# Renal Angioplasty with Stent...Please HELP



## brandyleigh23 (May 20, 2013)

*I am trying to bill this note appropriately and have two interpretations.*



RENAL ANGIOGRAM/ANGIOPLASTY STENTING:

REFERRING PHYSICIAN:  Dr. H; Dr. T

PROCEDURE:
1.  Selective right and left renal angiography.
2.  Balloon angioplasty of the left renal artery using 5.0 x 20 mm Slalom
over-the-wire balloon.
3.  Stenting of the left renal artery using 6.0 x 15 mm Palmaz Blue stent
dilated up to 10 atmospheres.  The 60-70% stenosis was reduced to 0%
residual stenosis without evidence of dissection and good distal flow.

OPERATOR:  Dr. SP

ASSISTANT:  Dr. MT

BRIEF CLINICAL HISTORY:  Mr. X is a very pleasant 75-year-old male who
is known to have peripheral vascular disease and renal artery stenosis.  He
underwent stenting of the right renal artery in the summer of 2012.  He is
being closely followed by Dr. H, and recently noticed that his renal
functions have deteriorated, creatinine up to 2.8 or so, and he was advised
to consider angioplasty/stenting of the left renal artery which was not
intervened on before.

Risks and benefits of the procedure were discussed in detail with the
patient.  The patient understands and wishes to proceed.

COMMENTS:  The case was technically routine.  There were no difficulties
with the study.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained.  The patient was
prepped and draped in the usual manner using lidocaine.  The right groin was
anesthetized.  Using 18 gauge needle and modified Seldinger technique, a 6
French sheath was advanced into the right femoral artery.  Then using a 6
French LIMA guide, the left renal artery was engaged and guiding shots were
performed.  At this time, the patient received 60 units of heparin per
kilogram IV dose (5700 units altogether).  At this time, using an SV 0.018
wire, the lesion in the left renal artery was crossed without any
difficulty.  We then used a 5.0 x 20 mm Slalom balloon and dilated up to 10
atmospheres.  Angiography at this time revealed improvement, however there
was still residual stenosis with short linear dissection.

At this time, we advanced a 6 mm x 15 mm Palmaz Blue stent and dilated up to
10 atmospheres.  At this time the balloon was pulled proximally, and the
ostium was flared up to 12 atmospheres.  The guiding catheter was then
pushed into the left renal artery, and the balloon was removed.  Angiography
at this time revealed significant improvement.  There was no evidence of
dissection.  There was good distal flow.  

The wire was removed and final cineangiography was performed.

At this time, I engaged the right renal artery and right renal angiography
was performed.

At this time, right femoral angiography was performed, and Mynx was used to
obtain hemostasis.

The ACT was 256.

PROCEDURE SUMMARY:

The patient underwent successful balloon angioplasty followed by stenting of
the left renal artery using 6 mm x 18 mm Palmaz Blue stent with significant
reduction from a 60-70% stenosis to 0% residual stenosis without evidence of
dissection and good distal flow.

The patient will continue taking aspirin and Plavix.

The patient will be watched overnight.  We will do a Lytes Plus in the
morning, and patient will be discharged home in the morning.

The right renal stent is patent.



*I have come up with codes: 
36252
37205
75960

I found coding documentation that states we can only bill angioplasty and stent separately when *the intention was to perform angioplasty as the primary intervention, AND *the stent placement was performed only after failed or suboptimal results from the angioplasty. 

However, I have someone else that believes codes should be: 
36245
75966-59
35471-59
75960
37205


Does anyone have any insight that will help us choose the correct codes for this procedure??

(Also, there is no mention anywhere of angiogram done prior to intervention and the history stated he had previous intervention but condition has gotten worse.)

Thank you*


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## Jim Pawloski (May 20, 2013)

brandyleigh23 said:


> *I am trying to bill this note appropriately and have two interpretations.*
> 
> 
> 
> ...



The problem that I have is that the doctor doesn't state how much residual stenosis there is and is the disection flow limiting.  That's why I lean to 36252, 37205, 75960.
Any other opinions?
Thanks,
Jim Pawloski, CIRCC


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## theresa.dix@tennova.com (May 21, 2013)

Here is that instruction and I do agree with Jim on the coding.

The key point to remember is this: When the intended intervention is primary stenting, PTA performed to predilate or as the method for stent deployment is NEVER a separately coded service. However, PTA is additionally reportable with stent placement when –

the intention was to perform angioplasty as the primary intervention, AND
the stent placement was performed only after failed or suboptimal results from the angioplasty.
To bill both renal PTA and stent interventions of the same vessel, the patient record must clearly establish angioplasty as the intended intervention. Most experts agree orificial lesions (the most common lesions involving the renal arteries)  should be treated by primary stenting; therefore, renal PTA would not be expected to be commonly reported in conjunction with renal stenting procedures.


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## brandyleigh23 (May 29, 2013)

Thank you both for your review and interpretation. It helps to get others insight. 
I am still going back and forth on using 36251 or 36252. After a bit more review we will make a decision, bill the procedure, and go from there.

Thanks again!


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