# Angioplasty or Primary thrombectomy Charge/Code?



## Chlrtrep (Dec 1, 2015)

I need an opinion on this procedure.  This has occurred a few times as of late and I am uncertain if this should be coded as an angioplasty or a primary thrombectomy.  I have seen it stated in the popular coding reference book that balloon maceration of a thrombus without documentation of stenosis should not be coded as an angioplasty.  If I take this into consideration this procedure would be coded: 37213 36247 37184 37185 37185.  The physician feels it should be coded as an angioplasty 37213, 37228, 37232, 37232 .  This patient has three days of procedures. Initial day, subsequent day and final day.  This encounter is day two. On the third day the patient also had angiojet, thrombolytic power spray 20 minutes and a stent placed due to dissection in the distal Tibial artery

I would love to here your thoughts and recommendations  here is the day two op report I have questions about:

_PREOPERATIVE DIAGNOSES:
1. Acute/subacute right leg ischemia.
2. Insulin-dependent diabetes mellitus.
3. Hypertension.

POSTOPERATIVE DIAGNOSES:
1. Acute/subacute right leg ischemia.
2. Insulin-dependent diabetes mellitus.
3. Hypertension.

NAME OF PROCEDURE:
1. Selective right lower extremity angiogram.
2. Aspiration thrombectomy of right anterior tibial artery.
3. Balloon angioplasty of right anterior tibial artery.
4. Aspiration thrombectomy of right posterior tibial artery.
5. Balloon angioplasty of right posterior tibial artery.
6. Balloon angioplasty of the common peroneal artery.
7. Insertion of 40 cm EKOS catheter-directed thrombolysis into
the right posterior tibial artery.

INDICATIONS: The patient is a 40-year-old who presented yesterday with
acute limb ischemia who was taken to the cath lab and was found to have
complete thrombotic occlusion of the infrapopliteal vessels. EKOS
thrombolytic catheter was inserted into the anterior tibial artery, TPA  
was
delivered overnight. He brought back today for a repeat angiogram and
intervention. Benefits and risks of the procedure were explained to the
patient, who agreed to proceed.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the
patient's left groin was prepped and draped in sterile fashion. The  
patient
already had a 6-French sheath which was inserted from yesterday. The EKOS
catheter was exchanged out over the MiracleBros 6 exchange wire. Angiogram
performed which showed improvement in flow through the right anterior
tibial artery; however, there was still extensive amount of clot burden
involving the proximal right anterior tibial artery, as well as involving
common peroneal and posterior tibial arteries. The MiracleBros 6 using
Rubicon crossing catheter was advanced all the way to the distal anterior
tibial artery.
Balloon angioplasty was performed initially using 2.0 x 300 followed by  
2.5
x 300 balloon. However, due to the extensive amount of clots, the
artery became occluded again. Aspiration thrombectomy using Pronto  
catheter
was then performed with retrieval of a significant amount of clot. Balloon
angioplasty was again performed using a 2.5 x 300 balloon with restoration
of flow. There was improvement of flow down the anterior tibial artery,  
all
the way to the ankle level. Following that, we wired the posterior tibial
artery using MiracleBros 6 Prowire and a Rubicon catheter all the way into
the distal posterior tibial artery. Aspiration thrombectomy was again
performed with retrieval of significant amount of clot. Following
that, balloon angioplasty was performed using 2.5 x 300 balloon; however,
still there was no flow down the posterior tibial artery due to the
extensive amount of clot causing no reflow. Following that we crossed with
a wire MiracleBros 6 brought to the common peroneal artery. Balloon
angioplasty was again performed using 2.5 x 300 with some improvement of
flow. However, again there was still extensive amount of clot involving
that artery. Due to the extensive amount of clot burden, we decided to  
proceed with insertion of
EKOS catheter-directed thrombolysis into the right posterior tibial artery  
to facilitate in clot lysis,
We will plan to obtain mechanical thrombectomy device for retrieval of all  
the clot burden
In the next 24 hours.



1. Significant clot burden involving all infrapopliteal vessels.
2. Improvement of flow down to the distal anterior tibial artery with
Doppler signal in the distal anterior tibial artery.
3. Posterior tibial and common peroneal remained totally occluded despite
aspiration thrombectomy and angioplasty due to extensive clot burden.
4. EKOS insertion into the right posterior tibial artery.

RECOMMENDATIONS: Continue EKOS management. Will place the patient on
nitroglycerin drip in hope of improving micro circulation. Will plan to
return to the cath lab tomorrow for mechanical thrombectomy using AngioJet
Dista catheter._


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## christoff9 (Dec 9, 2015)

You are correct.  PTA to macerate clot is a thrombectomy.  I agree with your codes, however, I would add 36248 for the additional select cath placement.  You have the posterior tibial and peroneal.


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