# SFA atherectomy and angioplasty for in stent restenosis



## sharper (Apr 16, 2010)

I would love any thoughts on the correct way to code this op report!

The patient was brought to the endovascular suite. She was preped and draped in the usual sterile fashion. 1% lidocine used to anesthetize the left groin.  There, a 6 French femoral arterial sheath was placed by Sledinger technique and contralateral access achieved using a rim catheter, Terumo Glidewire, Terumo glide catheter , and a SuperCore wire.  A 7 French contralateral sheath was placed.  Angiography revealed a patent right external and common femoral.  The right superficial femoral artery had in-stent restenosis of approximately 80 percent, patent popliteal, and three vessel runoff.  There was diffuse lesions in the posterior tibia.  The anterior tibial and peroneal made it to the ankle.  The posterior tibia made it to the ankle with a segment of diffuse disease of approximately 75 to 80 percent distally.  The superficial femoral artery was wired using a 0.014 Spartacore wire.  Heparin was given to maintain ACT greater than 250.  A turbo tandem laser catheter was used to ablate plaque through the superficial femoral artery.  Two passed were performed which reduced the stenosis to less than 50 percent.  Balloon dilatation ws performed with a 5 X 120 VascuTRAK two balloon, relieving the stenosis to less than 10 percent.

Impression:  Status post successful right superficial femoral artery in-stent restenosis atherectomy and angioplasty, using a Turbo tandem laser and a 5 X 120 VascuTRAK two balloon.  No complications.

I am really confused and don't actually understane the in-stent restenosis!  Any help would be appreciated.

Thanks,
Susan


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## Jim Pawloski (Apr 18, 2010)

sharper said:


> I would love any thoughts on the correct way to code this op report!
> 
> The patient was brought to the endovascular suite. She was preped and draped in the usual sterile fashion. 1% lidocine used to anesthetize the left groin.  There, a 6 French femoral arterial sheath was placed by Sledinger technique and contralateral access achieved using a rim catheter, Terumo Glidewire, Terumo glide catheter , and a SuperCore wire.  A 7 French contralateral sheath was placed.  Angiography revealed a patent right external and common femoral.  The right superficial femoral artery had in-stent restenosis of approximately 80 percent, patent popliteal, and three vessel runoff.  There was diffuse lesions in the posterior tibia.  The anterior tibial and peroneal made it to the ankle.  The posterior tibia made it to the ankle with a segment of diffuse disease of approximately 75 to 80 percent distally.  The superficial femoral artery was wired using a 0.014 Spartacore wire.  Heparin was given to maintain ACT greater than 250.  A turbo tandem laser catheter was used to ablate plaque through the superficial femoral artery.  Two passed were performed which reduced the stenosis to less than 50 percent.  Balloon dilatation ws performed with a 5 X 120 VascuTRAK two balloon, relieving the stenosis to less than 10 percent.
> 
> ...



The patient has a previous stenosis that was opened w/ a stent.  Now the patient developed another stenosis inside the stent.  You would code this as an atherectomy, which supercedes the angioplasty charge.
I hope this helps you,
Jim Pawloski


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## sharper (Apr 19, 2010)

Thanks Jim and yes that helps a lot.  My doc actually coded an atherectomy AND a stent but I couldn't see the stent placement in the dictation, therefore the post here! I'm having a hard time finding information on multiple procedures and what bundles to what.  I need to educate my doc's on things just like this but can't put my hands on anything.  Any suggestions?

Have a great day,
Susan


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## Jim Pawloski (Apr 19, 2010)

sharper said:


> Thanks Jim and yes that helps a lot.  My doc actually coded an atherectomy AND a stent but I couldn't see the stent placement in the dictation, therefore the post here! I'm having a hard time finding information on multiple procedures and what bundles to what.  I need to educate my doc's on things just like this but can't put my hands on anything.  Any suggestions?
> 
> Have a great day,
> Susan



Book wise, either SIR coding book or Z-health publishing.  Also watch this web site, you may see someone else ask a question that may assist you.  Good luck and keep asking!
Jim Pawloski, MSA, CIRCC, R.T.(R)(CV)


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## GBielskis (Apr 21, 2010)

*atherectomy and angioplasty*

I thought you can now code both the atherectomy and angioplasty in vascular only, per Medicare guidelines, plus the S & I codes.  CCI says no bundling.
In heart caths, you can only bill the stent.


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## sharper (Apr 21, 2010)

I don't know but I sure hope we get some more comments on this one!  I've heard both ways but I don't know for sure.  I think it has a lot to do with the dictation and the original intent.


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## Jim Pawloski (Apr 21, 2010)

GBielskis said:


> I thought you can now code both the atherectomy and angioplasty in vascular only, per Medicare guidelines, plus the S & I codes.  CCI says no bundling.
> In heart caths, you can only bill the stent.



Hello,
Check out my question in the Interventional Radiology section, on pg 2.  I had asked the same question and was told that Dr Z states that the atherectomy supercedes the angioplasty.  It's the one that someone had labeled it with four stars.
Thanks,
Jim Pawloski,CIRCC


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## Jess1125 (Apr 22, 2010)

The following is in Medicare's online CCI manual:

17. When percutaneous angioplasty of a vascular lesion is followed at the same session by a percutaneous or open atherectomy, generally due to insufficient improvement in vascular flow with angioplasty alone, only the more comprehensive atherectomy that was performed (generally the open procedure) should be reported (see sequential procedure policy, Chapter I, Section M).

Jessica CPC, CCC


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## GBielskis (Apr 22, 2010)

*Angioplasties and atherectomies*

I am sorry -I did not make myself clear - If the doctor plans only to do an angioplasty - completes the angioplasty, states it did not solve the problem, then proceeds to do a stent, both the procedures are billable per CMS.  If the doctor initially plans to do the stent and does the angioplasty prior to the stent, it is included - only bill the stent.  

That is the only situation I know where they are both billable and payable.

I am currently trying to find information to support this.


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## sharper (Apr 22, 2010)

Please post it if you find anything.
Thanks,
Susan


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## Jim Pawloski (Apr 22, 2010)

GBielskis said:


> I am sorry -I did not make myself clear - If the doctor plans only to do an angioplasty - completes the angioplasty, states it did not solve the problem, then proceeds to do a stent, both the procedures are billable per CMS.  If the doctor initially plans to do the stent and does the angioplasty prior to the stent, it is included - only bill the stent.
> 
> That is the only situation I know where they are both billable and payable.
> 
> I am currently trying to find information to support this.



Dr. Z has it in his Cardiovascular Interventional book on pg 279.  I will bill both if there is a dissection from the angioplasty and it is documentated.


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