# need help to code peripheral



## bhargavi (Nov 9, 2017)

Conclusion 

This patient has a history of nonhealing lesion and pain in the right foot, previous intervention at Christiana Hospital earlier this year with SFA popliteal angioplasty. He initially had improvement after his procedure in the spring time but has now had recurrent pain and noninvasive studies have revealed significant distal right SFA stenosis and subtotal occlusion of the anterior tibial vessel. Angiography is requested with possible intervention.
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After obtaining informed consent the patient a 5 French sheath was placed in the left common femoral artery and a 5 French contra catheter was positioned abdominal aorta, aortography was performed. Catheter was then withdrawn and aortoiliac injury gram was performed and the catheter was advanced across the aortic bifurcation into the right common femoral artery selectively over a hydrophilic wire. Selective right lower extremity digital subtraction Angiogram with runoff was performed. After I identification of the lesions in the distal right SFA and ostial segment of the anterior tibial vessel, the original sheath and catheter were exchanged out over a stiff support wire for a 6 French by 65 cm destination sheath which was then positioned into the right SFA selectively. With some difficulty a 0.035 hydrophilic wire was able to be advanced through the subtotal occlusion in the ostial segment of the right anterior tibial vessel with use of a 4 French 120 cm glide catheter with an angled tip. The glide catheter was positioned in the proximal anterior tibial and the 035 wire was exchanged for a 0.014 journey wire. Thereafter scoring balloon angioplasty with a 2.5 followed by a 3.0 mm balloon was performed of the ostial proximal segment of the right anterior tibial and distal popliteal vessel. Angiographic result was excellent with brisk restoration of flow in the right anterior tibial, preservation of flow in the tibioperoneal trunk peroneal and proximal posterior tibial vessels as well. Noncritical disease in the distal popliteal was unchanged. Thereafter scoring balloon angioplasty was performed of the distal SFA proximal popliteal stenosis at the abductor canal, at the superior aspect of the patellar shadow. 5 mm scoring balloon angioplasty was performed followed by placement and application of a 6 mm x 60 mm Lutonix drug-eluting stent, 28 atm pressure. After prolonged drug application and balloon removal angiographic result was excellent with brisk runoff down 3 vessel proximally, anterior tibial vessel patent as well as the peroneal to the ankle with distal occlusion of the posterior tibial. The sheath was then removed to the left iliofemoral system and iliofemoral angiography on the left revealed the sheath in the common femoral artery and closure was obtained with a Mynx closure device without complication.
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Hemodynamics:
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Central aortic pressure 120/70.
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Diagnostic digital subtraction angiography:
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Abdominal aorta was patent no ectasia no aneurysm, 2 left renal artery single right renal artery patent celiac SMA and inferior mesenteric arteries. Aortic bifurcation was patent with patent common internal and external iliac vessels bilaterally.
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On the left common femoral vessel was patent with patent proximal left SFA and deep femoral.
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On the right common deep and superficial femoral vessels were patent. The distal SFA had a calcified tubular narrowing of 80% or greater distant the abductor canal and proximal popliteal. Moderate calcification was present. The mid popliteal was patent across the knee the distal vessel has eccentric stenosis of 50% which appeared nonflow limiting. Immediately below the origin of the anterior tibial vessel was subtotally occluded with TIMI grade one flow into this anterior tibial. The tibioperoneal trunk and peroneal vessels were patent, the peroneal was large and was the major vessel all the way to the ankle. The posterior tibial vessel was patent to its distal one third just above the ankle mortise and was occluded at this point with some bridging collaterals. Anterior tibial vessel beyond its subtotal ostial occlusion was patent to the ankle.
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Intervention:
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As detailed above scoring balloon angioplasty and opening of the right anterior tibial vessel was performed.
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Scoring balloon angioplasty and drug-coated balloon treatment was performed of the distal right SFA proximal popliteal lesion at the abductor canal.
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Summary and conclusions:
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Nonhealing lesion right foot severe ischemia.
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Successful opening of the right anterior tibial vessel, patient now has proximal three-vessel runoff, occlusion of the distal segment of the posterior tibial vessel with large peroneal collateralizing the vessel distally and anterior tibial now patent to the ankle and dorsalis pedis.
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Successful treatment of the right distal SFA stenosis as detailed above with patent popliteal
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Bilateral patent aortoiliac vessels.
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*I was going to code as 75716-xu,75625,37224-rt, 37228-rt but I always get confused whether to code as 75630 instead of 75716,75625 ? or when to code 75630
thanks in advance


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## heart123 (Nov 9, 2017)

New research on abdominal aortography in conjunction with lower extremity angiography reported by the Mayo Clinic in Rochester, Minn., is prodding interven-tional radiologists to recommend aortographic procedures more frequently to patients at risk for cardiovascular diseases. 

As a result, IR coders can expect to be grappling with the specifics of abdominal aortography more often. A firm grasp on the differences between 75630 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological S&I) and the associated CPT 75625 (Aortography, abdominal, serialography, radiological S&I) and 75716 (Angiography, extremity, bilateral, radiological S&I) is the hinge upon which accurate reimbursement depends.

Angiography, the family of procedures that includes aortography, refers to the process of injecting blood vessels with contrast material that shows up on X-rays. The procedure may be only for diagnostic purposes or it may be used to guide and monitor treatment, in which case it is known as interventional angiography. This technique can be used to look at arteries in many areas of the body; when the aorta is injected, the procedure is called an aortography.

75630 Versus 75625/75716

According to C.J. Wolf, MD, CPC, CPC-H, senior consultant at Intermountain Health Care in Salt Lake City, CPT Code 75630 should be reported when the abdominal aorta and the lower extremities iliofemoral studies are studied via a single catheter position and single contrast injection. Generally, the way the procedure works is that the physician will insert the catheter and advance it into the proximal aorta; at that point, he will inject the contrast and obtain radiographic images that will later be interpreted. This study provides information about the distal abdominal aorta and the lower extremity arteries in an examination commonly referred to as a un-off"" angiogram (e.g. an examination in which the contrast outlines the run-off arteries of the lower abdominal aorta). The key to this procedure Wolf says is that it is performed via a single catheter position without regard to the number of contrast injections. 

This procedure is commonly referred to as a nonselective examination of the pelvic arteries and lower extremities says Jeff Fulkerson BA CPC coding specialist at the Emory Clinic in Atlanta.

In addition 75630 is used to describe a focused angiogram that is restricted to studying the abdominal aorta the pelvic vessels and the proximal lower extremity arteries as is often performed in patients with abdominal aortic aneurysms without symptoms of claudication or lower extremity ischemia and normal noninvasive vascular tests.

Coding scenarios may get more complicated Wolf says if as frequently occurs after positioning the catheter in the proximal aorta the physician brings it back to the bifurcation of the abdominal aorta i.e. where the aorta splits into the common iliacs. The physician may then reposition the catheter and inject contrast again to examine the lower extremities thoroughly.

Report 75625 and 75716 together only when a full and complete abdominal aortogram is followed by a full and complete bilateral lower extremity study one that includes iliofemoral and lower extremity arteries. ""The key words here are 'full and complete ' "" Wolf says because the run-off dye from a simple 75630 aortography will provide some opportunity to view the lower extremities.

The two critical elements to justify reporting both 75625 and 75716 are: 


the necessity of repositioning the catheter within the aorta between the performance of the complete aortogram and the lower extremity angiogram 
the performance of a complete bilateral lower extremity angiogram to the extent allowed by the patient's underlying anatomy and physiology and using a nonselective catheter position.
If selective catheterization is necessary to allow complete visualization of the vessels into the patient's feet then further surgical and RS&I codes may be indicated as well.

Wolf's advice echoes SIR's 2001 Users Guide for Interventional Radiology: ""If the legs are studied only to the level of the groins or proximal thighs 75630 appropriately describes this procedure rather than 75716.""

Clinical Example

Wolf shares this clinical case study for which the documentation reads in part:

Right common femoral artery was entered and a 5-French sheath placed. A 5-French pigtail catheter was advanced into the upper abdominal aorta followed by digital aortography with Isovue 370. Catheter was repositioned into the distal abdominal aorta followed by stepped lower extremity digital arteriography with Isovue 370.

Atherosclerotic irregularity is seen in the abdominal aorta. Focal 90% stenosis is seen at the origin of one of the branches of the left renal artery which originates approximately 1 cm from the origin of the main branch off of the aorta. Right renal artery is unremarkable. Irregular 60% stenosis is seen in the proximal left common iliac artery. Atherosclerotic irregularity is seen in the iliac arteries bilaterally. Superficial femoral and common femoral arteries are patent.

Mild stenosis at the origin of the left superficial femoral artery is seen. Significant atherosclerotic irregularities with multi-segment stenoses are noted within the distal superficial femoral artery and popliteal arteries bilaterally. Two-vessel runoff is noted proximally on the right at the tibioperoneal trunk with three-vessel runoff proximally on the left. One vessel is noted extending into the foot via anterior tibial on the left with two vessels eventually extending into the foot on the right via anterior tibial and peroneal.

According to Wolf the first paragraph documents the femoral access point and the catheter placement. The well-documented S&I for the abdominal aorta study justifies coding 75625. However if the physician had provided only the information in the first part of the S&I (paragraph two) Wolf says you would only be able to report 75630.

""It's not good enough to read just the iliofemorals because that's not an extremity study "" he clarifies. However since the physician goes on to dictate additional information in paragraph three ""with that nice detailed S&I description we can code 75625 and 75716.""

Physician interpretation for the lower extremity studies should always include diagnostic evaluation of the iliofemoral arteries as well as additional distal lower extremity arteries such as the popliteal tibial and peroneal.

Therefore the appropriate aortography codes for this scenario are 75625 and 75716. Wolf notes that he reviewed this case for a client who had originally assigned 36200 (Introduction of catheter aorta) and 75630 because they weren't aware of situations in which ""you could code the two S&Is in place of that one 75630."" Wolf was able to tell them ""You're more than compliant; you actually undercoded.""

Other Factors: Catheter Selection Add-On Options

Should the case under consideration have been a nonselective aortography catheter placement would be reported simply as 36200. However once you can determine that this is a selective study 36200 goes away Fulkerson says. ""If you run across the bifurcation and select for example the superficial femoral artery and beyond you want to choose 36247 (Selective catheter placement arterial system; initial third order or more selective abdominal pelvic or lower extremity artery branch within a vascular family) for catheter placement."" 

It is far more usual however to place the catheter into the contralateral iliac system (36245 ... each first order abdominal pelvic or lower extremity artery branch; or 36246 ... initial second order). And if a pull-back angiogram of the ipsilateral extremity is also performed (in addition to a selective study of the contralateral side) then the procedural codes 36140 is also coded. In such a case there would be two procedural codes one from the series 36245-36247 and the second 36140.

While you may report either one or two surgical code(s) for catheter placement Fulkerson explains additional injections and interpretations may be paid for using add-on code +75774 (Angiography selective each additional vessel studied after basic examination radiological supervision and interpretation [list separately in addition to code for primary procedure]) for each of the selective catheterizations. Because the physician performed selectives after the basic exam (75716) this radiology practice may bill either one or two units of 75774 as well.

Code 75774 is not billed for each injection of view; it is billed once for each additional selective examination performed to supplement the basic examination. If selective catheterization of one lower extremity is performed in addition to the nonselective 75716 then only one instance of 75774 is billed. If both lower extremities are selectively studied in addition to 75716 then 75774 is billed twice. If only selective studies are performed (absent a nonselective study) then 75774 is not billed at all.

With closely related aortography procedures Wolf and Fulkerson remind readers it's vital to scrutinize the documentation and know whether you can report single or multiple S&I codes thus legitimately boosting your revenue from the erroneously lower revenue that results from improperly undercoding services provided.


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## theresa.dix@tennova.com (Nov 10, 2017)

bhargavi said:


> Conclusion
> 
> This patient has a history of nonhealing lesion and pain in the right foot, previous intervention at Christiana Hospital earlier this year with SFA popliteal angioplasty. He initially had improvement after his procedure in the spring time but has now had recurrent pain and noninvasive studies have revealed significant distal right SFA stenosis and subtotal occlusion of the anterior tibial vessel. Angiography is requested with possible intervention.
> *
> ...



You would code 75625 and 75716 when you have two cath placements. One in the aorta ( interpretation of the aorta) and then the cath is moved down to the bifurcation and another shot is done there to look at the legs ( interpretation of the legs). 75630 is only coded when the cath is placed high into the aorta  and one shot is done and there is an interpretation of the aorta and the legs at least to the femoral.


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