# Selective catheter placement lower extremities



## CPCCODERII (Mar 28, 2012)

*I am quite new to peripheral coding and I am having quite a bit of difficulty coding this operative note for selective catheter placement.  I have done a lot of research and am undecided as to how this should be coded.  I chose the codes:
93458-26
36246
75716-26/59
75625-26/59

Any help with this would be much appreciated!   I am including the majority of the OP note, but have underlined the areas where I am struggling.  If it is better to not include so much info, please let me know.  Just wanted to make sure the needed information is there * 

PROCEDURE: 
1.  Left heart catheterization via the left common femoral artery (CFA).
2.  Angiography of the left ventricle, coronary arteries, and left CFA.
3.  Peripheral artery catheterization via the left CFA.
4.  Digital subtraction angiography of the abdominal aorta with flush renal artery angiogram bilaterally.
5.  Angiography with selective catheter placement and injection in the right common iliac artery, right external iliac artery, left common iliac artery, and left external iliac artery.

DESCRIPTION OF PROCEDURE:
Informed consent was obtained.  We discussed the goals, risks and alternatives to proceeding with cardiac catheterization.  Since she had undergone multiple percutaneous coronary interventions (PCI), she did not wish to undergo PCI at the same setting.  She is inclined to favor coronary artery bypass surgery.  We also discussed the goals, risks and alternatives to proceeding with abdominal aortography and lower extremity arterial angiography.

Left heart catheterization was performed percutaneously via the left CFA using a 6 French 10 cm sheath. Catheters were exchanged over a guidewire.  A straight pigtail catheter was advanced into the LV.  A left ventriculogram performed.  The aortic valve was evaluated using catheter pullback technique.

Coronary angiography was performed using an FL4 to inject the left coronary arteries and an AR Mod to inject the right coronary artery.

DSA of the abdominal aorta was performed, with flush renal artery angiography bilaterally.  DSA of the terminal abdominal aorta was also performed with runoff imaging of the iliac arteries bilaterally.

DSA of the right lower extremity arteries was performed by selective catheter placement and injection through a 6 French IM catheter into the right common iliac artery, and by selective catheter placement and injection through an MPA2 catheter into the right external iliac artery.

DSA of the left lower extremity arteries was performed by selective catheter placement and injection through the MPA2 catheter into the left common iliac artery, followed by selective placement and injection in the left external iliac artery.
The catheters and 6 French sheath were removed from the left common femoral artery, and hemostasis was obtained using local manual compression.

HEMODYNAMIC SUMMARY:
The aortic pressure measured 116/59 (mean 84).  The LV pressure measured 116/0 with
an end diastolic pressure of 20 mm Hg. There was no aortic valve gradient.

LEFT VENTRICULOGRAM:
The LV was mildly dilated.  The LV systolic function was mildly reduced, ejection fraction 45%.  Hypokinesis involved the posterobasal and diaphragmatic segments.  Mitral insufficiency was mild.

CORONARY ANGIOGRAM:
1.  Coronary artery dominance:  Right.
2.  Left main coronary artery (LMCA):  the distal segment was 30% obstructed.
3.  Left anterior descending coronary artery (LAD):  Type 1 not reaching the apex.  The proximal segment was previously stented more than once with no in-stent restenosis.  The middle segment was previously stented and 50% obstructed by diffuse disease.  Just distal to the distal end of multiple stents in the middle LAD, the native LAD was 60% obstructed.  The LAD diameter was small.  D1 and D2 were each small sized, diseased.
4.  Left circumflex coronary artery (LCX):  Normal sized, diseased.  OM1 was small sized, diseased.  OM2 was normal sized, diseased, and 30% obstructed by a tubular lesion.
5.  Right coronary artery (RCA):  Normal sized, diseased.  The proximal 
segment was previously stented with no in-stent restenosis.  The middle segment was 60% obstructed by diffuse disease.  The right PDA was 85% obstructed by a tubular lesion at its origin.  The right PL was 30% obstructed at its origin and 90% obstructed in its middle segment.

DSA OF THE ABDOMINAL AORTA WITH FLUSH RENAL ARTERY ANGIOGRAM:
The suprarenal abdominal aorta was normal sized, mildly diseased.  The infrarenal abdominal aorta was involved by a small, saccular aneurysm which began at least 1 cm below the origin of the secondary left lower renal artery.  The terminal aorta dilatation extended into the right common iliac artery which was mildly dilated in its proximal segment.

The right renal artery was single and 50% obstructed proximally by a tubular lesion. The left kidney was supplied by 2 renal arteries.  The primary artery was an upper renal artery, which supplied more than two-thirds of the left kidney.  The left primary renal artery was 10% obstructed in its mid body, and at its first bifurcation the lower bifurcation limb was 40% obstructed.  The secondary left lower renal artery supplied the inferior pole of the left kidney and it was 90% obstructed at its origin with associated atherosclerotic disease involving the abdominal aorta at that site.

RIGHT LOWER EXTREMITY ARTERIES:
1.  Common iliac artery:  Normal sized, diseased, with mild dilatation in the proximal segment.
2.  Internal iliac artery:  Normal sized, diseased.
3.  External iliac artery:  Normal sized, diseased.
4.  Common femoral artery:  80% obstructed by an eccentric, complex plaque with ulceration.
5.  Deep femoral artery:  Normal sized, diseased, and essentially normal after its origin.
6.  Superficial femoral artery:  20% obstructed at its origin and essentially normal after the origin.
7.  Popliteal artery:  Normal.
8.  Anterior tibial artery:  Normal.
9.  Posterior tibial artery:  Normal.
10. Peroneal artery:  Normal.

LEFT LOWER EXTREMITY ARTERIES: 
1.  Common iliac artery:  Normal sized, diseased.
2.  Internal iliac artery:  80% obstructed at its origin.
3.  External iliac artery:  Normal sized, diseased.
4.  Common femoral artery: 30% obstructed by diffuse disease.
5.  Deep femoral artery:  Normal sized, diseased, and essentially normal after its origin.
6.  Popliteal artery:  Normal.
7.  Anterior tibial artery:  Normal.
8.  Posterior tibial artery:  Normal.
9.  Peroneal artery:  Normal.


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## theresa.dix@tennova.com (Mar 29, 2012)

CPCCODERII said:


> *I am quite new to peripheral coding and I am having quite a bit of difficulty coding this operative note for selective catheter placement.  I have done a lot of research and am undecided as to how this should be coded.  I chose the codes:
> 93458-26
> 36246
> 75716-26/59
> ...



That looks good! What about your angiograms for the selective cath placements in the lower extremities?


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## CPCCODERII (Mar 29, 2012)

Thats the area where were confused....we chose the 75716-26/59 for the angio of the lower extremeties, but the catheter was placed in the internal iliacs on both the left and right side.....would we also use the 36248 for the additional views on the right side, or would this be a situation where we would use 75774?  And for the left, since it was the side of entry, can we bill for the views of the internal iliacs?  And if so, for the left, would we bill the 75774?


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## theresa.dix@tennova.com (Mar 30, 2012)

CPCCODERII said:


> Thats the area where were confused....we chose the 75716-26/59 for the angio of the lower extremeties, but the catheter was placed in the internal iliacs on both the left and right side.....would we also use the 36248 for the additional views on the right side, or would this be a situation where we would use 75774?  And for the left, since it was the side of entry, can we bill for the views of the internal iliacs?  And if so, for the left, would we bill the 75774?



 oh yes this is tough. Someone may have to refresh my memory. On the right side you have two cath placements code the furthest 36246 s&i 75774 ,75774-59. Then they cross the aortic bifurcation( i guess) back to the left side and cath placement in the left common and inject. You may be able to code that cath placement .You can code the s&i 75774-59.

can someone confirm that?


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## dpeoples (Mar 30, 2012)

CPCCODERII said:


> *I am quite new to peripheral coding and I am having quite a bit of difficulty coding this operative note for selective catheter placement.  I have done a lot of research and am undecided as to how this should be coded.  I chose the codes:
> 93458-26
> 36246
> 75716-26/59
> ...



My two cents worth..the access was the LCF artery, the furthest catheter end position was the RT Ext Iliac. There is no documentation that the internal iliacs were selected unless I am missing that. Here is my code selection:
93458-26
36246 (RT External Iliac)
75716-26 (bilat lower extremities)
75625-26,59 (abd aortography)

The reason I would be reluctant to code an additional after basic is because there is no separately dedicated portion of the report (interpretation) to support that. It seems the "extra" images were performed to "complete" the basic exam of the lower extremities, which is a common technique. 

HTH


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## dpeoples (Mar 30, 2012)

CPCCODERII said:


> Thats the area where were confused....we chose the 75716-26/59 for the angio of the lower extremeties, but the catheter was placed in the internal iliacs on both the left and right side.....would we also use the 36248 for the additional views on the right side, or would this be a situation where we would use 75774?  And for the left, since it was the side of entry, can we bill for the views of the internal iliacs?  And if so, for the left, would we bill the 75774?



My eyes are old eyes...please highlight where the "internal iliac arteries " were selected.
Thanks.


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## CPCCODERII (Mar 30, 2012)

dpeoples said:


> My two cents worth..the access was the LCF artery, the furthest catheter end position was the RT Ext Iliac. There is no documentation that the internal iliacs were selected unless I am missing that. Here is my code selection:
> 93458-26
> 36246 (RT External Iliac)
> 75716-26 (bilat lower extremities)
> ...



I am so happy to know we are on the right track.  And regarding the 75774 codes, I think the descriptions we have found are as clear as mud LOL  But from what I'm understanding, there has to be a separate interpretation of the findings of additional views of the selected areas, and then you can use code 75774 x's the number of areas that the catheter was selectively placed into?  Would you also bill out the additional selective catheter code-36248?


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## theresa.dix@tennova.com (Apr 3, 2012)

Danny,
 Yes I think you are right on not coding for the extra angiograms of the legs. After re reading this I agree. my eyes are old too.  There was no documentation for it. Thanks for point that out!


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