# please help with coding this surgery!!



## HCC12345 (Jun 2, 2014)

I am new at this and need help coding this surgery!! I am at a loss trying to understand this!

Procedure:
1. Left heart catheterization
2. Ascending aortogram
3. Distal aortogram and pelvic angiogram
4. Selective left lower extremity angiograms
5. Arthrectomies of the dorsalis medis, anterior tibial, posterior tibial,     superficial femoral vessels.
6. Angioplasty of the dorsalis pedis, anterior tibial, popliteal and superficial femoral vessels.
7. Right femoral and iliac angiography
8. Vascular closure device.
9. Selective brachiocephalic angiography
10. Selective subclavian angiography
11. Selective left internal mammary angiography
12. Selective occluded venous bypass graft angiography.


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## Jim Pawloski (Jun 2, 2014)

juliedale said:


> I am new at this and need help coding this surgery!! I am at a loss trying to understand this!
> 
> Procedure:
> 1. Left heart catheterization
> ...



A lot of stuff going on.  Can you post a report?  make sure there is not patient of doctor identification on it.

Thanks,
Jim Pawloski, CIRCC


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## HCC12345 (Jun 3, 2014)

Description of procedure:
The patient was taken to the catheterization lab, prepped and draped in the usual manner, given incremental doses of Versed and Fentanyl. The right groin was anesthetized with local anesthetic and the right common femoral artery was entered with modified percutaneous Seldinger technique. The short sheath was estimated in the right common femoral artery and left heart catheterization performed beginning with angiography of the native left system using the JL-4 catheter and then the right artery using the 3DRC, then bypass angiography was performed of the occluded SVG and there were clips seen in the right chest so selective brachiocephalic angiography was performed. Then, selective angiography was performed of the left subclavian vessel and then selective angiography was performed of the left internal mammary artery. Then, left ventriculography was performed. Then, ascending aortic angiography was performed. Then, the pigtail was used for both left ventriculography and descending aortic angiography. Then, the pigtail catheter was placed in the distal aorta and angiogram was taken of the distal abdominal aorta and pelvis. Then, the rim catheter was used along with angled long stiff glide wire. This was used across the bifurcation and advanced the rim to the superficial femoral artery. Then, angiography was performed of the left lower extremity using digital subtraction. Then, the stiff angled glide were was used to pass through the occlusion of the distal superficial femoral through the popliteal. Then, the rim catheter was removed while the wire was held in place with removal of the short sheath and the 45 destination sheath was established. The, anticoagulation with Angiomax was started. Then, the Navacroft catheter was used and advanced past the popliteal and the Choice PT wire was used to engage the anterior tibial artery and passed into the mid-anterior tibial vessel. Then, the catheter was advanced into the distal vessel and the wire was placed into the mid-foot. The, the PT2 wire was replaced through the catheter with the Viper wire and the catheter was removed. Then, the CS1 device with the 1.25 burr was used to perform arthrectomy of the distal popliteal through the proximal anterior tibial. Then, subsequently arthrectomy was performed through the anterior tibial and in the proximal dorsalis pedis. Then, the CS1device was removed and the 2.5 balloon was placed in the proximal dorsalis pedis and inflated and held for one minute. The, the balloon was removed. Then, the 1.5 CS1 device was used to perform the arthrectomy of the popliteal vessel and the entire superficial femoral vessel. Then, the 5 mm balloon was used to inflate the superficial femoral vessel from ostium through popliteal. Then, angiography was performed. There was a stenosis of the proximal to mid-dorsalis pedis. The, the PT2 wire was used with the balloon for guidance and angioplasty was performed of this region. Then, angiography was performed. Then, the PT2 wire was placed again and repeat plasty was performed. Note the nitroglycerin was given after multiple CS1 passes as well as on needed plasties and angiographies. Then, right common femoral angiogram was performed and closure device was placed.


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## HCC12345 (Jun 3, 2014)

Thank you for your help Jim!


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## Jim Pawloski (Jun 4, 2014)

juliedale said:


> Description of procedure:
> The patient was taken to the catheterization lab, prepped and draped in the usual manner, given incremental doses of Versed and Fentanyl. The right groin was anesthetized with local anesthetic and the right common femoral artery was entered with modified percutaneous Seldinger technique. The short sheath was estimated in the right common femoral artery and left heart catheterization performed beginning with angiography of the native left system using the JL-4 catheter and then the right artery using the 3DRC, then bypass angiography was performed of the occluded SVG and there were clips seen in the right chest so selective brachiocephalic angiography was performed. Then, selective angiography was performed of the left subclavian vessel and then selective angiography was performed of the left internal mammary artery. Then, left ventriculography was performed. Then, ascending aortic angiography was performed. Then, the pigtail was used for both left ventriculography and descending aortic angiography. Then, the pigtail catheter was placed in the distal aorta and angiogram was taken of the distal abdominal aorta and pelvis. Then, the rim catheter was used along with angled long stiff glide wire. This was used across the bifurcation and advanced the rim to the superficial femoral artery. Then, angiography was performed of the left lower extremity using digital subtraction. Then, the stiff angled glide were was used to pass through the occlusion of the distal superficial femoral through the popliteal. Then, the rim catheter was removed while the wire was held in place with removal of the short sheath and the 45 destination sheath was established. The, anticoagulation with Angiomax was started. Then, the Navacroft catheter was used and advanced past the popliteal and the Choice PT wire was used to engage the anterior tibial artery and passed into the mid-anterior tibial vessel. Then, the catheter was advanced into the distal vessel and the wire was placed into the mid-foot. The, the PT2 wire was replaced through the catheter with the Viper wire and the catheter was removed. Then, the CS1 device with the 1.25 burr was used to perform arthrectomy of the distal popliteal through the proximal anterior tibial. Then, subsequently arthrectomy was performed through the anterior tibial and in the proximal dorsalis pedis. Then, the CS1device was removed and the 2.5 balloon was placed in the proximal dorsalis pedis and inflated and held for one minute. The, the balloon was removed. Then, the 1.5 CS1 device was used to perform the arthrectomy of the popliteal vessel and the entire superficial femoral vessel. Then, the 5 mm balloon was used to inflate the superficial femoral vessel from ostium through popliteal. Then, angiography was performed. There was a stenosis of the proximal to mid-dorsalis pedis. The, the PT2 wire was used with the balloon for guidance and angioplasty was performed of this region. Then, angiography was performed. Then, the PT2 wire was placed again and repeat plasty was performed. Note the nitroglycerin was given after multiple CS1 passes as well as on needed plasties and angiographies. Then, right common femoral angiogram was performed and closure device was placed.




This is how I would code;
93459-59 - LHC w/ grafts
75710- 59 - Lt Lower Extremity Arteriogram
37229- Atherectomy w/angioplasty tibioperoneal region.

Thanks,
Jim Pawloski, CIRCC


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## HCC12345 (Jun 4, 2014)

Are there codes that are not billable per the cci edits?


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## Jim Pawloski (Jun 4, 2014)

juliedale said:


> Are there codes that are not billable per the cci edits?



You lose the catheter placement code on this one (36247) when a revascularization of the lower extremities is performed.  The imaging is billable but you need the modifier -59 to separate the diagnostic portion from the interventional portion of the procedure.

HTH,
Jim Pawloski, CIRCC


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