# Help.. Need help breaking this one down. overwhelmed!



## Chlrtrep (Apr 23, 2015)

I could use some help breaking this one down.  We don't do exciting procedures like this that often and could use some opinions.

Concerns are the use of covered stents in distal aorta and bilateral iliacs. The use of self expanding stents in iliacs. Mechanical thrombectomy performed in iliacs, external iliacs , femoral arteries and aorta

I have the  diagnostic portion.  However I question  the ability to charge diagnostic portion since this was confirmed by a recent CT as dictated by physician. I am not aware of a recent angio.

SO if I can code diagnostic I a looking at

Brachial approach  : 75630 with additional selective angio 75774(36245)

Left femoral access: 36140  

After that  I am uncertain.

I could use some help..... So here we go!


...known history of systemic hypertension and

peripheral arterial occlusive disease, status post multiple endovascular

aortic and iliac artery stents in the past, who now presents with

debilitating bilateral lower extremity claudication, who was recently

admitted to the hospital with resting claudication. The patient recently

had a CT angiogram of the abdominal aorta and lower extremities, which

revealed a chronic totally occluded infrarenal abdominal aorta as well

as bilateral right and left iliac arteries. She now presents for an

attempt at percutaneous endovascular revascularization.


PROCEDURES

1. Abdominal aortography with bilateral iliofemoral runoff.

2. Selective angiography of the right lower extremity via a left

brachial artery access with the catheter being placed in the proximal

portion of the right superficial femoral artery.

3. Selective angiography of the left iliofemoral system with a catheter

being placed selectively via access from the left common femoral artery.

4. Percutaneous thrombectomy of the infrarenal abdominal aorta.

5. Percutaneous thrombectomy of the right and left common iliac

arteries.

6. Percutaneous thrombectomy of the right external iliac

artery and common femoral artery.

7. Intraarterial thrombolysis.

8. Percutaneous transluminal balloon angioplasty with endovascular

stenting of the infrarenal abdominal aorta using 2 kissing stents.

9. Percutaneous transluminal balloon angioplasty with endovascular

stenting of the right and left common iliac arteries utilizing balloon

expandable covered stents.

10. Percutaneous transluminal balloon angioplasty with endovascular

stenting of the right external iliac artery utilizing a self-expanding

stent.

11. Percutaneous transluminal balloon angioplasty with endovascular

stenting of the left external iliac artery utilizing a self-expanding

stent.



ACCESS

1. The left brachial artery was accessed initially with a micropuncture

system.

2. The left common femoral artery was accessed again with a

micropuncture system.



RESULTS: After applying local anesthesia to the left antecubital fossa,

a 5-French micropuncture system was placed into the left brachial artery

utilizing a modified Seldinger technique. This was followed by the

passage of a 0.035 inch guidewire into the descending thoracic aorta.

Subsequently, a 5-French pigtail catheter was passed over the guidewire

into the abdominal aorta at the level of the renal arteries. Subsequent

abdominal aortography with iliofemoral runoff was performed. This

revealed the right and left renal arteries to be widely patent. The

infrarenal abdominal aorta was completely occluded approximately 10 cm

above the iliac bifurcation. There was evidence of multiple bilateral

stents in the right and left common and right external iliac arteries.

All stents were completely occluded as well as the right and left

external iliac arteries. The right common femoral artery was also

occluded. There was some reconstitution of the left common femoral

artery via collaterals from what appears to be lumbar arteries. There

was some faint collateralization and visualization of the most distal

aspect of the right common femoral artery.



At this point in time, local anesthesia was given to the left groin and

utilizing a micropuncture kit, the left common femoral artery was

accessed followed by the passage of a 5-French introducer catheter.

Contrast was injected through this catheter which revealed the patent

left common femoral artery and subtotal occlusion of the left external

iliac artery and complete occlusion within the stent that was previously

placed in the left common iliac artery. The proximal portions of the

left superficial and deep femoral arteries were all patent. At this

point in time, the 5-French micropuncture dilator was exchanged for a 6-

French introducer sheath followed by the passage of a 0.035 inch

guidewire, which was used to recanalize the completely occluded segments

of the left external and common iliac arteries as well as the infrarenal

abdominal aorta. This was used with the assistance of an 0.035 inch

support catheter that was again passed over the guidewire and positioned

at the abdominal aorta at the level of the renal arteries. The guidewire

was removed and contrast again was injected and abdominal aortography

was performed, which confirmed that the catheter was in the true lumen.



At this point in time, the catheter was removed after placement of a

0.035 inch guidewire into the descending thoracic aorta. Attention was

then given 2 the occluded abdominal aorta from a left brachial approach.

The 5-French pigtail catheter was removed over a 0.035 inch guidewire

and replaced with a 7-French, 90 cm introducer sheath that was passed

over the guidewire into the abdominal aorta just below the renal

arteries. The dilator was removed and a 0.035 inch guidewire was passed

beyond the occluded segment into the right common and external iliac

arteries. The 0.035 inch support catheter was passed over the guidewire

into the right external iliac artery. The guidewire was then further

passed beyond the occluded segment of the right external iliac artery

and common femoral artery and into the right superficial femoral artery.

This was followed by the passage of the support catheter that was

positioned into the proximal third of the right superficial femoral

artery. The guidewire was removed and contrast was injected, and

angiographic evaluation of the right lower extremity was performed which

revealed a widely patent right superficial femoral artery and popliteal

arteries. At the level of the trifurcation, there was evidence of

thrombotic occlusion of the tibioperoneal trunk with faint filling of

the proximal portions of the peroneal and posterior tibial arteries.

There also appeared to be subtotal occlusion of the anterior tibial

artery with flow down to the foot.



At this point in time, 4 mg of TPA was given as a slow continuous

infusion followed by reinsertion of an 0.035 inch guidewire and removal

of the support catheter. Subsequently, a 6-French, 120 cm AngioJet

catheter was passed over the guidewire and passed into the right common

femoral artery and percutaneous thrombectomy began of the entire

occluded segments of the right common femoral artery, external iliac

artery, and right common iliac artery as well as the abdominal aorta.

Upon removal of the thrombectomy catheter, repeat angiography was

performed which revealed marked improvement in antegrade flow throughout

the occluded segment, but there were still multiple areas of high-grade

focal stenosis which was at the right external iliac artery just distal

to the stent as well as the proximal portions of the common iliac artery

and the infrarenal abdominal aorta.



At this point in time, an 8 mm x 8 cm self-expanding stent was passed

over the guidewire and positioned into the stenotic segment of the right

external iliac artery and subsequently deployed. This was followed by

the passage of an 8 mm x 8 cm balloon angioplasty catheter was passed

over the guidewire into the stenotic segment of the left external iliac

artery and inflated to a maximum of 16 atmospheres of pressure. The

balloon catheter was then pulled into the common iliac abdominal aorta

and subsequently dilated to a maximum of 18 atmospheres of pressure. The

balloon catheter was removed and contrast was injected through the 90 cm

sheath which revealed now marked improvement in antegrade flow and no

significant residual stenosis in the right common femoral artery and

external iliac artery. However, there remained again a significant high-

grade stenosis in the abdominal aorta and the right common iliac

artery.



At this point in time, attention was given to the left iliofemoral

system whereby the AngioJet catheter was passed over the 0.035 inch

guidewire and percutaneous thrombectomy of the left external iliac

artery as well as the common iliac artery and abdominal aorta was

performed which revealed limited improvement in overall luminal patency.

At this point in time, it was felt that we were dealing with

predominantly fixed chronic obstructive lesions at this point in time,

and so a 7 mm x 10 cm balloon angioplasty catheter was passed over the

guidewire and subsequently used for dilatation of the left external

iliac artery and eventually the left common iliac artery and abdominal

aorta. After balloon angioplasty there was significant residual stenosis

and actually an intimal dissection flap was noted in the left external

iliac artery.



At this point in time, it was felt the patient would benefit from

endovascular stenting. Consequently, an 8 x 59 mm iCast covered balloon

expandable stent was passed over a 0.035 inch wire from the left

brachial access into the right common iliac artery and a second iCast

stent measuring 7 x 59 mm was passed over the guidewire through the 7-

French sheath that had been previously placed via the left common

femoral artery into the left common iliac artery and subsequently

deployed at 24 atmospheres of pressure. This was followed by deployment

of the right iCast stent at 20 atmospheres of pressure. The balloon

delivery catheter was removed from the left and an 8 mm x 8 cm balloon

angioplasty catheter was passed into the stent and simultaneous

inflation of both 8 mm balloons was subsequently performed. This

resulted in marked improvement, but there continued to be a high-grade

stenosis of the abdominal aorta above the stents, so consequently 2

additional 8 mm x 59 mm iCast stents were placed in a kissing fashion

via the left common femoral artery as well as the left brachial artery

access in an overlapping fashion and subsequent deployed at 20

atmospheres of pressure. The balloon delivery systems were subsequently

removed and the pigtail catheter was placed via the 6-French 90 cm

sheath at the level of the renal arteries and subsequent aortography was

performed. This revealed that the abdominal aorta was now widely patent

with excellent antegrade flow throughout the right iliofemoral system

and markedly improved flow down the left iliofemoral system, but there

was evidence of a high-grade flow limiting dissection in the left

external iliac artery.



At this point in time, a 10 mm x 8 cm self-expanding stent was passed

over a 0.035 inch guidewire through the sheath in the left common

femoral artery and subsequently deployed, followed by post-balloon

inflation with a 7 mm x 10 cm balloon angioplasty catheter. At this

point in time, the final abdominal aortography was performed via the

pigtail catheter that had been placed via the left brachial artery. This

was of excellent result. Both renal arteries remained widely patent. The

infrarenal abdominal aorta now had 0% residual stenosis and excellent

antegrade flow. The right and left common as well as external iliac

arteries were also widely patent with 0% residual stenosis.



COMPLICATIONS: No immediate complications were noted.


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## j.monday7814 (Apr 23, 2015)

wow, that is a rough report. he is all over the place anatomically which makes it very difficult to code. Here is what I got:

L brachial access
L femoral access
diagnostic - 75630, 75774x2

aspiration thrombectomy of R femoral, iliac, and abdominal aorta- not separately reportable

intervention to R & L external and common iliacs through both access sites so that means both access sites are bundled into the intervention and not billable.

37221x2 - R & L
37223 - R & L
75630-26-XU
75774x2-26-xu


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## Chlrtrep (Apr 23, 2015)

j.monday7814 said:


> wow, that is a rough report. he is all over the place anatomically which makes it very difficult to code. Here is what I got:
> 
> L brachial access
> L femoral access
> ...



Thanks for your response.

I do have a few questions...

I was under the impression that angiojet was considered mechanical thrombectomy therefore coded as 37184-37185 respectively. In addition to intervention performed. Is that not the case in this situation


In the above report I only  read one additional selective angiogram not two.  What was there other one you read?  What about selective catheter placement in the Right SFA.  That is the furthest cath placement even though no intervention was performed in SFA. Can this still be coded?(75774,36246)

Bilateral Kissing Stents in iliacs 37221-50

I read one stent in right  ext iliac(37223)  and a PTA to the left ext iliac           (37222?)

What about the infrarenal aorta stenosis. This is dictated as a separate stenosis although overlapping the stents with previous implanted iliac stents. Can you not code for stent placement in aorta (37236)?


That is what I saw originally I see that you have read it differently.  THe abdominal stent and thrombectomy is what is causing me the greatest concern.


Charles


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## j.monday7814 (Apr 28, 2015)

sorry I didn't break it all down for you in my first response, hopefully this will clear up some confusion...

37184-37185 is primary mechanical thrombectomy, so it cannot be billed as a secondary intervention. "primary" thrombectomy is planned out extensively prior to the procedure and is typically the only intervention performed. If you have one of Dr. Z's books he goes into this and probably explains it better than I do.

Angiojet is aspiration thrombectomy, not mechanical. You could argue for 37186 which is secondary thrombectomy (almost any technique) of an artery or arterial bypass graft.  I'm on the fence about billing the 37186, it is a high dollar code for very little detail in his report.

As for the aortic stenosis and overlapping stents. The same concept applies here as any vascular stent, if a stent is deployed across two arteries but it is only treating one long occlusion then it is reported with only one intervention code. The only time you can bill for one stent deployed across two arteries is if the physician identifies two distinct occlusions in each artery and just happens to be able to treat them with one very long stent.

I hope that helps! Let me know if you have any other questions or if I didn't answer something clearly.


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## Chlrtrep (Apr 30, 2015)

Thanks for your input. I appreciate the feed back...

I am somewhat perplexed in regards to angiojet. It looks as thought I have to disagree in regards to angiojet being an "aspiration" thrombectomy device. Everything I have read states mechanical thrombectomy. Even Dr. Z . I called Boston Scientific who owns the angiojet now and their reimbursement person said mechanical.

They do make the Fetch2  which is an aspiration catheter.

If there is other information available that states it is an aspiration cathteter and should be coded as such please point me in that direction.

charles


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## Jim Pawloski (Apr 30, 2015)

j.monday7814 said:


> sorry I didn't break it all down for you in my first response, hopefully this will clear up some confusion...
> 
> 37184-37185 is primary mechanical thrombectomy, so it cannot be billed as a secondary intervention. "primary" thrombectomy is planned out extensively prior to the procedure and is typically the only intervention performed. If you have one of Dr. Z's books he goes into this and probably explains it better than I do.
> 
> ...



I need to correct your thought of atherectomy.  And Angiojet injected either saline or TPA, and then sucks out the thrombous materal.  It is mechanical thrombectomy.  Suction thrombectomy is placing a catheter and applying manual suction. (Cannot be billed in heart intervention)
Thanks,
Jim Pawloski R.T.(CV), CIRCC


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