# Atherectomy and angioplasty help



## dlb_2000 (May 27, 2010)

Hello all, Can I get someones expert advice on coding this report. I have shortend it alot just to show what he did. Should I code all three Atherectomies and all three Angioplasties? The thing is, it seems he always does these together because of sub-optimal results, so I feel they are adjunctive procedures, but in this report I feel it my be warrented. PLEASE what are your thoughts?

Using an up and over catheter and an angled Glidewire
 we were able to manipulate the wire and the catheter over into the
 right common femoral artery. Previous aortograms were used for
 anatomy. A selective right lower extremity arteriogram was performed.
 This showed a patent common femoral, superficial femoral, profunda
 arteries. A stent in the proximal superficial femoral artery was
 patent without any evidence of narrowing. There was some narrowing in
 the distal superficial femoral artery in the 50% range at the
 adductor canal. The popliteal artery was then occluded just above the
 knee joint. It ended in several collaterals. Recanalization of the
 posterior tibial artery was seen likely several centimeters after the
 origin. Also seen was reconstitution of the anterior tibial artery
  several centimeters after the origin as well.
  Given her critical limb ischemia we felt trying to open her occlusion
  would be of her best interest. Intravenous Heparin was given.
  Activated clotting times were checked. A wire followed by a catheter
  was placed down into the proximal popliteal artery. A more selective
  right lower extremity arteriogram was performed just to get better
  visualization of the target vessel, the posterior tibial artery. We
  were then able to cross the occluded popliteal artery, tibioperoneal
  trunk, and proximal posterior tibial artery with a combination of an
  0.035 inch Glidewire and a QuickCross catheter. The wire was removed.
  Dye was injected into the QuickCross catheter to confirm intraluminal
  placement of the posterior tibial artery. Several instillations of
  intraarterial nitroglycerin were given to prevent vasospasm. I then
  exchanged for a smaller 0.014 inch wire. A Pathway Jetstream device
  was used for orbital atherectomy. The Pathway Jetstream device was
  then chosen performing a percutaneous atherectomy. Several passes
  were made with the blades down and then the blades up given a 3 mm.
  maximal luminal gain. Completion arteriogram showed essentially no
  flow or very stagnant flow through the treated artery but it did
  trickle down suggesting either distal vasospasm or maybe embolic
debris. Prolonged angioplasty was then performed with a 3 mm. x 150
 cm. balloon. Completion arteriogram showed the same result. More
 nitroglycerin was instilled. We let a few minutes lapse and repeated
 injection. It now revealed that the popliteal artery now was open
 with nice inline flow into the tibioperoneal trunk and posterior
 tibial artery which made it all the way down to the ankle. A small
 area of extravasation was seen likely in the tibioperoneal trunk was
 fairly small and did not seem concerning or to be growing rapidly.
 Balloon angioplasty was then performed of the narrowing in the distal
 superficial femoral artery. A 4 mm. balloon was chosen. Completion
 arteriogram showed decent result throughout the entire leg without
 any evidence of embolization.


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## Jim Pawloski (May 28, 2010)

I posted a question just like your recently.  Basically, a coder went to Dr. Z's conference, and he said that you code for the atherectomy, even if angioplasty is done before or after the atherectomy.  

I hope this answers your question,
Jim Pawloski, CIRCC, R.T.(CV)


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## sbicknell (May 28, 2010)

To tell you the truth I looked at this several times yesterday but just didnt have the patience to read the whole report. 

But for issue of both an ather and plasty being done. The guideline is the only the most extensive service is performed and this means the ather.  You can code all 3 atherectomies IF they were on separate vessles.

Like I said I didnt read the report, but for example, if an ather/plasty was done on the left iliac, the right SFA and the left popliteal, then he is on three separate vessels and you would code for all 3 atherectomies.

You should also be coding for all the diagnostic selective cath placements and angiographies if done during this same session to idenitfy the locations needing the ather/plasty

If you dont have the Interventional Radiology Coder, I would suggest getting it. Includes the above guidance. Can't code peripheral vascular without it
https://catalog.ama-assn.org/Catalog/product/product_detail.jsp?productId=prod1450006


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## dlb_2000 (May 28, 2010)

*Atherectomy and Angioplasty Help*

Thank you both so much for taking the time to reply. I never bill for both but for some reason I was starting to falter with this report. You confirmed my gut instincts. Have a GREAT Holiday!


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