iamlou
Networker
Hi,
What are your thoughts on coding this? Dr. angioplastied the left tibial, and attempted the left anterior tibial. If he had successfully angioplastied the anterior tibial, I would use codes 37228 and 37232. Since the angio of the ant tib wasn't successful, would I then use 36247/75774 with the 37228 (he also had aortography and bilateral angiogram 75625, 75716)? Below is the op report if you're interested in reading it. Thanks for your help!!!
PROCEDURES PERFORMED:
Abdominal aortography, bilateral femoral runoff angiography, left posterior
tibial balloon angioplasty, attempted left distal posterior tibial and
anterior tibial recanalization
ACCESS SITE:
Right common femoral artery
CATHETER POSITION:
Proximal abdominal aorta, distal abdominal aorta, left external iliac
artery, left SFA, left popliteal artery, left anterior tibial artery,
left peroneal artery, left posterior tibial artery
TECHNIQUE:
The skin overlying the right and left groins were sterilely prepped and
draped in standard fashion as described above. Under ultrasound guidance,
after achieving local anesthesia with 1 percent lidocaine, the right common
femoral artery was accessed in retrograde fashion. Over a guidewire a 5
French sheath was inserted followed by placement of a 4 French Omni Flush
catheter placed in the proximal abdominal aorta. AP abdominal aortography
performed. Catheter was repositioned at the aortic bifurcation. Bilateral
femoral runoff examination was performed. Catheter advanced into the left
external iliac artery. With the catheter in this position DSA images were
obtained to the level of the left calf and lateral foot. There is
extensive left sided distal tibial occlusive disease. Endovascular
intervention was elected to promote limb salvage.
Diagnostic catheter and sheath were removed over a guidewire and a 5 French
Ansell sheath was advanced across the acutely angled aortoiliac bifurcation
into the left SFA. Patient received heparin titrated to the patient's ACT.
Throughout the course of the procedure, aliquots of intra-arterial
nitroglycerin was were administered.
The left lower extremity demonstrates patent left iliac inflow, SFA and
popliteal artery. There is a focal high-grade stenosis in the proximal
left posterior tibial artery, and a short segment occlusion of the distal
left posterior tibial artery at the level of the ankle. In addition there
is severe segmental occlusive disease of the distal left anterior tibial
artery that extends into the proximal left dorsalis pedis artery. The
peroneal artery is patent with multilevel plaque. There is a high-grade
stenosis of the distal peroneal artery anterior perforating branch.
Initially, through the sheath a 0.035 inch quick cross catheter was
advanced into the popliteal artery. Injections were performed. Catheter
was further advanced to the level of the origin of the left posterior
tibial artery. The quick cross catheter was exchanged over 0.014 inch
Rugulia wire for a 0.018 inch quick cross catheter which was advanced into
the proximal left posterior tibial artery. Injections were performed. The
high-grade left posterior tibial was traversed with the Rugulia wire.
Quick cross catheter advanced across the stenosis. Rugulia wire exchanged
for a 0.014 inch Cordis XS wire. Over this the lesion was dilated with a
2.5 x 20 mm Powerflex balloon. Completion study demonstrates widely patent
proximal posterior tibial artery.
The balloon was removed and was exchanged for a 0.018 inch quick cross
catheter. Quick cross catheter positioned to the level of the distal
posterior tibial artery occlusion. Multiple attempts at traversing the
distal posterior tibial artery occlusion were performed using a series of
guidewires, without success.
The quick cross catheter was subsequently positioned in the proximal
anterior tibial artery. Injections were performed. Multiple attempts were
subsequently performed using a series of multiple 0.014 inch and 0.018 inch
guidewires, at traversing the distal high-grade calcified segmental disease
of the distal ATA and proximal dorsalis pedis. These were unsuccessful.
Catheter was repositioned in the peroneal artery. Injection performed to
finding multilevel disease. It was elected to do a second stage procedure
to minimize contrast load, and consider alternative exercise including
ipsilateral antegrade or pedal retrograde. The sheath was removed.
Access site closed using Starr close.
FINDINGS:
Patent abdominal aorta. Patent right and left common iliac, external
iliac, internal iliac arteries. No Iliac inflow stenosis.
(Right lower extremity asymptomatic) . There is diffuse atherosclerotic
disease. The right SFA, popliteal arteries are patent. The right profunda
femoral artery is patent. The right anterior tibial artery is patent
however functionally occludes in the distal calf. The tibial artery is
patent. The peroneal artery demonstrates severe multilevel disease. The
posterior tibial artery is patent.
Left upper extremity (symptomatic side): The left common femoral, profunda
femoral, SFA, popliteal arteries are patent. The left anterior tibial
artery is patent however demonstrates moderate diffuse calcific
atherosclerotic disease, with high-grade segmental occlusion of the distal
anterior tibial artery just above the ankle, extending into the dorsalis
pedis artery. This segment demonstrates extensive calcific
atherosclerotic change. The left tibial peroneal trunk is patent. The left
posterior tibial artery is patent however demonstrates a high-grade
stenosis in the proximal calf which is treated with 2.5 mm angioplasty with
satisfactory result. Segmental occlusion of the distal posterior tibial
artery to the level of the ankle. Attempts at recanalizing this were
unsuccessful. Peroneal artery is patent with multilevel moderate to severe
calcific stenosis. There is high-grade stenosis in the distal peroneal
anterior perforating branch.
The distal dorsalis pedis artery is patent. The pedal arch is incomplete.
There is reconstitution of the lateral and medial plantar arch.
COMPLICATIONS: None.
IMPRESSION:
BILATERAL FEMORAL ANGIOGRAPHY DEMONSTRATES PATENT ILIAC INFLOW, AND ON THE
SYMPTOMATIC LEFT SIDE, PATENT SFA POPLITEAL ARTERY. THERE IS THREE-VESSEL
TIBIAL RUNOFF HOWEVER THERE IS EXTENSIVE SEGMENTAL CALCIFIED OCCLUSIVE
DISEASE OF THE DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL ARTERIES AT THE
LEVEL OF THE ANKLE AS DESCRIBED ABOVE. THERE IS A HIGH-GRADE STENOSIS AT
PROXIMAL POSTERIOR TIBIAL ARTERY WHICH WAS TREATED SUCCESSFULLY WITH
BALLOON ANGIOPLASTY. THE PERONEAL ARTERY DEMONSTRATES MULTILEVEL DISEASE.
AS DESCRIBED ABOVE, ATTEMPTS AT RECANALIZING THE DISTAL ANTERIOR TIBIAL AND
POSTERIOR TIBIAL ARTERIAL OCCLUSIVE DISEASE WERE UNSUCCESSFUL. THE PATIENT
PRESENTS FOR SECOND STAGE PROCEDURE UTILIZING THE ACCESS ROUTES INCLUDING
ANTEGRADE IPSILATERAL COMMON FEMORAL ARTERY AND POTENTIALLY RETROGRADE
PEDAL ACCESS.
What are your thoughts on coding this? Dr. angioplastied the left tibial, and attempted the left anterior tibial. If he had successfully angioplastied the anterior tibial, I would use codes 37228 and 37232. Since the angio of the ant tib wasn't successful, would I then use 36247/75774 with the 37228 (he also had aortography and bilateral angiogram 75625, 75716)? Below is the op report if you're interested in reading it. Thanks for your help!!!
PROCEDURES PERFORMED:
Abdominal aortography, bilateral femoral runoff angiography, left posterior
tibial balloon angioplasty, attempted left distal posterior tibial and
anterior tibial recanalization
ACCESS SITE:
Right common femoral artery
CATHETER POSITION:
Proximal abdominal aorta, distal abdominal aorta, left external iliac
artery, left SFA, left popliteal artery, left anterior tibial artery,
left peroneal artery, left posterior tibial artery
TECHNIQUE:
The skin overlying the right and left groins were sterilely prepped and
draped in standard fashion as described above. Under ultrasound guidance,
after achieving local anesthesia with 1 percent lidocaine, the right common
femoral artery was accessed in retrograde fashion. Over a guidewire a 5
French sheath was inserted followed by placement of a 4 French Omni Flush
catheter placed in the proximal abdominal aorta. AP abdominal aortography
performed. Catheter was repositioned at the aortic bifurcation. Bilateral
femoral runoff examination was performed. Catheter advanced into the left
external iliac artery. With the catheter in this position DSA images were
obtained to the level of the left calf and lateral foot. There is
extensive left sided distal tibial occlusive disease. Endovascular
intervention was elected to promote limb salvage.
Diagnostic catheter and sheath were removed over a guidewire and a 5 French
Ansell sheath was advanced across the acutely angled aortoiliac bifurcation
into the left SFA. Patient received heparin titrated to the patient's ACT.
Throughout the course of the procedure, aliquots of intra-arterial
nitroglycerin was were administered.
The left lower extremity demonstrates patent left iliac inflow, SFA and
popliteal artery. There is a focal high-grade stenosis in the proximal
left posterior tibial artery, and a short segment occlusion of the distal
left posterior tibial artery at the level of the ankle. In addition there
is severe segmental occlusive disease of the distal left anterior tibial
artery that extends into the proximal left dorsalis pedis artery. The
peroneal artery is patent with multilevel plaque. There is a high-grade
stenosis of the distal peroneal artery anterior perforating branch.
Initially, through the sheath a 0.035 inch quick cross catheter was
advanced into the popliteal artery. Injections were performed. Catheter
was further advanced to the level of the origin of the left posterior
tibial artery. The quick cross catheter was exchanged over 0.014 inch
Rugulia wire for a 0.018 inch quick cross catheter which was advanced into
the proximal left posterior tibial artery. Injections were performed. The
high-grade left posterior tibial was traversed with the Rugulia wire.
Quick cross catheter advanced across the stenosis. Rugulia wire exchanged
for a 0.014 inch Cordis XS wire. Over this the lesion was dilated with a
2.5 x 20 mm Powerflex balloon. Completion study demonstrates widely patent
proximal posterior tibial artery.
The balloon was removed and was exchanged for a 0.018 inch quick cross
catheter. Quick cross catheter positioned to the level of the distal
posterior tibial artery occlusion. Multiple attempts at traversing the
distal posterior tibial artery occlusion were performed using a series of
guidewires, without success.
The quick cross catheter was subsequently positioned in the proximal
anterior tibial artery. Injections were performed. Multiple attempts were
subsequently performed using a series of multiple 0.014 inch and 0.018 inch
guidewires, at traversing the distal high-grade calcified segmental disease
of the distal ATA and proximal dorsalis pedis. These were unsuccessful.
Catheter was repositioned in the peroneal artery. Injection performed to
finding multilevel disease. It was elected to do a second stage procedure
to minimize contrast load, and consider alternative exercise including
ipsilateral antegrade or pedal retrograde. The sheath was removed.
Access site closed using Starr close.
FINDINGS:
Patent abdominal aorta. Patent right and left common iliac, external
iliac, internal iliac arteries. No Iliac inflow stenosis.
(Right lower extremity asymptomatic) . There is diffuse atherosclerotic
disease. The right SFA, popliteal arteries are patent. The right profunda
femoral artery is patent. The right anterior tibial artery is patent
however functionally occludes in the distal calf. The tibial artery is
patent. The peroneal artery demonstrates severe multilevel disease. The
posterior tibial artery is patent.
Left upper extremity (symptomatic side): The left common femoral, profunda
femoral, SFA, popliteal arteries are patent. The left anterior tibial
artery is patent however demonstrates moderate diffuse calcific
atherosclerotic disease, with high-grade segmental occlusion of the distal
anterior tibial artery just above the ankle, extending into the dorsalis
pedis artery. This segment demonstrates extensive calcific
atherosclerotic change. The left tibial peroneal trunk is patent. The left
posterior tibial artery is patent however demonstrates a high-grade
stenosis in the proximal calf which is treated with 2.5 mm angioplasty with
satisfactory result. Segmental occlusion of the distal posterior tibial
artery to the level of the ankle. Attempts at recanalizing this were
unsuccessful. Peroneal artery is patent with multilevel moderate to severe
calcific stenosis. There is high-grade stenosis in the distal peroneal
anterior perforating branch.
The distal dorsalis pedis artery is patent. The pedal arch is incomplete.
There is reconstitution of the lateral and medial plantar arch.
COMPLICATIONS: None.
IMPRESSION:
BILATERAL FEMORAL ANGIOGRAPHY DEMONSTRATES PATENT ILIAC INFLOW, AND ON THE
SYMPTOMATIC LEFT SIDE, PATENT SFA POPLITEAL ARTERY. THERE IS THREE-VESSEL
TIBIAL RUNOFF HOWEVER THERE IS EXTENSIVE SEGMENTAL CALCIFIED OCCLUSIVE
DISEASE OF THE DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL ARTERIES AT THE
LEVEL OF THE ANKLE AS DESCRIBED ABOVE. THERE IS A HIGH-GRADE STENOSIS AT
PROXIMAL POSTERIOR TIBIAL ARTERY WHICH WAS TREATED SUCCESSFULLY WITH
BALLOON ANGIOPLASTY. THE PERONEAL ARTERY DEMONSTRATES MULTILEVEL DISEASE.
AS DESCRIBED ABOVE, ATTEMPTS AT RECANALIZING THE DISTAL ANTERIOR TIBIAL AND
POSTERIOR TIBIAL ARTERIAL OCCLUSIVE DISEASE WERE UNSUCCESSFUL. THE PATIENT
PRESENTS FOR SECOND STAGE PROCEDURE UTILIZING THE ACCESS ROUTES INCLUDING
ANTEGRADE IPSILATERAL COMMON FEMORAL ARTERY AND POTENTIALLY RETROGRADE
PEDAL ACCESS.
