# Peripheral Intervention



## amym (Oct 19, 2011)

Is it appropriate to bill this procedure as 37225, 75716-26, 75625-26 or am I missing something?

PROCEDURE PERFORMED: 
1. Bilateral selective femoropopliteal and intrapopliteal angiography. 
2. PTA of the right SFA. 
3. TurboHawk atherectomy of the right popliteal artery. 

CHIEF COMPLAINT: 
Severe bilateral claudication in this patient with know peripheral 
arterial disease and coronary artery disease who presented who after 
having stenting to the left SFA he was noted to have severe occlusive 
disease below the knee and high-grade stenosis of the SFA bilaterally. 
After his stenting of the left SFA significant improvement in his pain 
was noted in his left leg by opening the inflow, following which now he 
presents to have significant claudication in the right leg, which 
remains. 

PROTOCOL:  The patient was brought to the endovascular lab and prepped 
and draped in the usual sterile fashion.  Xylocaine was infiltrated and 
both groins were prepped.  The left femoral artery was cannulated 
without difficulty and a J-wire was advanced and an OmniFlush 5-French 
catheter was used to advance a Stiff glidewire was used to cross over to 
the contralateral side.  At this point, using the left femoral sheath, 
angiography of the left popliteal artery was performed all the way to 
the popliteal artery and it was noted to be the left SFA stent is widely 
patent with good flow, however, the flow was slower due to significant 
occlusive intrapopliteal disease. 

After the identification, a 7-French Pinnacle Destination sheath was 
then advanced and crossed over to the contralateral side with placement 
of the tip at the contralateral femoral artery and at this point images 
were performed and showed multiple areas of stenosis in the SFA on the 
right side.  The proximal third of the lesion was 50 to 60%, the middle 
third the lesion was 60 to 70% and the distal third lesion was 90%. 
Immediately below the SFA, the popliteal artery had a focal discrete 90% 
stenosis, which was leading up to having a disease trifurcation with 
occlusive disease involving all three intrapopliteal vessels with 
collateral network, which was faint. 

After lesions were identified, it was felt the most appropriate approach 
would be a TurboHawk atherectomy involving these two lesions.  At this 
point, 0.014 Spartacore wire was then advanced and the lesion was 
crossed and the wire tip was placed above the trifurcation and the Ellis 
TurboHawk catheter was advanced but at the level of the distal third 
where there was severe stenosis of the SFA, the TurboHawk could not be 
advanced and therefore was removed.  At this point, a 4 x 80 Ampherion 
Medtronic balloon was then advanced and dilated to 6 atmospheres and 
full extension was noted.  This was a calcified lesion.  After two 
balloon inflations, marked improvement was noted up to a maximum of 6 
atmospheres with no residual narrowing.  There is thrombus or 
dissection.  There was a mild residual narrowing present.  The balloon 
was removed and the Turbo Hawk catheter was now successfully advanced 
into the popliteal artery stenosis, which was treated with multiple 
passes of TurboHawk atherectomy.  Two separate runs were done and a 
large amount of plaque was removed, revealing smooth margins and an 
excellent flow with only then 20% residual narrowing at this lesion site 
and at that point, imaging of the intrapopliteal vessels shows no 
changes in anatomy.  At this point the entire assembly was removed and 
ProGlide Perclose device was used for closure, which was successful and 
no complications occurred.  Final pulses interrogated with Doppler in 
both dorsalis pedis, which were unchanged prior to the start of the 
procedure. 

IMPRESSION: 

1. SUCCESSFUL PTA OF THE DISTAL THIRD OF THE SFA USING 4 X 80 AMPHERION 
BALLOON WITH A STENOSIS REDUCTION FROM 90% TO LESS THAN 20%. 

2. SUCCESSFUL TURBOHAWK ATHERECTOMY OF THE RIGHT POPLITEAL ARTERY WITH 
MULTIPLE PASSES USING ELLIS DEVICE WITH LESION REDUCTION FROM 90% TO 
LESS THAN 20% WITH ATHERECTOMY ALONE. 

Thanks.


----------



## donnajrichmond (Oct 19, 2011)

You'll really need to clarify with the physician about 75625 and 75716.  It appears that this patient has had previous angiography that identified the stenoses.  CPT tells us that if there has been previous angiography you can only code it again if the patient's condition has changed, the previous angiogram wasn't sufficiently detailed or there is a change in the patient's condition during the intervention that requires imaging outside the area of therapy.


----------



## jewlz0879 (Oct 20, 2011)

amym said:


> Is it appropriate to bill this procedure as 37225, 75716-26, 75625-26 or am I missing something?
> 
> PROCEDURE PERFORMED:
> 1. Bilateral selective femoropopliteal and intrapopliteal angiography.
> ...



If you look at pg 373 in CPT it will outline the rules for billing those codes. If you deem they are billable, you'll need to attach a 59.


----------

