# need help with this procedure



## Rita Bartholomew (Aug 22, 2011)

I got:
75625-59  abd aortogram
75716-59  LE runoff
75774 x 2  lt & rt CIA's
37226  lt SFA stent placement (from rt femoral approach)
37225-59  lt SFA atherectomy/angioplasty (from rt brachial approach)
36247-59  rt SFA (from rt brachial approach)

Are these codes correct?

POSTOPERATIVE DIAGNOSIS:  Atherosclerosis with intermittent claudication, bilateral lower extremities.

NAME OF PROCEDURE:  
1.  Angiogram of the abdominal aorta with bilateral lower extremity runoff. 
2.  Additional views, bilateral lower extremities.
3.  Selective catheterization of the right superficial femoral artery.
4.  Selective catheterization of the abdominal aorta from the right arm.
5.  Atherectomy, angioplasty, and stent placement of left superficial femoral artery (6 mm x 150 mm LifeStent).

SURGEON:  XXXXXXXXXXX

ANESTHESIA:  General.

EBL: Minimal.

COMPLICATIONS:  None.

ACCESS: Six French sheath, right brachial artery. Six French sheath, right common femoral artery.

CLINICAL HISTORY:  This 67-year-old gentleman has severe peripheral arterial occlusive disease as well as neurogenic problems in his back and lower extremities.  He has debilitating intermittent claudication at less than 50 yards and has previous intervention which ultrasound demonstrates is failing. He comes for arteriography with intention to treat. Due to his severe morbid obesity, chronic back pain with lying flat, and inability to hold still with local moderate sedation, general anesthesia was chosen.

Due to his deep aortic bifurcation and the bilaterality of his disease as well as his very large panniculus, a right arm approach was decided upon. 

After atherectomy and angioplasty of the left superficial femoral artery, I found that I did not have a stent that was long enough to reach the left superficial femoral artery from the right arm and so a right groin puncture was required for deployment of the stent. 

Mynx closure devices were used both in the right upper extremity and the right groin. 

RADIOLOGIC FINDINGS: 
1.  The abdominal aorta was patent with 2 right renal arteries which were patent and a solitary left renal artery.  The superior mesenteric artery was patent as was the celiac access. Inferior phrenic arteries were also noted to be patent. 
2.  The abdominal aorta appeared to be normal with patent common iliac arteries bilaterally.  The right and left common iliac artery had shadows over the dye, suggesting a 50% stenosis, this did not appear to be hemodynamically significant. 
3.  Both hypogastric arteries were patent, although somewhat small.  
4.  Both external iliac arteries and common femoral arteries were patent.
5.  On the left side, the superficial femoral artery and profunda femoris arteries were patent.  The superficial femoral artery was also noted to be somewhat small.  The left superficial femoral artery occluded in the mid thigh area for a length of approximately 10 cm and then reconstituted as an above the knee popliteal artery.  The above the knee popliteal artery was patent. There was a 30% stenosis above the knee which was focal.  Below the level of the knee, the common TP trunk was quite large, or as the origin of the left anterior tibial artery had a 70-80% stenosis.  The posterior tibial artery was the dominant runoff to the left lower extremity with a diminutive anterior tibial artery and peroneal arteries.  The anterior tibial artery was, however, continuous on to the foot as a 2 mm vessel.  
6.  The left superficial femoral artery was successfully treated with a pilot hole using a 1.25 mm CSI Stealth device.  After creation of the pilot flow, a subsequent improved channel with a 2 mm Stealth device was performed.  This was then treated with a sleek balloon measuring 5 mm x 120 mm at 4 atmospheres with good effacement of the balloon at low pressure.  
7.  A stent could not be deployed from the left arm, and so later a right groin puncture was performed.
8.  The stent deployed easily across the lesion after the right groin puncture and completion angiogram showed residual of 0-10% stenosis throughout the length of the superficial femoral artery.
9.  On the right side, there appeared to be a common iliac artery lesion of approximately 50%. The common femoral artery was patent. The superficial femoral and profundus femoris arteries were initially patent. In the mid thigh area, the superficial femoral artery became chronically totally occluded with large collaterals noted.  Chronic total occlusion length was approximately 3 cm. The artery reconstituted as a popliteal artery which was widely patent.  Below the level of the knee, the anterior tibial artery was initially patent as was the common TP trunk.  Anterior tibial, posterior tibial and peroneal arteries were patent with again dominant posterior tibial artery runoff and a diminutive appearing peroneal artery in the distal third of the calf.  
10.  I attempted to cross the right superficial femoral artery lesion unsuccessfully with a 0.018 inch mini device.  I desisted at this.  The puncture sites were closed in both right arm and right groin with a Mynx closure device.  There were no complications and Mr. Walter tolerated the procedure well.  


OPERATIVE REPORT: The patient was taken to the cardiac catheterization laboratory where he was placed on the table in a dorsal recumbent position.  After excellent induction with general anesthesia, the patient was intubated with an LMA airway and the skin of the right upper extremity was prepared and draped in the standard sterile fashion.  The right groins were also prepared and draped. I then called a time-out for patient and procedure identification.  Next, under ultrasound guidance and using a micro-access system, access to the right brachial artery on the first puncture. A 0.08 inch guidewire advanced easily into the right brachial artery and through this, a 5 French micro-access sheath was advanced. The sheath was aspirator flushed easily.  Through the sheath I advanced a long pigtail catheter over guidewire.  The pigtail catheter was directed with the guidewire into the descending thoracic aorta using an LAO projection, and the pigtail catheter was then advanced into the abdominal aorta to the L1-L2 vertebral body position.

An AP angiogram of the abdominal aorta was obtained.  I then advanced the catheter into the abdominal aorta to the level of the aortic bifurcation, and oblique images of the ileofemoral and pelvic runoff were obtained.  There was a suggestion of a 40-50% right common iliac artery stenosis and left common iliac artery stenosis.  These did not appear to be hemodynamically significant.  

I then selectively catheterized the left common iliac artery and a bolus-chase angiogram of the left lower extremity was performed. The findings are noted in the findings section below. I then heparinized the patient with a total of 70 mg per kg of unfractionated heparin IV, exchanged the pigtail catheter over a guidewire for a 90 cm 6 French shuttle sheath.  The shuttle sheath was positioned in the common iliac artery at which point the sheath was hubbed at the level of the arm. A bolus-chase angiogram of the left lower extremity was then performed. This demonstrated a chronic total occlusion of the superficial femoral artery in the mid thigh area over a length of approximately 10 cm.  

This chronic total occlusion was successfully crossed with a CXI catheter and a treasure wire. A 1.25 mm Stealth device was then used to treat the superficial femoral artery occlusion on low, medium, and high speeds. Two runs of 30 seconds apiece were utilized and 30 seconds of rest was performed between runs. Nitroglycerin boluses of 200 mcg were given intermittently between runs.

A 2 mm Stealth device was then used to the lesion at low, medium, and high speeds.  A completion angiogram demonstrated improvement of the lesion with persistence of the craniad-most portion of the lesion, which was questionably treated with the atherectomy device. I then selected a 5 mm x 120 mm sleek balloon and inflated this to 4 atmospheres with complete effacement of the lesion.  Completion arteriogram appeared quite acceptable with less than 20% stenosis throughout. Nonetheless, the patient had recurred his stenosis within 4 months of his previous treatment, and had had 2 treatments of this area, and so I decided to deploy a LifeStent. A 6 mm by 150 mm LifeStent was selected and this was passed through the shuttle sheath and was found to come short of the lesion by approximately 15 cm.  

At this point, I decided that a right groin access would be needed, but I wanted to visualize and potentially treat the right femoral position.  

I then pulled the shuttle sheath back into the abdominal aorta and advanced the obturator and a wire and selectively catheterized the right common iliac artery.  Additional images of the right lower extremity were then performed.  A separate visualization of each lower extremity was required due to the patient's body habitus.  

On the right side, the common femoral artery was patent and the superficial artery was noted to occlude in the mid thigh in a "mirror image" fashion to that of the left side.  There was evidence of 3 vessel runoff on the right with dominant runoff by the anterior tibial artery and posterior tibial artery.  The anterior tibial artery was noted to have a focal stenosis proximally.  I then used a CXI catheter in conjunction with a treasure wire and attempted to cross the lesion in the right superficial femoral artery. This was unsuccessful. An Astato wire was also used in conjunction with a straight mini 0.018 inch device and this was also unsuccessful at crossing the right superficial femoral artery lesion.  I desisted.  

I then pulled the shuttle sheath back into the abdominal aorta.  The shuttle sheath was then exchanged over a stiff wire for a standard short 6 French sheath and a Mynx closure device was used to close the puncture site in the right brachial posterior after repreparing and redraping the patient's arm.  

I then turned my attention to the right groin area, and accessed the right common femoral artery under ultrasound guidance.  This was noted to be quite difficult due to the patient's large panniculus.  A 0.018 inch guidewire advanced easily through the micro-access needle and using Seldinger technique, I advanced a 5 French sheath.  Next, through the 5 French sheath, I passed an Omni Flush catheter into the abdominal aorta, and I was able to successfully selectively catheterize the left popliteal artery from the right.  A stiff wire was then placed in the left popliteal artery and I exchanged the 5 French sheath for a 6 French shuttle sheath which was positioned in the right superficial femoral artery.  The aortic bifurcation was noted to be quite steep and it was difficult to negotiate the sheath over the bifurcation.

Next, the LifeStent was selected and this was used to treat the left superficial femoral artery in the position treated.  The LifeStent deployed nicely into the left superficial femoral artery and completion arteriogram demonstrated significantly improved patency of the artery with no residual stenosis of greater than 10%.  I was pleased with this result.  The right groin area was then also reprepared and redraped and a Mynx closure device was used to close the right groin area.  There were no complications and Mr. Walter tolerated the procedure well. Sponge and needle counts following the case were correct x2.


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## donnajrichmond (Aug 23, 2011)

I would not code both 37225 and 37226.  I would code 37227 even though the procedures were performed through different accesses.  They were still performed in the same territory/same leg, and the only reason different accesses were used was because the doctor didn't have a stent long enough.  
Because the doctor says "He comes for arteriography with intention to treat", I would make double sure that the requirements for the separate angiogram coding were met since it is apparent that they knew the problem.  That would be: 
No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR
A prior study is available, but as documented in the medical record: 
The patient's condition with respect to the clinical indication has changed since the prior study, OR
There is inadequate visualization of the anatomy and/or pathology, OR
There is a clinical change during the procedure that requires new evaluation outside the target area of intervention.


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## dpeoples (Aug 23, 2011)

Rita Bartholomew said:


> I got:
> 75625-59  abd aortogram
> 75716-59  LE runoff
> 75774 x 2  lt & rt CIA's
> ...



I agree with donnaj. based on the documentation I would not code/bill for diagnostic angiographies (75716/75625/75774), catheter placements are included. All I see is 37227.


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## K.hancin (Aug 23, 2011)

I'm probably wrong but I'm so confused I just have to ask:

"Diagnostic angiography performed at the time of an interventional procedure is separately reportable if all 3 criteria are met:

1) No prior cather-based angiographic study is available.
2) A full diagnostic study is performed.
3) The decision to intervene is based on this study.

If a prior study is available, a diagnostic study may be reportable if any one of the following conditions is met:

The patient's status has changed since the time of the previous study.
There is inadequate visualization of the anatomy or pathology.
There is a clinical change during the procedure that requires new evaluation outside the target area of intervention."

Correct me if I'm wrong but it is my understanding that the above quote pertains to lower extremity interventions.

Wouldn't we still report the aortogram from high and low cath postions from the brachial?


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## rhondatalley (Sep 2, 2011)

*IR*

The codes should be 75625 (no modifier needed), 75716-59, 36246-59 and 37227-LT.

The abdominal aortogram does not create a CCI edit with the other codes, so no mod. needed.  The surgeon did a runoff bilaterally, which is allowed if no previous films are documented, and will require a 59 mod.  Even though he states additional views, the documentation would not support such, only a bilateral runoff.   37227-LT includes angioplasty, stent placement and atherectomy anywhere in the fem/pop region no matter how many places were treated as long as all 3 procedures are documented.  No cath placement or closure should be coded with this as it is all inclusive.  However, the 36246-59 will be coded because the cath was placed in the common femoral on the right and no procedure was done on that side.


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