# Iliac Revascularization Unilateral PTA/Stent Right and Left



## Jane5711 (May 8, 2019)

Hi...

Need help with getting 37221 RT and 37221 LT 59 paid and 37223 LT.  According to a very famous payer only one can be paid however they didn't even pay ONE!!!!!  They denied all THREE after a review stating that the number of items billed for this date of service is above standard.  Shouldn't they pay for at least ONE!! They are also quoting PER CPT GUIDELINES.  Any help!!!!! Please......


PROCEDURES  PERFORMED:
Aortagram-Abdominal
Bilateral Lower Extremity Angio Bilateral Renal Angiogram
IVUS- Arterial (non-coronary vessel) initial vessel IVUS- Arterial (non-coronary vessel) each additional Iliac Revascularization Unilateral PTA/Stent- Right Iliac Revascularization Unilateral PTA/Stent- Left
Iliac Revascularization PTA ipsilateral each additional Left PTA/Stent

INDICATIONS:
173.9	170.211
Essential/Primary hypertension (110) 

PROCEDURE NOTES
The patient was brought to the cath lab in a resting and fasted state. The patient was prepped and draped in the usual sterile fashion.  Initial vascular access was obtained with micropuncture kit, and modified Seldinger technique to the left common femoral artery, and 5 French sheath was introduced.  Five French contra catheter was used for abdominal aortic angiogram, and bilateral iliac angiogram, the catheter was then advanced across the aortic bifurcation with the support of 260 centimeter Verascore Wire, and positioned with its tip to the right superficial femoral artery and right lower extremity angiogram was obtained.  Sheath was then exchanged for 6 French 45 centimeter cook sheath which was used for intravascular ultrasound of the right SFA, CFA, external and common iliac artery, and left common and external iliac artery and was used for the angioplasty and stent of the left common and external iliac arteries.  A 6 French 25 centimeter sheath was used for the right common femoral access which was obtained with micropuncture kit, and modified Seldinger technique, and sheath was used for the angioplasty and stent of the right common iliac artery.  A 5 French IM catheter was used for selective renal angiogram bilaterally.  Aspirin, Plavix, unfractionated heparin were used for anticoagulation during the procedure.  Manuel management of exercise provided.

FINDINGS:
Abdominal aortogram, obtained with the contra catheter positioned to the abdominal aorta right above renal arteries origin with power injection of 10 cc of contrast in AP projection.
Peri-renal abdominal aorta is of normal size with moderate partietal plaque without mobile or
protruding plague.
Distal abdominal aorta has narrowing with moderate plaque and overall about 40 percent diffuse stenosis without evidence of dissection or aneurysm, stenosis is not occlusive without evidence of gradient across the narrowing.

Bilateral selective renal artery angiogram.
was obtained with a 5 French IM catheter and selective engagement of right, and then left common renal artery in AP projection.
Right renal artery is a medium-sized vessel with not more than 20 percent proximal stenosis,
nonobstructive. there is a small calcified aneurysm of the distal right main renal artery, no obstrucive lesions of the branches.
Normal sized right kidney.
Left renal artery is a medium-sized vessel without any stenosis. NO distal renal artery disease.  Normal size left kidney.
Bilateral iliac angiogram. was obtained with the contra catheter positioned to the distal aorta above the aortic bifurcation. and power injection of 10 cc of contrast in AP projection.

Right common iliac artery is a large calcified vessel with about 50 percent midportion stenosis. Right hypogastric artery is a medium-sized vessel with moderate diffuse disease. without obstructive stenosis.
Right external iliac artery is a medium size calcified vessel with 20-30 percent luminal stenosis.

Left common iliac artery is a large calcified vessel. there is 70-80 percent ostial stenosis. 40 percent diffuse stenosis. 60 percent distal stenosis.
Left hypogastric artery is medium-sized vessel with 80-90 percent ostial stenosis.
Left external iliac artery is a medium size calcified vessel with diffuse 50 percent proximal and midportion stenosis.

Right lower extremity angiogram.
Angiogram was obtained with the positioning of the Contra catheter to the proximal right superficial femoral artery across the aortic bifurcation for better imaging.
Common femoral artery is a medium size calcified vessel with 30-40 percent midportion stenosis.
Superficial femoral artery is a medium-sized vessel with moderate diffuse irregularity. but not more than 40 percent stenosis.  worse in the midportion. and in the area of Hunter's canal.
Popliteal artery is a medium-sized vessel with mild luminal irregularities. not more than 30 percent
stenosis.
There is 2 vessel below-the-knee runoff. Occluded proximal anterior tibial artery.
Patent tibioperoneal trunk and a large peroneal artery. patent small proximal posterior tibial artery.

Left lower extremity angiogram.
Angiogram was obtained through the 5 French sheath in the left femoral artery.
Common femoral artery is a medium size calcified vessel with 20 percent midportion stenosis. Superficial femoral artery is a medium-sized vessel with moderate diffuse irregularity. but not more than 40-45 percent stenosis, worse in the proximal portion. and in the area of Hunter's canal.
Popliteal artery is a medium-sized vessel with mild luminal irregularities. not more than 20 percent stenosis.
There is 2 vessel below-the-knee runoff.
Occluded proximal posterior tibial artery.
Patent tibioperoneal trunk and peroneal artery. patent proximal  anterior tibial artery.

lntravascular ultrasound of the:
right proximal superficial femoral artery. right common femoral artery.
right external iliac artery.

right common iliac artery. left common iliac artery. left external iliac artery.

procedure was performed through the 6 French 45 centimeter cook sheath 1st position across the aortic bifurcation to the right external iliac artery. and then pulled back to the distal left external iliac artery to complete the ultrasound.
the IVUS catheter was advanced across the aortic bifurcation to the proximal right superficial femoral
artery over the 300 centimeter grand slam wire. pulled back and recordings were performed. Findings:
Right SFA is relatively small vessel with the vessel diameter of 4.4-4.7 millimeter. with eccentric. and
concentric plague with less than 50 percent diameter stenosis.
Right CFA is medium-sized vessel with 6.4 x 6 millimeter diameter. with less than 40 percent diameter stenosis.
Right external iliac artery is medium-sized vessel with 6.2 x 6.4 vessel diameter. with less than 30
percent diameter stenosis.
Right common iliac artery is the large vessel with 9 x 9.2 millimeter vessel diameter. 8 millimeter lumen diameter. and 65 percent proximal stenosis.
Left common iliac artery is a large vessel with 7 x 8 millimeter vessel diameter. and 72 percent  ostial
stenosis.
Left external iliac artery is the large vessel with 6.9 x 7.2 vessel diameter and diffuse 70 percent  stenosis.

Angioplasty and stent of the left common. and external iliac artery.
a 6 French 45 centimeter cook sheath was placed to the left femoral artery with the tip to the left common iliac artery.  a 260 centimeter Versacore wire was advanced through the lesion and positioned to the descending aorta 
a 6 French 25 centimeter sheath was placed to the right femoral artery with its tip to the right common
iliac artery. at 260 J wire was advanced to the lesion and positioned to the descending aorta.

an 8 x 37 millimeter express balloon expandable stent was positioned to the ostial left common iliac artery and deployed at 6 atmospheres for 1 minute: an 8 x 60 millimeters self expanding stent was positioned overlapping with a Express stent and covering left external iliac artery. post dilatation of the external iliac artery was performed with a 7 x 60 millimeter balloon inflated to 6 atmospheres for 40 seconds.
there  was excellent  procedural  result  achieved. with O percent  residual stenosis. unaffected   aortic
carina. unaffected diseased left hypogastric artery. there was very mild non flow limiting distal aortic dissection without any evidence of staining or extravasation. excellent brisk flow to the iliac/femoral artery. Clinically patient experienced no pain. 


Angioplasty and stent of right common iliac artery 
An 8x12 millimeter express balloon expandable stent was positioned to the mid right common iliac artery, and deployed at 7 atmospheres for 1 minute.  Final angiogram showed excellent procedural result, with full stent expansion and apposition.  0 percent residual stenosis, and excellent brisk flow.

CONCLUSIONS:
Peripheral Vascular disease
Severe Stenosis of the right common artery - 65 percent, successful angioplasty and stent with 8x27 millimeter express stent.
Severe stenosis of the left common iliac artery - 71 percent, successful angioplasty and stent with 8x37 millimeter express stent.
Severe stenosis of the left external iliac artery - 70 percent, successful angioplasty and 8 x 60 millimeter self expanding stent.
Intermediate, less than 50 percent stenosis of the left and right SFA by angiogram and intravascular ultrasound.
2 vessel below-the-knee runoff bilaterally.
No evidence of obstructive renal artery stenosis.


Thanks in advance; greatly appreciate any assistance....

Jane


----------



## Jane5711 (May 8, 2019)

*Still seeking lots of help*

Jim, I see you are on the www... ant thoughts


----------



## Jim Pawloski (May 8, 2019)

Jane5711 said:


> Hi...
> 
> Need help with getting 37221 RT and 37221 LT 59 paid and 37223 LT.  According to a very famous payer only one can be paid however they didn't even pay ONE!!!!!  They denied all THREE after a review stating that the number of items billed for this date of service is above standard.  Shouldn't they pay for at least ONE!! They are also quoting PER CPT GUIDELINES.  Any help!!!!! Please......
> 
> ...



Boy, are you lucky tonight. One thing that I see is a picky insurance company, but enough of that. This is how I would code this, 36252 for the renals, 75716-59 for the lower extremities, 37221-50 for the iliac stents, and 37223-LT for the external iliac stent. I guess that the third party payer doesn't want to see so many numbers. That why I used modifier -50 for the bilateral stents.
HTH,
Jim


----------



## Jane5711 (May 9, 2019)

*Thank you!!!*

I am lucky...my knight and shining armor has come to the rescue
  Now I have to do the 3rd appeal with the modifier 50s.  Thanks again for your help, very greatly appreciated!!!


----------

