# Need help with ptca coding



## Jane5711 (Jul 20, 2016)

HI,
I'm finding this report difficult to code. Any help will do!  Thanks.

PROCEDURES PERFORMED:                                                          
1.  Bilateral lower extremity arterial angiography with runoff.                
2.  Angioplasty of the right external iliac artery with a 6.0/60 mm Armada     
    balloon.                                                                   
3.  Stent of the right external iliac artery with a 8.0/59 mm Omnilink         
    stent.                                                                     
4.  Angioplasty of the right common femoral artery with a 6.0/60 mm Armada     
    balloon.                                                                   
5.  Stenting of the right common femoral artery with a 6.0/39 mm Omnilink      
    stent.                                                                     

INDICATIONS:                                                                   
1.  Peripheral artery disease with severe claudication pain of the right       
    lower extremity with a previous history of angioplasty and stent of the    
    right external iliac artery and angioplasty and stent of the right         
    superficial femoral artery.                                                
2.  Abnormal duplex lower extremity arterial ultrasound study of the lower     
    extremities with a history of angioplasty and stent of the right           
    external iliac artery, angioplasty and stent of the right superficial      
    femoral artery, and angioplasty and stent of the left superficial          
    femoral artery in the past.                                                



PROCEDURE IN DETAIL: After the informed consent was obtained, the patient      
was prepped and draped in the usual sterile fashion.  Lidocaine 2 percent      
was used for local anesthesia in the left groin and right groin.  Vascular     
access was obtained in the left femoral artery.  Over a guidewire, a           
6-French long crossover sheath was introduced into the distal abdominal        
aorta through the left femoral artery.                                         

CO2 Angiography of the distal abdominal aorta with a runoff to the left        
common /external iliac artery and right common/ external iliac artery were     
performed through the sheath.                                                  

Then, a 6-French IM catheter was introduced through the femoral sheath in      
the left femoral artery and was used to cross into the right common iliac      
artery.  The crossover sheath was then advanced into the right common iliac    
artery.                                                                        


CO2 Angiography was performed in the right common iliac artery for runoff to   
visualize the right lower extremity in a similar fashion as previous           
CO2 angiography performed in the left common iliac artery with a runoff in the 
left lower extremity arteries.                                                 

Initially, CO2 angiography was performed.  This was followed by conventional   
angiography with a convention contrast.                                        

Then, the IM catheter was removed.  Then, a Glidewire was used to try to       
cross the lesion in the right external iliac artery.                           

A 0.035 Quick-Cross catheter was then used to attempt to cross the lesion      
through the right external iliac artery, this was not successful.              

Then, a 0.035 glide catheter was used for support and 0.035 J-wire was used    
to try to cross the lesion, this was not successful. Hence, 0.018 Glidewire    
was used to try to cross the lesion in the right external iliac artery, this   
was not successful.  There is a total occlusion of the right external iliac    
artery within the stent.                                                       

At this point,  the films were reviewed and it was decided to obtain the       
access in the right femoral artery.                                            

Access was obtained in the right femoral artery, and over a guidewire, and     
0.035 J-wire was introduced through the 5-French micropuncture sheath.  This   
micropuncture sheath was advanced over the guidewire into and I was able to    
cross the lesion in the right common femoral artery.  The wire then was able   
to cross through the lesion in the right external iliac artery stent and the   
wire was introduced into the aorta.                                            

The 5-French micropuncture sheath was removed from the right femoral artery    
and a 6-French marker sheath was introduced over a guidewire.                  

Angiography of the CO2 was performed and then followed by angiography with a   
conventional contrast was performed.                                           

This delineated the entire lesion in the right external iliac artery and       
right common femoral artery.                                                   

A 6.0/60 mm Armada balloon was advanced over the guidewire into the right      
external iliac artery and was used to dilate the stent in the lesion in the    
right external iliac artery at 6 atmospheres with multiple inflations,         
balloon was removed.                                                           

Another attempt was tried to cross the lesion from the left femoral sheath     
and a Glidewire was introduced to try to cross into the right external iliac   
artery, which was not successful.                                              

Hence, angiography was performed again through the right femoral arterial      
sheath and then a 6.0/60 mm balloon was reintroduced into the right common     
femoral artery and was used to dilate the lesion at 6 and 4 atmospheres        
successfully.  The balloon was removed.                                        

Angiography was obtained of the right common femoral artery and right          
external iliac artery.                                                         

It was noted that the angiography showed suboptimal results of angioplasty     
in the right external iliac artery and suboptimal result of angioplasty of     
the right common femoral artery.                                               

Because of the suboptimal angioplasty results after the balloon angioplasty,   
it was decided to stent these lesions.                                         

Then, an 8.0/59 mm Omnilink stent was advanced into the right external iliac   
artery and was deployed in the right external iliac artery and was advanced    
proximal to the previously placed stent as well as a part of the stent was     
within the previously placed stent and the stent was deployed at 10            
atmospheres with good results and balloon was removed.                         

Then, a 6.0/40 mm Omnilink stent was advanced into the right common femoral    
artery.  Prior to this, the right common femoral artery angiography was        
performed.  It was noted that the angioplasty results were suboptimal in the   
right common femoral artery after the balloon angioplasty.                     

Hence, a 6.0/39 mm Omnilink stent was advanced into the right common femoral   
artery and the stent was deployed to overlap the previously placed stents      
and another stent was deployed at 13 atmospheres with excellent results.  The  
stent balloon was advanced more proximally and was used to dilate the          
junction of the 2 stents at 14 atmospheres with excellent results.  The        
stent balloon was removed.  Angiographic images obtained through the right     
femoral arterial sheath as well as the left femoral arterial sheath with a     
CO2 as well as the conventional contrast agents.                               

Then, a Glidewire was introduced through the left femoral artery sheath into   
the crossover sheath.  The crossover sheath was removed and exchanged for a    
6-French standard sheath over the wire.  Both the arterial sheaths were        
sutured in the right groin and left groin and the patient was transferred in   
a very stable condition to floor for further care with no complications.       

RESULTS:                                                                       
1.  LOWER EXTREMITY ANGIOGRAPHY WITH A RUNOFF.                                 
    a.  Distal abdominal aorta: Distal abdominal aorta has mild                
        atherosclerosis.  It bifurcates into 2 iliac arteries bilaterally.     
2.  COMMON ILIAC ARTERIES.                                                     
    a.  Right common iliac artery:  Right common iliac artery has mild         
        atherosclerosis.  It has calcification in its very proximal portion    
        with a 40 percent stenosis in its proximal portion.  The right         
        common iliac artery bifurcates into the right external iliac artery    
        and right internal iliac artery.  Right external iliac artery is       
        totally occluded in its proximal portion. Right internal iliac         
        artery is a moderate vessel and it provides collaterals to the right   
        common femoral artery and right deep superficial femoral artery.       
    b.  Left common iliac artery:  Left common iliac artery has mild           
        atherosclerosis.  It has 30-40 percent stenosis in its proximal        
        portion.  It bifurcates into the left internal iliac artery and left   
        external iliac arteries.                                               
3.  EXTERNAL ILIAC ARTERIES.                                                   
    a.  Right external iliac artery:  The right external iliac artery is       
        totally occluded with a stent present in its proximal portion.         
    b.  Left external iliac artery:  The left external iliac artery has mild   
        diffuse atherosclerosis with up to 30-40 percent diffuse stenosis.     
4.  INTERNAL ILIAC ARTERIES: Both the right and left external iliac arteries   
    are patent.                                                                
    a.  Right internal iliac artery:  Right internal iliac artery is a         
        significant vessel, provides profuse collaterals to the left pelvic    
        area.                                                                  
    b.  Left internal iliac artery:  Left internal iliac artery has moderate   
        diffuse disease throughout its course.                                 
5.  COMMON FEMORAL ARTERIES.                                                   
    a.  Right common femoral artery:  Right common femoral artery is not       
        visualized because of the total occlusion.  After the angioplasty,     
        the right common femoral artery is noted to have significant lesion    
        and then after stenting the right common femoral artery has no other   
        residual stenosis with a runoff to the right deep femoral artery and   
        right superficial femoral artery.                                      
    b.  Left common femoral artery:  Left common femoral artery has            
        mild-to-moderate diffuse disease and bifurcates into the left          
        superficial femoral artery and left deep femoral artery.               
6.  SUPERFICIAL FEMORAL ARTERIES:                                              
    a.  Right superficial femoral artery: The right superficial femoral        
        artery is noted to feel after the angioplasty of the right common      
        femoral artery was performed and is noted to have moderate disease     
        in its proximal portion with a 30-40 percent stenosis followed by      
        50-60 percent stenosis in its proximal portion.  The stent is noted    
        in its mid portion, which is patent.                                   
    b.  Left superficial femoral artery: Left superficial femoral artery has   
        about 30 percent diffuse stenosis in the proximal portion, widely      
        patent stent in the mid portion.                                       
    c.  Beyond the mid portion of the right and left superficial femoral       
        arteries, angiography was not performed.                               
7.  DEEP FEMORAL ARTERIES: Both the right and left deep femoral arteries       
    have mild diffuse disease.                                                 

FINAL RESULTS:                                                                 
1.  Prior to the procedure, there is a total occlusion of the proximal         
    portion of the right external iliac artery within the stent as well as     
    proximal to the stent.                                                     

2.  Prior to the procedure, there was a total occlusion of the right common    
    femoral artery.                                                            
3.  Post-procedure, after angioplasty of the right external iliac artery,      
    there is suboptimal result with more than 50 percent residual stenosis     
    of the right external iliac artery.                                        
4.  Post-procedure, after angioplasty of the right common femoral artery,      
    there is more than 50 percent residual stenosis of the right common        
    femoral artery.                                                            
5.  Post-procedure, after stenting of the right external iliac artery with     
    an 8.0/59 mm Omnilink stent, there is 0 percent residual stenosis of       
    this lesion with no dissection, no thrombosis and excellent distal flow.   
6.  Post-procedure, after stenting of the right common femoral artery, there   
    is 0 percent residual stenosis of the lesion.  The stent is noted to end   
    just about 4 mm proximal to the _____ in the pelvic area and above the     
    groin fold.  The stent is 6.0/39 mm Omnilink stent in the right common     
    femoral artery with 0 percent residual stenosis in the right common        
    femoral artery and excellent distal flow.                                  

PLAN:                                                                          
1.  The patient will be kept on aspirin and clopidogrel.                       
2.  Renal functions will be monitored closely.                                 
3.  Both arterial sheaths in the right and left groin will be removed later.   

Thanks for your help in advance!


----------



## cpc2007 (Sep 19, 2016)

I see you posted this a little while back but hadn't received a reply.  I thought I would reply in the event you are still looking for guidance or encountered something similar in future.  The main interventions in this case (the right external iliac stent and right common femoral stent) are coded as 37221 for the iliac and 37226 for the femoral artery.  Per CPT guidelines you can report one primary lower extremity revascularization code per "vascular territory" (the iliac arteries are one territory, the femoral/popliteal arteries are another territory, and the tibial/peroneal arteries are a third and final territory for each extremity).  The codes are hierarchal meaning you report the most extensive procedure performed in any one territory as the primary code for that territory and it includes all less extensive interventions in the same vessel (so in this case the angioplasty in the right external iliac and right common femoral are included in the stent placements). 

These codes also include the work of selectively catheterizing and accessing the vessels undergoing intervention and all radiology S&I needed to perform the interventions (including confirmatory angiograms, guiding shots, and completion angiograms).  One area where your physician could be clearer in his documentation is on the lower extremity angiogram that was performed at the start of the case.  If he performed an initial catheter-based angiogram/CTA during this procedure and he documents a full diagnostic angiogram (which he did), and "the decision to intervene is based on the findings of the angiogram" (which is the part that is not clear from the report), you can unbundle the radiology S&I for a bilateral lower extremity angiogram with runoff in this case (75716.26.59).  But he would have to make clear that the angiogram was needed to determine the need for intervention (if he brought the patient to the cath lab planning to angioplasty/stent the right external iliac and the right common femoral arteries on the basis of the preoperative doppler, you cannot report the angiogram separately as it would be a confirmatory/guiding shot at that point).  In this particular case also, if the angiogram was truly diagnostic allowing you to unbundle the 75716.26.59, you could also unbundle the 36245.59 for the catheterization related to that angiogram since the most extensive catheterization to perform the angiogram was a first order selective catheterization from the left common femoral artery to the right common iliac artery and he used a separate less selective access from the right common femoral artery to perform the stent placements/angioplasties (the 36140 from the right common femoral artery bundles to the 37221/37226 but the 36245 which is more selective and from a separate access would not).  Again though in order to unbundle the 75716.26.59 and 36245.59 documentation clarification would be needed from the physician to determine if the angiogram was truly diagnostic (sharing this feedback in case you work directly with the physician and have the opportunity to share the CPT guidelines with him ).


----------



## Jane5711 (Sep 26, 2016)

Thank you


----------

