# coding failed results



## Rita Bartholomew (Oct 18, 2013)

I'm unsure about coding procedures with failed results.  For this procedure, I have the following codes:  75625, 75710, 37225, 37228.  Should I append modifier on 37228 to indicate failed result?  Also, can I add 75774 for images obtained after selective catheterization of the right above-knee popliteal artery?  I'm coding for FACILITY, not PROFESSIONAL.  Any guidance is appreciated.

PREOPERATIVE DIAGNOSIS:  
1.  Atherosclerosis and tissue loss, right lower extremity, status post failed right lower extremity peripheral interventions.
2.  Status post failed right femoral to peroneal artery bypass graft.

NAME OF PROCEDURE:  
1.  Angiogram of the aorta and right lower extremity.
2.  Rotational atherectomy and balloon angioplasty of the right popliteal artery and right peroneal artery (results failed).

SURGEON:  Xxxx Xxxxx, M.D.

ANESTHESIA:  Local with moderate sedation.

ESTIMATED BLOOD LOSS:  Minimal.

ACCESS:  Left common femoral artery, retrograde, 6-French sheath.

RADIOLOGIC AND OPERATIVE FINDINGS:
1.  The abdominal aorta was noted to be patent with solitary renal arteries bilaterally, both of which were patent.  The aortic bifurcation was noted to be very steep at approximately a 170-degree turn.
2.  Both common iliac arteries, both external iliac arteries, and both internal iliac arteries were noted to be widely patent.  
3.  Both common femoral arteries were noted to be widely patent, and the proximal superficial femoral and profunda femoral arteries are widely patent. 
4.  Kissing stents were also identified in the left common TP trunk extending into the origins of posterior tibial and peroneal arteries here.  I did not image the arteries of the left lower extremity further.   

On the right side the common femoral artery and profunda femoris artery was patent.  The profunda was noted to be somewhat attenuated.  Surgical staples were noted in the medial right thigh extending distally.  The superficial femoral artery was noted to be patent.  The popliteal artery above the level of the knee to behind the knee was patent.  At the level of the patella, the popliteal artery became chronically totally occluded.  The anterior tibial artery reconstituted via collaterals.  Two "kissing stents were noted" extending into both peroneal artery and posterior tibial arteries.  Both of these stents were totally occluded for approximately 1 cm at their origin.  The peroneal artery stent then reconstituted at its distal aspect of the stent, significant in-stent restenosis was again noted of approximately 80%.  The peroneal artery then reconstituted for a short distance.  The posterior tibial artery stent was occluded proximally, then reconstituted for approximately 1 cm at which point, again within the stents, the artery became totally occluded again.  These stents were placed at the origin of the arteries.  In the mid-leg, surgical staples were present.  The popliteal artery again became occluded for approximately 3 cm and then reconstituted via  collateral distally.

The posterior tibial arteries were also reconstituted for a short length, and then became totally occluded again.  Runoff to the foot was via the peroneal artery only and this then fed the posterior tibial artery, which appeared quite small.  The pedal arch reconstituted late and is a very small 1 mm artery.  It did not appear to be a suitable target for a bypass.  

I was able to successfully cross the area of popliteal artery and common TP trunk total occlusion.  I then entered both the posterior tibial artery stent and the peroneal artery stent using a CXI catheter in conjunction with a PT Graphix wire.  I was unable to cross the posterior tibial artery total occlusion with a crossing wire, and in the peroneal artery I was able to cross into the occluded stent and across the area where the stent reconstituted.  I was unable to cross the more distal total occlusion in the peroneal artery, as the crossing catheter would not cross through the proximal stent.   This point I started to perform rotational atherectomy using a CXI 1.25 mm device.  The device passed through the area of the popliteal total occlusion and through the proximal stent.  On the second run of the device, however, significant resistance was noted in the proximal aspect of the stent.  On the second run of the device while on low, the device grabbed the stent and torsed the stent significantly.  At this point, I was able to enter the proximal stent with a 2 mm balloon with great difficulty, and even after inflation of the balloon at greater than burst atmospheres, although the stent did open a little bit into a 2 mm opening, I could not get the stent to open further than this.  In addition, I still could not pass the crossing catheter into the more distal peroneal artery.  At this point, I terminated the operation.  

ADDENDUM TO CLINICAL HISTORY OF CHART:  I have discussed matters with Mr. Xxxxx and his wife, and they indicate that they understand that this is a "last ditch" attempt in order to regain vascular continuity to the limb, and they understand a significant amount of intervention has happened before.  

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 moderate sedation, the skin of the groin areas was prepared and draped in the standard sterile fashion.  I first accessed the left common femoral artery in the retrograde direction under local anesthesia after I had called a time-out for correct patient and procedural identification per Xxxxx Hospital protocol.  A 5-French sheath was inserted and aspirated and flushed easily.  Through the sheath, I advanced the Omni Flush catheter into the abdominal aorta through the L1-L2 vertebral body space and bubbles were removed from the Omni Flush catheter; 3000 units of unfractionated heparin were administered IV.  Next, an AP angiogram of the abdominal aorta was obtained.  I then pulled the catheter down to the aortic bifurcation where block images of the iliofemoral and pelvic runoff were obtained.  Significant calcification was noted throughout all arteries.  The aortic bifurcation was determined to be very steep.  I then selected to catheterize the right common femoral artery from the left side, and serialography of the right lower extremity was obtained.  I did not obtain images while below the level of the knee, and so I selected to catheterize the right above-the-knee popliteal artery and obtained images of the right lower extremity with the catheter tip here.  Next, I advanced a Rosen wire into the right popliteal artery and advanced an Ansel 2 sheath into the right superficial femoral artery.  A CXI catheter in conjunction with a Treasure 12 wire was used to cross the right popliteal artery chronic total occlusion.  I then used a PT Graphix wire and was able to negotiate this into first the right posterior tibial artery stent.  I deliberately formed a "J" shape to the tip of the PT Graphix wire before it entered the stent and then forced the J through the stent.  This remained true _______.  In spite of this maneuver, the CXI catheter did not want to track into and through the stent.  I eventually got the CXI catheter across the entire posterior tibial artery stent, but could not pass the Treasure 12 wire any further down the chronically totally occluded posterior tibial artery.  I felt that the peroneal artery was the site of greatest benefit, so I attempted this maneuver again at the origin of the posterior tibial artery stent.  A PT Graphix wire was allowed to form a J, and the J was then forced through the occluded right peroneal artery stent.  The PT Graphix wire crossed.  The tip of the catheter managed to get approximately half way through the stent before it encountered some further obstruction.  I could not negotiate it further.  I then used a Treasure 12 wire and negotiated this through the stent entirely, but could not negotiate it through the more distal total occlusion in the more distal peroneal artery.  I decided to treat the popliteal occlusion and the stent first, and then if I was successful with this, I would work on crossing the more distal peroneal artery occlusion.  I then passed a ViperWire into the proximal peroneal artery.  A 1.25 mm CSI device was selected, and a total of 70 mg/kg of unfractionated heparin was given IV.  Next, the CSI device was advanced into the popliteal artery to just above the knee where it was used to treat the popliteal artery and common TP trunk total occlusion at low speed.  I allowed the proximal aspect of the device to cross into the stent to the area where I had met significant resistance with the CXI catheter, and a very significant resistance was encountered here with the device.  Nonetheless, the device crossed through the area of occlusion.  On the second run of the device, I was encountering this area again, when I noticed a 360-degree wrap of the stent around the device tip.  This was around the portion of the device which was extending into the common TP trunk.  This created a significant "twist" in the drug-eluting stent here.  I was able to remove the 1.25 mm device.  I attempted to cross the twisted stent with a 3 mm balloon, and this was unsuccessful.  I then used a 2 mm x 4 cm balloon, and this was successful in crossing the twist in the stent.  The balloon was inflated to up to 14 atmospheres with poor effacement of the balloon within the stent.  A completion arteriogram showed that the stent was patent in this area, and the popliteal artery was partially recanalized, but flow was quite poor.  As I still had significant total occlusion distally to cross and felt that this was going to be unsuccessful, I decided not to perform any further maneuvers.  At this point, I told Mr. Xxxxx that there was no further hope for his limb.  I then used a Mynx closure device on the left common femoral artery puncture site through a 6-French sheath.  Good hemostasis was achieved.


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## Jim Pawloski (Oct 21, 2013)

Rita Bartholomew said:


> I'm unsure about coding procedures with failed results.  For this procedure, I have the following codes:  75625, 75710, 37225, 37228.  Should I append modifier on 37228 to indicate failed result?  Also, can I add 75774 for images obtained after selective catheterization of the right above-knee popliteal artery?  I'm coding for FACILITY, not PROFESSIONAL.  Any guidance is appreciated.
> 
> PREOPERATIVE DIAGNOSIS:
> 1.  Atherosclerosis and tissue loss, right lower extremity, status post failed right lower extremity peripheral interventions.
> ...



I would not code the 75774, because I feel that is the completion of the lower extremity run-off.  As for the 37229, yes you need modifier-52 if in-patient or 74 if out-patient.  Otherwise, I agree with your codes.
HTH,
Jim Pawloski, CIRCC


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## Rita Bartholomew (Oct 22, 2013)

Thank you so much, Jim.  So, just to clarify, you feel 37229-74 (it's outpatient) is more appropriate than 37228-74?


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## Jim Pawloski (Oct 22, 2013)

Rita Bartholomew said:


> Thank you so much, Jim.  So, just to clarify, you feel 37229-74 (it's outpatient) is more appropriate than 37228-74?



Atherectomy supersedes angioplasty (PTA is included)


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## Rita Bartholomew (Oct 23, 2013)

Got it! Thanks so much!


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