# Diagnostic Aortogram w/runoff w/percutaneous angioplasty lt peroneal w/left SFA



## armedical (Sep 16, 2013)

This OP is a runoff..need some options for coding. 

Dr. A performed alone. 
We coded 37224-LT

Op Report
A 6-French side arm sheath w/modified Seldinger technique was placed in the right radial artery.  Dr. then took a 5-French Jacky catheter w/aide of a long glidewire went up and over into the descending aorta and performed angiography of the aorta and digital subtraction angiography in AP view.  The Dr. then took a glidewire 260 exchange length and 150 cm Quick Cross and cannulated the proximal iliac of the left leg and performed angiography of the left leg.  Then manipulated a catheter into the right common iliac and performed angiography of the right system to the foot w/runoff. 

Dr. A then assisted Dr. B. 
We coded 37204-80-RT
37224-80-59RT
75894 ? not sure if who bills? 

Op Report
Selective right external iliac angiography, selective right circumflex femoral angiography, Coil embolization of the right circumflex femoral, Balloon angioplasty of the right common femoral artery.


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## dpeoples (Sep 17, 2013)

armedical said:


> This OP is a runoff..need some options for coding.
> 
> Dr. A performed alone.
> We coded 37224-LT
> ...



It is very difficult to give code choices with only partial information, even if the information constitutes the essential elements of the procedure. It is necessary to know the reason for the exam (medical necessity), known conditions etc. 

You coded 37224 for the first report but I do not see a revascularization, only potential aortogram and bilateral extremity angiography (36245-LT, 36245_RT,75625,75716). I say _potentia_l because I do not see an interpretation of the images.

The second note leaves more questions. Why is the embolization being performed, was the condition known or is this also a diagnostic test? Was the balloon used to facilitate the embolization or is it true angioplasty (different medical necessity)? Too many unanswered questions for me to attempt coding.

HTH


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## armedical (Sep 18, 2013)

*More operative report*

Hi Danny, sorry I quit typing way to soon....this is the entire OP report

Our coding; 
37224-LT
37204-80RT
75894
37224-80RT

The patient was brought to the cardiac catheterization lab, prepped and draped in sterile fashion.  Lidocaine 1% was used to infiltrate the right radial artery.  A 6-French side-arm sheath with modified Seldinger technique was placed in the right radial artery.  I then took a 5-French Jacky Catheter with the aide of a long glidewire and went up and over into the descending aorta and performed angiography of the aorta and digital subtraction angiography in AP view.  I then took a glidewire 260 exchange length and 150 cm Quick-Cross and cannulated the proximal iliac of the left leg and performed angiography of the left leg.  I then manipulated a catheter into the right common iliac and performed angiography of the right system to the foot with runoff.

Results of the diagnostic angio are as follows: Aorta: The patients aorta is patent with patent iliacs bilaterally and patient renals noted with no significant disease. 

The right leg is as follows: The internal and external iliac are patent and femoral has mild to moderate disease.  The SFA is moderate to severely diseased and is occluded at the distal popliteal.  The profunda is patent on the right with some mild to moderate disease up to 70% with no significant stenosis.  Below the knee, again, the popliteal distally occludes to being subtotaled.  This is very faint below the knee infra popliteal runoff.  The TP trunk is heavily diseased with a patent peroneal and anterior tibial.  The posterior tibial appears to be subtotally occluded going around the medial malleolus. 

The left leg is as follows:  The left SFA heavily diseased up to 80% at the Hunter's canal.  Popliteal is patent but occludes distally with a subtotaled anterior tibial peroneal and occluded posterior tibial. 

I elected to intervene on the peroneal and SFA.  I placed a 55 cm Cook sheath up and over from the right common femoral into the left mid SFA.  I took a whisper wire, 300 cm, with an 0.014 trailblazer and was able to wire a subtotally occluded peroneal and in fact were able to wire a collateral from the peroneal to the posterior tibial and push the wire back up past the subtotal occlusion of the distal popliteal.  I then took a 2 x 150 Invatec balloon and inflated the collateral back into the peroneal up to the level of the posterior tibial.  Then, next, I took a 5 x 120 balloon in the distal popliteal and distal SFA/Hunter's canal.  Angiography at this point showed patent SFA with good 2 vessel runoff filling the peroneal and collaterals from the peroneal to the posterior tibial.  However, unfortunately at this time, the patient did complain of belly pain and developed hypotension.  I removed the 55 cm sheath and placed a short 5 in.  Multiple injections were performed.  At this time there was no evidence of RP bleed, howerver, subsequently shots did show what appeared to be an inferiorly directed inferior epigastric with what appeared to be a hemorrhagic leak.  We then quickly inserted an 8 x 40 Medtronic balloon into the common iliac.  We made multiple inflations at low atmospheres of 4 for up to approximately 80 minutes.  Patient was hemodynamically stable with the balloon up.  Once the balloon was down when angiography performed, it was clearly evident there was still a persistant retroperitoneal bleed.  

At this point, I elected to discuss the case with Dx. X.  We then elected to attempt to try to coil the artery.  Access was gained by Dr. X , please refer to his surgical note, in the left femoral artery.  We went up and over the 55 cm Raabe shath.  We then took a rimmed catheter and selectively cannulated the inferior epigastric artery and put 1 Cook coil 18cm into the iliac artery.  There was some of the coil hanging out in the common femoral.  We then took a 6 x 20 balloon from left to right up and over and pushed the remainder of the coil against the wall.  Final angiography performed, cessation of blook flow.  Patient remained hemodynamically stable.  Manual pressure was held by both groins and TR brand to right radial artery.  Patient will be admitted overnight for observation, including type and screen and CBC, BMP, etc. He will be discharged tomorrow stable.


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## dpeoples (Sep 18, 2013)

Based on the complete report, I would code:

1) 37224-LT
36245-51,59
75625-59
75716-59

2) 37204/75894/75898

I would not code angioplasty for the balloon used to facilitate embolization, that is part of this procedure. I would also not code for additional diagnostic because this is still the same session. Modifier 80 is really payor dependent but does seem appropriate in this case.

HTH


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## armedical (Sep 18, 2013)

You are the bomb


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