General Surgery Coding Alert

Question: Our surgeon performed a “cutting balloon atherectomy.” Services were for the right femoral artery and for in-stent restenosis in the left iliac artery. What is the proper way to code this?

Maryland Subscriber

Answer: A cutting balloon is an angioplasty device, so you will need to clarify whether the documentation supports reporting angioplasty alone or atherectomy along with the cutting balloon angioplasty.

Angioplasty only: To report cutting balloon angioplasty, you’ll use these codes:

• Femoral code 37224 (Revascularization, endovascular, open or percutaneous, femoral, popliteal artery[s], unilateral; with transluminal angioplasty)
• Iliac code 37220 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty).

Using these two “initial vessel” codes is appropriate because each code applies to a different territory, one for femoral and one for iliac. However, if there isn’t a break within the stenosis, and the treatment is for one continuous stenotic region, you would code the procedure with one procedural code not two procedural codes. Remember that the external iliac artery runs into the common femoral artery. 

Angioplasty + Atherectomy: If documentation supports reporting both atherectomy and angioplasty in both vessels, you should report these codes:

• Femoral code 37225 (Revascularization, endovascular, open or percutaneous, femoral, popliteal artery[s], unilateral; with atherectomy, includes angioplasty within the same vessel, when performed)
• Iliac angioplasty code 37220 and atherectomy code 0238T (Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel).

Notice how the coding for iliac angioplasty and atherectomy requires use of multiple codes because Category III code 0238T includes only atherectomy and radiological supervision and interpretation.

Device explained: A cutting balloon is an angioplasty catheter outfitted with several small blades mounted on the outside of the balloon. As the balloon expands inside a lesion, the blades cut into the lesion, making it easier to dilate. Without these blades, your surgeon may not be able to perform the angioplasty because the lesion might have hardened (with plaque) over time. So although these balloon tips have blades on the outside, your surgeon performed work similar to a traditional angioplasty.

Term tip: Words that end with -ectomy indicate that the surgeon removed something. For instance, atherectomy refers to removal of atheroscelerotic plaque. When your surgeon uses cutting balloons, he does not remove the plaque. Instead, he simply cuts and dilates to permit greater blood flow through the area of obstruction.