# Renal angioplasty then stent



## Rita Bartholomew (Nov 6, 2012)

For the following procedure, I get: 36251, 37205, 75960 and G0269.  Because it sounds like they would've stopped at angioplasty if it worked well, can I also bill 35471 and 75966? Also, can I even use 36251 since there was a recent MRI identifying the renal artery stenosis?

_PREOPERATIVE DIAGNOSIS:  Renovascular hypertension with known left renal artery stenosis.

POSTOPERATIVE DIAGNOSIS:  Renovascular hypertension with known left renal artery stenosis.

NAME OF PROCEDURES:  
1.  Bilateral renal arteriograms.
2.  Selective catheterization of left renal artery.
3.  Placement of left renal artery angioplasty.
4.  Placement of left renal artery stent.  

SURGEON:  Xxxx X. Xxxxx, MD

ANESTHESIA:  Local with moderate sedation.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

ACCESS:  A #6-French sheath, right common femoral artery, retrograde (ultrasound guided).  

CLINICAL HISTORY:  This 76-year-old woman has left renal artery stenosis and is on multiple medications to control hypertension.  MRI shows left renal stenosis, and she comes for renal artery imaging with intention to treat.  

OPERATIVE FINDINGS:  The abdominal aorta was patent with solitary renal arteries bilaterally.  There was no evidence of right renal artery stenosis.  On the left side, a left renal artery stenosis was noted approximately 3.5 cm from the origin of the artery; this was an approximately 70% stenosis and was at a branch point in the renal artery.  I first attempted to treat this with cutting balloon angioplasty using an AngioScore balloon.  Although this had a radiologically reasonable result, dissection was noted in the artery.  The plaque was noted to be acentric on the artery on the side opposite the branch.  The branch came off the cranial portion of the artery and the plaque on the caudal portion.

After this, I used a 6 x 18-mm Express stent, and this resulted in a good result with patency of the superior polar branch of the artery in question. 

Of note, a metal density was present inferior to the left renal artery consistent with a prior coiling procedure, although the patient denies any prior coiling of blood vessels.  Nonetheless, there was a metal density structure caudal to the left renal artery.

PROCEDURE:  The patient was taken to the cardiac catheterization laboratory where she 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 standard sterile fashion.  I then called a time-out for the correct patient and procedure identification per Mercy Hospital protocol.  Next, I accessed the right common femoral artery in a retrograde direction under local anesthesia and using ultrasound guidance.  The 0.018-inch guidewire advanced easily as did the #5-French sheath.  Next, through the sheath I advanced an Omni-Flush catheter to the L1-L2 vertebral body level, and bubbles were removed from the catheter.  An AP angiogram of the abdominal aorta was obtained.  Next, I obtained oblique images of the abdominal aorta near the renal arteries to further identify the anatomy of the lesion.  The nephrograms appeared reasonable bilaterally, although the kidneys were somewhat small.  A metal density, as noted above, was present medial to the hilum of the kidney on the left.  The patient was questioned about this on the table and had no recollection of any coiling procedure.

Next, I exchanged the #5-French sheath in the right femoral position over a stiff wire over a #6-French sheath.  Through the #6-French sheath, an Omni-Flush catheter was advanced.  A 0.018-inch Guidewire was advanced into the left renal artery.  Next, with the left renal artery selectively catheterized, I advanced an AngioScore 5-mm balloon and performed scoring angioplasty of the lesion in the left renal artery.  The patient was given a total of 70 mg/kg of unfractionated heparin IV upon insertion of the #6-French sheath.  

Next, after 1 minute of inflation, I deflated the balloon slowly and removed it.  A significant improvement of the lesion was noted, but some dissection was noted on the plaque on the inferior wall of the artery.  Next, I reinflated the balloon in the lesion and performed balloon angioplasty a second time with no change in the result.  I decided to use a stent.  A 6 x 18-mm Boston Scientific Express balloon-mounted stent was then negotiated into the lesion over a 0.018-inch guidewire.  The stent was deployed across the lesion.  Complete opening of the stent was noted.  I performed a completion arteriogram after removal of the balloon, and this demonstrated wide patency of the artery with no evidence of distal embolization and a good left-sided nephrogram, improved from the preoperative study.  I accepted this result.

Ms. Xxxxx tolerated the procedure well.  Sponge and needle counts following the case were noted to be correct x2.  Upon completion, I re-prepared and re-draped the right groin area, and an Angio-Seal device was used to close the right femoral artery position.  There were no complications.  A dry sterile dressing was applied.  _

Thanks,


----------



## rhondatalley (Jan 6, 2013)

Rita Bartholomew said:


> For the following procedure, I get: 36251, 37205, 75960 and G0269.  Because it sounds like they would've stopped at angioplasty if it worked well, can I also bill 35471 and 75966? Also, can I even use 36251 since there was a recent MRI identifying the renal artery stenosis?
> 
> _PREOPERATIVE DIAGNOSIS:  Renovascular hypertension with known left renal artery stenosis.
> 
> ...



Since the lesion was documented prior to this procedure and there is no documentation of a change, I would not code 36251.  Also, 36251 indicated angiography from the selective location in the renal, but in this case, it was done from the abdominal aorta to confirm the lesion and the catheter was advanced for treatment only.  I would code the PTA and the stent since the PTA was performed effectively, but there was a dissection necessitating the addition of the stent which is medically necessary.  

Hope that helps!
Rhonda


----------



## donnajrichmond (Jan 7, 2013)

rhondatalley said:


> Since the lesion was documented prior to this procedure and there is no documentation of a change, I would not code 36251.  Also, 36251 indicated angiography from the selective location in the renal, but in this case, it was done from the abdominal aorta to confirm the lesion and the catheter was advanced for treatment only.  I would code the PTA and the stent since the PTA was performed effectively, but there was a dissection necessitating the addition of the stent which is medically necessary.
> 
> Hope that helps!
> Rhonda



I agree with Rhonda - no selective diagnostic angiogram, so no 36251.  There was an abdominal aortogram, so it might be possible to code 75625, but since the stenosis was known, and this appears mostly roadmapping, I wouldn't.  
Do remember to code 36245 for the catheterization since you aren't coding 36251.
I would also code both the PTA and the stent.


----------

