maine4me
Guru
I have a question about the attached operative report and diagnosis selection. This doctor currently codes his own procedures, however I code the diagnoses. On this note the diagnosis code selected was I70.221 based on the preoperative and postoperative diagnosis. Included in the procedure codes the doctor has included75630, which was denied for medical necessity based on the LCD. In an effort to support medical necessity for this procedure I reviewed the indications for the procedure and did not feel I could add another diagnosis, not even I73.9, since I feel like this is an assumption based on the operative report alone. In addition, I reviewed the notes for previous visits and found that the I73.9 was there, however the I70.221 was not. So, does anyone see something I am missing that would allow added the I73.9 at the very least?
PREOPERATIVE DIAGNOSIS: Lower extremity atherosclerosis with rest pain.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES:
1. Percutaneous access ultrasound guided left common femoral artery.
2. Radiologic supervision and interpretation of aortogram with iliofemoral runoff.
3. Radiologic supervision and interpretation of bilateral lower extremity arteriogram.
4. Selective catheterization third order right popliteal artery.
5. Insertion of a 5 mm spider FX distal embolic protection device into the popliteal artery.
6. Percutaneous atherectomy of the right superficial femoral artery with a Hawk 1 medium vessel device.
7. Angioplasty of the bilateral common iliac arteries and right superficial femoral artery.
8. Closure of access site with a 6 French Angio-Seal.
(75630-59, 75710-50, 37225, 37220-50)
ANESTHESIA: Local and sedation.
INDICATIONS FOR PROCEDURE: This is an 81-year-old female who was referred to our office with complaints of numbness and coolness of her right lower extremity representing a significant change from previous evaluation. She had undergone noninvasive segmental pressures one year previous, which were completely normal. The decision was made to repeat noninvasive studies given the significant change and these indeed demonstrated progression to severe levels of arterial insufficiency especially on the right. Given the findings and her symptoms, the decision was made to offer arteriogram for further investigation and potential treatment. Risks and benefits of this approach were discussed at length with the patient, informed consent was obtained and she now presents in an elective fashion for the procedure.
DESCRIPTION OF PROCEDURE: The patient was brought into the Angiography suite and laid supine on the table. Time out for identification was performed. The bilateral groins were prepped and draped in standard sterile fashion. The left femoral head was identified under fluoroscopy and 1% lidocaine was used to anesthetize the skin in this region. With ultrasound guidance, access was obtained into the left common femoral artery at a spot where no visible plaque was noted. A 5 French sheath was placed with the Seldinger technique and a Glidewire advantage was inserted towards the abdominal aorta. Limited femoral arteriogram demonstrated good position of the sheath and an Omni flush catheter was then inserted. The catheter was placed at the level of the distal abdominal aorta and from this region, aortogram with iliofemoral runoff was performed. The aortogram demonstrated a very tortuous and angulated aorta at the bifurcation level with calcification that resulted in approximately 50% stenosis of the right common iliac artery and also apparent 30-40% stenosis of the left common iliac artery. The rest of the common iliac arteries were patent, as well as the external and internal iliac arteries although they were small in caliber. Attempts at advancing up and over the bifurcation with the Omni flush catheter and Glidewire advantage were not successful so this catheter was exchanged for a RIM catheter. We were then able to successfully perform advancement into the right femoral region and the wire was directed towards the right superficial femoral artery. A Glidecath was then inserted and advanced to the level of the right femoral head. From this region, a right lower extremity arteriogram was performed. The common femoral and profunda femoris arteries were noted to be patent with minimal disease. The superficial femoral artery was noted to be small in caliber, and had a long segment of stenosis of approximately 10 cm in its proximal to mid segment with the lesions being near occlusive. Additionally, the distal superficial femoral demonstrated an area of approximately 60% stenosis for about 4 cm right before the transition into the popliteal artery at Hunter's canal. The rest of the runoff below the knee demonstrated that the popliteal artery was patent and the anterior tibial artery was noted to be small in caliber and have areas of occlusion at the pedal level and high-grade stenosis in the proximal segment for about a centimeter. The tibioperoneal trunk was continuous with the posterior tibial artery, which was the main runoff all the way down into the plantar vessels although the artery was small in caliber. The peroneal artery appeared to be occluded and only a long branch was present in its place. At that point, the decision was made to intervene and the patient received 5000 units of intravenous heparin which were allowed to circulate.
Next, a 6 French sheath was then inserted over the Glidewire advantage and this was a 6 French x 55 cm Cook sheath. The sheath was placed at the level of the right femoral head. A LeMaitre tape was used to guide treatment. The decision was made to cross the areas of stenosis of the femoral artery with a Glidewire advantage and an ultra 5 Trailblazer catheter. This catheter was advanced to the level of the below knee popliteal artery and a 5 mm Spider FX distal embolic protection device was inserted and deployed at this level. A 6 French Hawk One M device was used to perform directional atherectomy of the right superficial femoral artery lesions. A total of 4 passes were performed in different quadrants with significant plaque obtained. Repeat arteriogram demonstrated a luminal gain of approximately 50% with atherectomy alone. We then inserted a 4 mm x 80 mm chocolate balloon, which was used to perform angioplasty with 2 different treatments of the atherectomized segment for one minute and 30 seconds to 10 atmospheres each. Next, a 4 mm x 150 mm IN.PACT drug-coated balloon was inserted and angioplasty was performed to 10 atmospheres for 3 minutes per indications for use. After this maneuver, repeat arteriogram demonstrated resolution of the area of stenosis of the proximal to mid superficial femoral artery with a non flow limiting dissection noted thus further intervention not performed. The distal SFA lesion became more evident so we elected to perform angioplasty with the previous 4 mm x 80 mm chocolate balloon, which was performed to 11 atmospheres for 2 minutes. Brisk flow was noted all the way down to the foot after this maneuver, so the decision was made to capture the spider filter with the aid of a Trailblazer catheter. Pressure gradients were then measured from the popliteal artery into the common femoral artery via the Trailblazer catheter and these were less than 20 so the decision was made not to treat further. Glidewire advantage was inserted.
Next, pull back pressures through the sheath were then performed into the left common iliac artery and there was a gradient of approximately 30 mmHg starting at the right common iliac artery. For this reason, the decision was made to intervene. Our Glidewire advantage was exchanged for a V18 wire, which allowed angioplasty of the bilateral common iliac arteries with a 5 mm x 40 mm chocolate balloon to 10 atmospheres for one minute on each and subsequently with a 6 mm x 40 mm IN.PACT drug-coated balloon for treatment of the bilateral common iliacs as well. Treatment time was 3 minutes to 10 atmospheres. Brisk flow was noted after this maneuver.
The sheath was brought up and over into the left femoral region and left lower extremity arteriogram was performed given the abnormal noninvasive studies on this side as well. The common femoral artery and profunda were noted to be patent. The superficial femoral artery was also noted to be patent with minimal disease and below the knee, the popliteal artery was patent with a high takeoff of the anterior tibial artery, which became diminutive and occluded in its proximal to mid segment. Runoff appeared to be mainly via the peroneal artery as the posterior tibial artery became diminutive and had a near occlusive stenosis in its proximal segment. The Glidewire advantage was reinserted which allowed closure of the access site with a 6 French Angio-Seal which was inserted and deployed in standard fashion. Palpable posterior tibial pulse was obtained on the right and strong signals at the pedal level bilaterally. Sterile dressing was applied and the patient was taken to the recovery area in stable condition.
ESTIMATED BLOOD LOSS: Minimal.
FLUOROSCOPY TIME: 21 minutes.
TOTAL CONTRAST: 100 mL of Visipaque.
COMPLICATIONS: None.
CONDITION: Stable.
PREOPERATIVE DIAGNOSIS: Lower extremity atherosclerosis with rest pain.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURES:
1. Percutaneous access ultrasound guided left common femoral artery.
2. Radiologic supervision and interpretation of aortogram with iliofemoral runoff.
3. Radiologic supervision and interpretation of bilateral lower extremity arteriogram.
4. Selective catheterization third order right popliteal artery.
5. Insertion of a 5 mm spider FX distal embolic protection device into the popliteal artery.
6. Percutaneous atherectomy of the right superficial femoral artery with a Hawk 1 medium vessel device.
7. Angioplasty of the bilateral common iliac arteries and right superficial femoral artery.
8. Closure of access site with a 6 French Angio-Seal.
(75630-59, 75710-50, 37225, 37220-50)
ANESTHESIA: Local and sedation.
INDICATIONS FOR PROCEDURE: This is an 81-year-old female who was referred to our office with complaints of numbness and coolness of her right lower extremity representing a significant change from previous evaluation. She had undergone noninvasive segmental pressures one year previous, which were completely normal. The decision was made to repeat noninvasive studies given the significant change and these indeed demonstrated progression to severe levels of arterial insufficiency especially on the right. Given the findings and her symptoms, the decision was made to offer arteriogram for further investigation and potential treatment. Risks and benefits of this approach were discussed at length with the patient, informed consent was obtained and she now presents in an elective fashion for the procedure.
DESCRIPTION OF PROCEDURE: The patient was brought into the Angiography suite and laid supine on the table. Time out for identification was performed. The bilateral groins were prepped and draped in standard sterile fashion. The left femoral head was identified under fluoroscopy and 1% lidocaine was used to anesthetize the skin in this region. With ultrasound guidance, access was obtained into the left common femoral artery at a spot where no visible plaque was noted. A 5 French sheath was placed with the Seldinger technique and a Glidewire advantage was inserted towards the abdominal aorta. Limited femoral arteriogram demonstrated good position of the sheath and an Omni flush catheter was then inserted. The catheter was placed at the level of the distal abdominal aorta and from this region, aortogram with iliofemoral runoff was performed. The aortogram demonstrated a very tortuous and angulated aorta at the bifurcation level with calcification that resulted in approximately 50% stenosis of the right common iliac artery and also apparent 30-40% stenosis of the left common iliac artery. The rest of the common iliac arteries were patent, as well as the external and internal iliac arteries although they were small in caliber. Attempts at advancing up and over the bifurcation with the Omni flush catheter and Glidewire advantage were not successful so this catheter was exchanged for a RIM catheter. We were then able to successfully perform advancement into the right femoral region and the wire was directed towards the right superficial femoral artery. A Glidecath was then inserted and advanced to the level of the right femoral head. From this region, a right lower extremity arteriogram was performed. The common femoral and profunda femoris arteries were noted to be patent with minimal disease. The superficial femoral artery was noted to be small in caliber, and had a long segment of stenosis of approximately 10 cm in its proximal to mid segment with the lesions being near occlusive. Additionally, the distal superficial femoral demonstrated an area of approximately 60% stenosis for about 4 cm right before the transition into the popliteal artery at Hunter's canal. The rest of the runoff below the knee demonstrated that the popliteal artery was patent and the anterior tibial artery was noted to be small in caliber and have areas of occlusion at the pedal level and high-grade stenosis in the proximal segment for about a centimeter. The tibioperoneal trunk was continuous with the posterior tibial artery, which was the main runoff all the way down into the plantar vessels although the artery was small in caliber. The peroneal artery appeared to be occluded and only a long branch was present in its place. At that point, the decision was made to intervene and the patient received 5000 units of intravenous heparin which were allowed to circulate.
Next, a 6 French sheath was then inserted over the Glidewire advantage and this was a 6 French x 55 cm Cook sheath. The sheath was placed at the level of the right femoral head. A LeMaitre tape was used to guide treatment. The decision was made to cross the areas of stenosis of the femoral artery with a Glidewire advantage and an ultra 5 Trailblazer catheter. This catheter was advanced to the level of the below knee popliteal artery and a 5 mm Spider FX distal embolic protection device was inserted and deployed at this level. A 6 French Hawk One M device was used to perform directional atherectomy of the right superficial femoral artery lesions. A total of 4 passes were performed in different quadrants with significant plaque obtained. Repeat arteriogram demonstrated a luminal gain of approximately 50% with atherectomy alone. We then inserted a 4 mm x 80 mm chocolate balloon, which was used to perform angioplasty with 2 different treatments of the atherectomized segment for one minute and 30 seconds to 10 atmospheres each. Next, a 4 mm x 150 mm IN.PACT drug-coated balloon was inserted and angioplasty was performed to 10 atmospheres for 3 minutes per indications for use. After this maneuver, repeat arteriogram demonstrated resolution of the area of stenosis of the proximal to mid superficial femoral artery with a non flow limiting dissection noted thus further intervention not performed. The distal SFA lesion became more evident so we elected to perform angioplasty with the previous 4 mm x 80 mm chocolate balloon, which was performed to 11 atmospheres for 2 minutes. Brisk flow was noted all the way down to the foot after this maneuver, so the decision was made to capture the spider filter with the aid of a Trailblazer catheter. Pressure gradients were then measured from the popliteal artery into the common femoral artery via the Trailblazer catheter and these were less than 20 so the decision was made not to treat further. Glidewire advantage was inserted.
Next, pull back pressures through the sheath were then performed into the left common iliac artery and there was a gradient of approximately 30 mmHg starting at the right common iliac artery. For this reason, the decision was made to intervene. Our Glidewire advantage was exchanged for a V18 wire, which allowed angioplasty of the bilateral common iliac arteries with a 5 mm x 40 mm chocolate balloon to 10 atmospheres for one minute on each and subsequently with a 6 mm x 40 mm IN.PACT drug-coated balloon for treatment of the bilateral common iliacs as well. Treatment time was 3 minutes to 10 atmospheres. Brisk flow was noted after this maneuver.
The sheath was brought up and over into the left femoral region and left lower extremity arteriogram was performed given the abnormal noninvasive studies on this side as well. The common femoral artery and profunda were noted to be patent. The superficial femoral artery was also noted to be patent with minimal disease and below the knee, the popliteal artery was patent with a high takeoff of the anterior tibial artery, which became diminutive and occluded in its proximal to mid segment. Runoff appeared to be mainly via the peroneal artery as the posterior tibial artery became diminutive and had a near occlusive stenosis in its proximal segment. The Glidewire advantage was reinserted which allowed closure of the access site with a 6 French Angio-Seal which was inserted and deployed in standard fashion. Palpable posterior tibial pulse was obtained on the right and strong signals at the pedal level bilaterally. Sterile dressing was applied and the patient was taken to the recovery area in stable condition.
ESTIMATED BLOOD LOSS: Minimal.
FLUOROSCOPY TIME: 21 minutes.
TOTAL CONTRAST: 100 mL of Visipaque.
COMPLICATIONS: None.
CONDITION: Stable.