed and bubbles were removed from the catheter.  An AP angiogram of the abdominal aorta was performed.  This has the findings as noted above.  The catheter was then pulled down into the abdominal aortic aneurysm where oblique imaging of the ileofemoral and pelvic runoff was obtained bilaterally.  No significant ileofemoral lesion was noted bilaterally.  

Next, I used the Omni flush catheter in conjunction with the J wire to selectively catheterize the left common femoral artery from the right side.  With the tip of the catheter in the left common femoral artery, I performed imaging of the left lower extremity using serialography.  The findings are as noted above.  Due to my interest in minimizing dye, as well as not encountering the lesion I expected to encounter, I decided to terminate the procedure here.  The sheath was removed from the right common femoral artery and a 5 French Mynx closure device was used to close the puncture site in the right femoral position.  There were no complications.  Mr. Xxxxx tolerated the procedure well and sponge and needle counts following the case were correct x2.  Dry sterile dressing was applied to the puncture site and contrast used was Isovue 300, 60 mL.


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## dadhich.girish (Apr 5, 2012)

I would absolutely agree with your code selection of 36246, 75630-26, 75710-26/LT.


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## jewlz0879 (Apr 6, 2012)

I agree as well


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## dpeoples (Apr 6, 2012)

Well, first of all I think there is no "right or wrong" answer, you can make a good case for either coding scenario.  I would code it as you did in your first choice, 36246,75625,75710.
My reason is fairly straightforward. Two injections in the aorta = two codes IMO (I am old school). 

Also, it is worth noting that 75710 will bundle with 75630 and will need a modifier 59 to bypass the CCI edits. That is inappropriate IMO because this was not a "distinct and separate test" but a continuation of the test in progress. 

Also, 75630 should include an interpretation of the aorta and bilateral iliac and femoral arteries. I do not remember seeing any information regarding the right femoral artery, but I could have missed that. 

Just my thoughts, HTH


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## Rita Bartholomew (Apr 9, 2012)

I did end up going with my first choice.  Thanks to all!


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